Pericarditis, Effusive-Constrictive

KEY FEATURES

ESSENTIALS OF DIAGNOSIS

• Echocardiographic demonstration of pericardial fluid with fibrinous strands and constrictive physiology

• Persistence of elevated intracardiac filling pressures after pericardiocentesis with constrictive features

• The most identifiable cause is uremia, although any cause of pericarditis can produce this condition

GENERAL CONSIDERATIONS

• Effusive-constrictive pericarditis combines features of pericardial effusion and constrictive pericarditis

• The syndrome is dynamic and may represent an intermediate stage of constrictive pericarditis

• No diagnostic criteria exist

• Etiology varies because of geographic variation in causes of pericardial disease

• Common causes are uremia, malignancy, radiation, and tuberculosis

• Although pericardiocentesis may be associated with symptomatic improvement, some patients require pericardiectomy

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

• Fatigue

• Dyspnea

• Increased abdominal girth

• Edema

• Malabsorptive diarrhea

• Chest pain

• Dizziness

PHYSICAL EXAM FINDINGS

• Markedly elevated jugular venous pressure with x and y troughs that are more prominent than the a and v peaks

• Pulsus paradoxus

• Kussmaul sign (lack of inspiratory decline in jugular venous pressure) in some

• Abdominal distention with fluid wave from ascites

• Pulsatile hepatomegaly

• Cachexia

• Edema/anasarca

DIFFERENTIAL DIAGNOSIS

• Cardiac tamponade

• Constrictive pericarditis

• Restrictive cardiomyopathy with incidental pericardial effusion

DIAGNOSTIC EVALUATION

LABORATORY TESTS

• Antinuclear antibody titer

• Rheumatoid factor

• Tuberculin skin test

ELECTROCARDIOGRAPHY

• Nonspecific ST- and T-wave changes

• Low-voltage QRS

• Atrial fibrillation

IMAGING STUDIES

• Chest x-ray:

  • – The cardiac silhouette may be small, normal, or enlarged

  • – Pericardial calcification is uncommon

• Echocardiography:

  • – Usually shows a small- to moderate-sized effusion with strands of solid material between the visceral and parietal pericardium

  • – Pericardial thickening and/or adhesions may be apparent

  • – Doppler evidence of exaggerated respirophasic variation in mitral E velocity may be present

  • – The inferior vena cava may be dilated

DIAGNOSTIC PROCEDURES

• Right heart catheterization during or after pericardiocentesis establishes the diagnosis

• After the effusion is drained, elevation of intracardiac filling pressures persists and the recorded waveforms may exhibit the classic appearance of constriction

TREATMENT

CARDIOLOGY REFERRAL

• Heart failure

• Chronic pericardial disease

• Persistent symptoms or evidence of right heart failure after pericardial fluid drainage

HOSPITALIZATION CRITERIA

• Decompensated heart failure

• Evidence of cardiac tamponade

MEDICATIONS

• Treat underlying cause if known

THERAPEUTIC PROCEDURES

• Pericardiocentesis alone may produce at least temporary relief of symptoms in most patients

SURGERY

• Pericardial resection of the visceral pericardium is often required

MONITORING