8.2: Pericardial Disease - Chronic

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Apr 12, 2024
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- 8.1: Pericardial Disease - Acute
- 8.3: Pericardial Disease - Specific Types

de Jong and van der Waals Eds.
Cardionetworks Foundation and the Health[e]Foundation

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The pericardial layers may become rigid, thickened, and may fuse, resulting in restriction of cardiac filling; constrictive pericarditis. In contrast to cardiac tamponade, where cardiac is hampered throughout diastole, cardiac filling is prohibited in the last two-thirds of diastole in constrictive pericarditis, with preserved abrupt filling in early diastole.

Chronic constrictive pericarditis

Any form of pericarditis may end in constrictive pericarditis, presenting with chronic fatigue, dyspnoea, jugular distension, proto-diastolic pericardial knock, hepatomegaly, ascites, peripheral oedema, and pleural effusion. Atrial fibrillation is a common finding, and diffuse flattened or negative T-waves are usually present. These suggestive clinical findings, in addition to a physiology of restriction or constriction on echocardiography, and the presence of a thickened pericardium provide the diagnosis. However, a thickened pericardium may be absent, which does not rule out constrictive pericarditis. Pericardiectomy is the only effective treatment, which should be instituted shortly after diagnosis, as surgical mortality increases with increasing age and functional impairment.

Table 8.3.1: Differential diagnosis between chronic constrictive pericarditis and restrictive cardiomyopathy.
Constrictive Pericarditis	Restrictive Cardiomyopathy
Physical Examination
Early diastolic precordial impulse	Apical impulse may be prominent
Pericardial Knock
No murmur	Third sound may be present Regurgitant murmur common
Electrocardiography
Low voltage Frequent atrial fibrillation Normal QRS complex	Low voltage in amiloidosis Frequent atrial fibrillation Bundle branch block
Chest Radiography
Pericardial calcification possible	Non-specific cardiomegaly
Echocardiography
Normal wall thickness	Pericardial thickening
Diastolic notch of interventricular septum
Increased wall thickness (amyloidosis)	Enlarged left and right atria
Doppler studies e' septal =8 cm/sec and normal S' mitral annular velocity
Mitral inflow increase during expiration Mitral flow propagation velocity M-mode colour =45cm/s Increased diastolic flow reversal in the hepatic vein with expiration e' septal <8cm/s and decreased mitral annular velocity	Mitral inflow velocity without respiratory variation Mitral flow propagation velocity M-mode colour <45cm/s Increased diastolic flow reversal in the hepatic vein with inspiration
Cardiac catheterization
RVEDP and LVEDP usually equal RV systolic pressure <50mmHg	RVEDP >one-third of RV systolic pressure LVEDP often >5mm greater than RVEDP
Endomyocardial biopsy
Normal or non-specific changes	May reveal specific causes
CT/MR imaging
Pericardium thickened or calcified	Normal pericardium
CT, computer tomography; e', e wave velocity by tissue velocity imaging;
LVEDP, left ventricular end-diastolic pressure; MR, magnetic resonance;	RV, right ventricular; RVEDP, right ventricular end-diastolic pressure.

Subacute elastic constriction

Elastic cardiac constriction, in contrast to the rigid chronic constriction, results from an elastic thickened pericardium, which still allows distension during the respiratory cycle. It may be seen in the first period after acute inflammatory or infectious pericarditis, and may progress to chronic pericardial constriction, or prove to be a transient process.

Effusive-constrictive pericarditis

Presenting with cardiac tamponade on admission, effusive-constrictive pericarditis is characterized by a persistent increase in right atrial and end-diastolic ventricular pressures after intrapericardial pressure has been alleviated by pericardiocentesis. Apart from idiopathic cases, it may accompany chest radiation, cardiac surgery, neoplasia, and tuberculosis. Most frequently, the disease will progress to persistent constriction for which epicardiectomy is indicated, but it may rarely be a transient phenomenon.

Transient cardiac constriction

Clinical and hemodynamic features of constrictive pericarditis may dissipate spontaneously, which is seen commonly (20%) in idiopathic acute pericarditis with effusion, but may also be seen in tuberculous and purulent pericarditis. Hence, a primarily conservative approach may alleviate the need for epicardiectomy.

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Chronic constrictive pericarditis

Subacute elastic constriction

Effusive-constrictive pericarditis

Transient cardiac constriction

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