What is the management of constrictive pericarditis?

Management of Constrictive Pericarditis

Pericardiectomy is the definitive treatment for chronic constrictive pericarditis, particularly for patients with persistent and prominent symptoms (NYHA class III or IV). 1, 2

Diagnostic Approach

Before deciding on management, proper diagnosis is essential:

1. Initial Imaging:

   • Transthoracic echocardiography (recommended for all suspected cases) 1
   • Chest X-ray (frontal and lateral views) to detect calcifications 1

2. Advanced Imaging:

   • CT and/or CMR to assess:
     • Pericardial calcifications (best seen on CT)
     • Pericardial thickness
     • Degree and extension of pericardial involvement 1

3. Hemodynamic Assessment:

   • Cardiac catheterization when non-invasive methods don't provide definitive diagnosis 1
   • Look for "dip and plateau" or "square root" sign and ventricular interdependence 1

Treatment Algorithm

Step 1: Determine if Constriction is Transient or Permanent

• Transient constriction (10-20% of cases):

  • Occurs during resolution of pericarditis
  • Indicators: Elevated CRP, imaging evidence of pericardial inflammation on CT/CMR 1
  • Management: Anti-inflammatory therapy (NSAIDs, colchicine, or glucocorticoids if necessary) 1, 3

• Specific etiologies:

  • For tuberculous pericarditis: Antituberculous antibiotics (can reduce risk of constriction from >80% to <10%) 1

Step 2: For Chronic Permanent Constrictive Pericarditis

Medical Management

• Supportive care with diuretics to manage volume expansion and edema 3
• Should not delay surgery if surgery is feasible 1
• Reserved for:
  • Patients with minimal symptoms
  • Cases where surgery is contraindicated
  • High-risk surgical candidates 1, 3

Surgical Management (Definitive Treatment)

• Indication: NYHA class II-IV symptoms with persistent evidence of constriction 1, 2, 3

• Surgical Approach:

  • Complete pericardiectomy via median sternotomy (preferred approach) 2, 4
  • Removal from phrenic nerve to phrenic nerve 2, 5
  • Complete liberation of right atrium, SVC, IVC, and inferior part of right ventricle 2
  • Preservation of bilateral phrenic nerves is critical 2

• Technical Considerations:

  • Cardiopulmonary bypass should be used only for co-existing cardiac lesions or on standby for potential hemorrhagic complications 2, 4
  • For suppurative pericarditis, lateral thoracotomy should be used to avoid sternal infection 3

Step 3: Special Considerations

Effusive-Constrictive Pericarditis

• Combination of pericardial effusion and constrictive physiology 1
• Diagnosis often becomes apparent during pericardiocentesis 1
• Management: Visceral pericardiectomy (should be performed at centers with experience) 1

High-Risk Patients

• Caution in:

  • Very mild or advanced disease
  • Radiation-induced constriction
  • Myocardial dysfunction
  • Significant renal dysfunction 1, 2

• Poor prognostic factors:

  • Prior radiation therapy
  • Renal dysfunction
  • Elevated pulmonary artery pressure
  • Left ventricular dysfunction
  • Hyponatremia
  • Advanced age
  • Child-Pugh score ≥7 1, 2

Outcomes and Follow-up

• Operative mortality: 6-12% 1, 2
• "End-stage" constrictive pericarditis patients derive little benefit from pericardiectomy 1
• Early diagnosis and surgical intervention before irreversible cardiac function deterioration leads to better outcomes 4, 6

Common Pitfalls

1. Delayed diagnosis: The sooner constrictive pericarditis is diagnosed, the better the outcome 6

2. Incomplete pericardiectomy: Ensure complete removal of all constricting pericardium; incomplete removal may necessitate reoperation 2, 5

3. Misdiagnosis: Carefully differentiate from restrictive cardiomyopathy, which requires different management 1, 7

4. Inappropriate surgical candidates: Pericardiectomy should be avoided in older patients, those with radiation-induced disease, very advanced symptoms, or evidence of myocardial fibrosis 3

5. Inadequate surgical expertise: Pericardiectomy should be performed by experienced cardiac surgeons, with referral to specialized centers when necessary 1, 2