What is the management of constrictive pericarditis?

Management of Constrictive Pericarditis

Pericardiectomy is the definitive treatment for chronic permanent constrictive pericarditis in symptomatic patients (NYHA class III-IV), but medical therapy should be attempted first in three specific scenarios: tuberculous pericarditis requiring antibiotics, transient constriction with active inflammation, and supportive care when surgery is contraindicated. 1

Initial Diagnostic Workup

Before determining treatment, confirm the diagnosis using a structured approach:

• Transthoracic echocardiography (Class I recommendation) to assess for septal bounce, respiratory variation of mitral E velocity >25%, and ventricular interdependence 1
• Chest X-ray (frontal and lateral views) to identify pericardial calcifications 1
• CT and/or cardiac MRI as second-line imaging to evaluate pericardial thickness (>3mm suggests chronic disease), calcifications, and degree of inflammation via contrast enhancement 1
• Cardiac catheterization when non-invasive methods are inconclusive, looking for "dip and plateau" sign and equalization of diastolic pressures 1

Treatment Algorithm

1. Medical Therapy (Three Specific Indications)

A. Tuberculous Pericarditis Prevention

• Rifampicin-based antituberculosis therapy for 6 months (rifampicin, isoniazid, pyrazinamide, ethambutol for 2 months, then rifampicin and isoniazid for 4 months) reduces progression to constriction from >80% to <10% 1
• Consider adjunctive prednisolone for 6 weeks, which reduces constrictive pericarditis incidence by 46%, though monitor for HIV-associated malignancies in immunocompromised patients 1

B. Transient Constriction (10-20% of cases)

• Empiric anti-inflammatory therapy (Class IIb recommendation) should be considered when: 1
  • Elevated CRP is present
  • CT/CMR shows pericardial contrast enhancement indicating active inflammation
  • No evidence of chronic disease (absence of calcifications, normal pericardial thickness)
• Use NSAIDs, colchicine, or glucocorticoids for active inflammation 2
• Serial echocardiography every 2-3 months to assess for resolution of constrictive physiology 3
• This approach may prevent unnecessary pericardiectomy in reversible cases 1, 3

C. Supportive Medical Management

• Loop diuretics for volume overload and edema control when surgery is contraindicated or high-risk 1, 2
• Critical caveat: Medical therapy should never delay surgery in appropriate surgical candidates, as advanced disease has higher mortality and worse outcomes 1

2. Surgical Pericardiectomy (Definitive Treatment)

Indications for Surgery:

• NYHA class III or IV symptoms with persistent constriction on imaging and catheterization 1
• Failure of medical therapy after 2-3 months in transient constriction 1
• Progressive symptoms despite optimal medical management 4

Surgical Approach:

• Complete pericardiectomy via midline sternotomy is the preferred approach, removing both parietal and visceral pericardium 1, 4
• Visceral pericardiectomy is essential since the visceral layer constricts the heart 1
• Surgery must be performed by experienced surgeons at centers with expertise in pericardial disease 1
• Operative mortality ranges from 6-12% 1

High-Risk Surgical Candidates (Exercise Caution):

Pericardiectomy should be approached cautiously or avoided in: 1, 2

• End-stage disease (cachexia, atrial fibrillation, cardiac index <1.2 L/m²/min, hypoalbuminemia, cardiogenic cirrhosis)
• Radiation-induced constriction (associated with concurrent cardiomyopathy and poor long-term outcomes)
• Child-Pugh score ≥7 (significantly worse survival)
• End-stage renal disease
• Significant myocardial dysfunction or fibrosis
• Older age with multiple comorbidities

These patients derive little benefit from surgery with inordinately high operative risk 1

Common Pitfalls to Avoid

• Do not rush to surgery in newly diagnosed constriction without assessing for reversibility—look for elevated CRP and pericardial enhancement on imaging suggesting transient constriction 1, 3
• Do not delay surgery in chronic symptomatic cases, as advanced disease significantly worsens surgical outcomes and mortality 1
• Do not assume normal pericardial thickness excludes constriction—up to 20% of cases have normal thickness 1
• Do not use vasodilators or aggressive diuretics in acute presentations, as they can worsen hemodynamics 1
• Do not perform pericardiectomy at inexperienced centers—referral to specialized centers is warranted for optimal outcomes 1

Prognostic Factors

Poor outcomes are predicted by: 1

• Prior mediastinal radiation
• Worse renal function
• Higher pulmonary artery systolic pressure
• Abnormal left ventricular systolic function
• Lower serum sodium
• Older age
• Child-Pugh score ≥7

Notably, pericardial calcification does not impact survival 1