What is the treatment for constrictive pericarditis?

Treatment of Constrictive Pericarditis

Pericardiectomy is the definitive treatment for chronic constrictive pericarditis, while medical therapy should be attempted first for transient forms or as a bridge to surgery in chronic cases. 1

Diagnosis and Classification

Before discussing treatment, it's important to identify the type of constrictive pericarditis:

1. Transient constrictive pericarditis: Temporary form that resolves with anti-inflammatory therapy within weeks
2. Effusive-constrictive pericarditis: Combination of pericardial effusion and constriction
3. Chronic constrictive pericarditis: Persistent constriction after 3-6 months

Diagnostic findings include:

• Echocardiographic features: septal bounce, respiratory variation of mitral peak E velocity >25%, ventricular interdependence
• CT/CMR: pericardial thickening (>3mm), calcifications
• Cardiac catheterization: "dip and plateau" or "square root" sign, equalization of ventricular end-diastolic pressures

Treatment Algorithm

Step 1: Initial Management (0-3 months)

• Anti-inflammatory therapy for all patients with newly diagnosed constrictive pericarditis who are hemodynamically stable 2, 1
  • NSAIDs (ibuprofen, aspirin)
  • Colchicine (0.5-1.0 mg daily)
  • Diuretics for volume overload and edema

Step 2: Reassessment after 2-3 months

• If symptoms resolve → continue medical therapy and monitor
• If symptoms persist → proceed to pericardiectomy evaluation

Step 3: Definitive Treatment

• Pericardiectomy for:
  • Persistent symptoms despite medical therapy
  • Evidence of chronic constriction (>3-6 months)
  • NYHA class II-III symptoms 3

Special Considerations

Tuberculous Pericarditis

• Standard anti-TB drugs for 6 months (rifampicin, isoniazid, pyrazinamide, ethambutol) 2
• Reduces risk of constriction from >80% to <10% 1
• Consider adjunctive prednisolone to reduce incidence of constrictive pericarditis by 46% 2

Surgical Approach

• Complete pericardiectomy via midline sternotomy is preferred 3
• Patient should be on a steroid-free regimen for several weeks before surgery 2, 1
• Avoid surgery in high-risk patients:
  • Advanced age
  • Radiation-induced disease
  • Very advanced symptoms
  • Evidence of myocardial fibrosis/atrophy
  • Child-Pugh score ≥7 1, 3

Important Clinical Pearls

• Normal pericardial thickness does not rule out constrictive pericarditis (present in 18% of surgical cases) 2, 1
• Early intervention leads to better outcomes; delayed intervention may result in incomplete recovery even after complete pericardiectomy 1
• Post-operative monitoring for acute cardiac insufficiency is essential 1
• Recurrences after pericardiectomy may occur due to incomplete resection 2

Common Pitfalls to Avoid

1. Delayed diagnosis: Constrictive pericarditis can mimic other cardiac conditions
2. Premature surgery: Failing to identify potentially reversible transient constriction
3. Incomplete pericardiectomy: Leading to symptom recurrence
4. Overlooking myocardial involvement: Presence of myocardial fibrosis increases surgical risk
5. Prolonged steroid use before surgery: Increases surgical complications

By following this structured approach to the management of constrictive pericarditis, clinicians can optimize outcomes and potentially cure this form of diastolic heart failure 4.