What is the pathophysiological mechanism of constrictive pericarditis in a patient with a history of Hodgkin's lymphoma (Hodgkin lymphoma) treatment, characterized by symptoms of constrictive pericarditis?

From the Guidelines

The correct answer is A. Calcification of pericardium. In constrictive pericarditis, the pericardium becomes thickened, fibrotic, and often calcified, leading to restriction of cardiac filling. This condition can develop as a late complication of Hodgkin lymphoma treatment, particularly following mediastinal radiation therapy, as noted in studies such as 1. Radiation can cause inflammation of the pericardium, which over time leads to fibrosis and calcification. The calcified, rigid pericardium acts like a shell around the heart, preventing normal diastolic filling of the ventricles. This results in symptoms such as dyspnea, fatigue, peripheral edema, and signs of right heart failure. The pathophysiology involves impaired ventricular filling during early diastole, equalization of diastolic pressures in all cardiac chambers, and ventricular interdependence.

Unlike option B, the endocardium is not primarily affected. Option C is incorrect as myocardial infiltration is more characteristic of restrictive cardiomyopathy. Option D describes cardiac tamponade, which involves fluid accumulation rather than the fibrotic process seen in constrictive pericarditis. The most recent and highest quality guidelines, such as those from 1 and 1, support the understanding that calcification of the pericardium is a key feature of constrictive pericarditis, and pericardiectomy is the accepted standard of treatment for patients with persistent and prominent symptoms.

Key points to consider in the management and diagnosis of constrictive pericarditis include:

• The role of radiation therapy in causing pericardial inflammation and subsequent fibrosis and calcification, as discussed in 1.
• The importance of distinguishing constrictive pericarditis from restrictive cardiomyopathy, as outlined in 1.
• The surgical approach to pericardiectomy, including the need for complete removal of the constricting pericardium and the potential use of cardiopulmonary bypass, as described in 1 and 1.

Overall, the management of constrictive pericarditis requires a comprehensive approach, considering the patient's symptoms, the extent of pericardial calcification, and the potential risks and benefits of surgical intervention, as emphasized in the guidelines from 1.

From the Research

Constrictive Pericarditis

• Constrictive pericarditis (CP) is a form of diastolic heart failure that arises because an inelastic pericardium inhibits cardiac filling 2.
• The key pathophysiological concepts of CP include dissociation of intrathoracic and intracardiac pressures and enhanced ventricular interaction 2.
• Risk factors for the development of CP include prior cardiac surgery and radiation therapy, which is relevant in the case of a patient who had Hodgkin lymphoma treatment 2, 3.

Pathophysiology and Symptoms

• CP is characterized by loss of pericardial elasticity and restriction of filling of the cardiac chambers, often leading to symptoms of heart failure 4.
• Pericardial calcification is a common finding in patients with CP and is often associated with idiopathic disease and other markers of disease chronicity 5, 6.
• The presence of pericardial calcification on a plain radiograph strongly suggests CP in patients with heart failure 5.

Correct Option

• The correct option is A. Calcification of pericardium, as it is a common finding in patients with constrictive pericarditis and is often associated with the symptoms and pathophysiology of the disease 4, 5, 6.

Relationship to Hodgkin Lymphoma Treatment

• Radiation therapy, which is a common treatment for Hodgkin lymphoma, is a known risk factor for the development of CP 2, 3.
• The patient's history of Hodgkin lymphoma treatment may have contributed to the development of CP, particularly if radiation therapy was involved 3.