What is the treatment for constrictive pericarditis?

Treatment of Constrictive Pericarditis

Pericardiectomy is the definitive treatment for chronic permanent constrictive pericarditis in symptomatic patients, but a 2-3 month trial of anti-inflammatory therapy should be attempted first in newly diagnosed, hemodynamically stable patients without signs of chronicity to identify the 10-20% with transient constriction. 1

Initial Assessment and Risk Stratification

When constrictive pericarditis is diagnosed, immediately assess for signs of chronicity that mandate surgery versus features suggesting potentially reversible disease:

Signs indicating chronic disease (proceed directly to surgical evaluation):

• Cachexia 1
• Atrial fibrillation 1
• Hepatic dysfunction 1
• Pericardial calcification 1

Features suggesting transient constriction (trial conservative management):

• Elevated CRP indicating active inflammation 1
• Pericardial contrast enhancement on CT/CMR suggesting ongoing inflammation 1
• Recent onset pericarditis with mild effusion 1
• Hemodynamically stable presentation 1

Treatment Algorithm by Clinical Scenario

1. Transient Constrictive Pericarditis (10-20% of cases)

Conservative management for 2-3 months before recommending pericardiectomy in patients without evidence of chronic disease 1:

• Anti-inflammatory therapy with NSAIDs, colchicine, or glucocorticoids for active inflammation 1, 2
• Loop diuretics for volume overload and edema control 3, 2
• CT/CMR surveillance to detect pericardial inflammation via contrast enhancement 1
• Resolution typically occurs within several weeks to months 1

2. Tuberculous Pericarditis (Most Common Cause Worldwide)

Rifampicin-based antituberculosis therapy for 6 months reduces progression to constriction from >80% to <10% 1, 3:

• Standard regimen: Rifampicin, isoniazid, pyrazinamide, and ethambutol for 2 months, followed by rifampicin and isoniazid for 4 additional months (total 6 months) 1, 4
• Adjunctive prednisolone (60 mg daily for weeks 1-4,30 mg for weeks 5-8,15 mg for weeks 9-10,5 mg for week 11) reduces constrictive pericarditis incidence by 46% in HIV-negative patients 1, 3, 4
• Critical caveat: Prednisolone increases risk of HIV-associated malignancies in HIV-positive patients 1, 4
• Intrapericardial urokinase may reduce constriction incidence 1, 4

3. Chronic Permanent Constrictive Pericarditis

Pericardiectomy is indicated for symptomatic patients (NYHA class III-IV) with persistent constriction after 3-6 months 1, 3, 2:

Surgical approach:

• Complete pericardiectomy via midline sternotomy removing both parietal and visceral pericardium is the preferred technique 3, 2
• Video-assisted thoracoscopic approach may be suitable in selected cases 2
• Lateral thoracotomy reserved for suppurative pericarditis to avoid sternal infection 2
• Operative mortality ranges from 6-12% 3, 5

Contraindications or high-risk scenarios for surgery:

• Prior mediastinal radiation 3, 5, 2
• Older age 3, 5, 2
• Worse renal function 3, 5
• Higher pulmonary artery systolic pressure 3, 5
• Abnormal left ventricular systolic function 3, 5
• Evidence of myocardial fibrosis 1, 2
• "End-stage" disease with very advanced symptoms 5, 2

4. Medical Management When Surgery Contraindicated

Loop diuretics for symptomatic relief in patients who are not surgical candidates 3, 2:

• Control volume overload and peripheral edema 3, 2
• Critical principle: Medical therapy should never delay surgery if the patient is an appropriate surgical candidate, as advanced cases have higher mortality and worse prognosis 1
• Medical therapy is purely palliative and does not alter disease progression 1

Special Considerations

Effusive-Constrictive Pericarditis

This variant presents with both effusion and constriction, diagnosed when right atrial pressure fails to fall by 50% or below 10 mmHg after pericardiocentesis 1:

• Most cases are idiopathic in developed countries, tuberculous in developing countries 1
• Requires same treatment approach as chronic constriction once identified 1

Timing of Surgery

The sooner the diagnosis is established, the better the outcome 6:

• Early pericardiectomy before development of myocardial atrophy or fibrosis improves survival 1, 6
• Patients with minimal symptoms (NYHA class I-II) may be managed conservatively with close surveillance 2
• Symptomatic patients (NYHA class III-IV) require prompt surgical referral 3, 2

Common Pitfalls

• Delaying surgery in appropriate candidates: Medical therapy provides only temporary symptom relief and does not prevent progression 1
• Operating on patients with end-stage disease: Operative mortality is prohibitively high when myocardial fibrosis or severe ventricular dysfunction is present 5, 2
• Assuming all constriction requires surgery: 10-20% have transient constriction that resolves with anti-inflammatory therapy 1
• Using steroids in HIV-positive tuberculous pericarditis: Increases risk of HIV-associated malignancies despite reducing constriction 1, 4