Table of ContentsView AllTable of ContentsConstrictive Pericarditis DefinitionCausesSymptomsDiagnosisTreatmentSurgery
Table of ContentsView All
View All
Table of Contents
Constrictive Pericarditis Definition
Causes
Symptoms
Diagnosis
Treatment
Surgery
Constrictive pericarditis is a chronic condition in which the pericardium (the membrane-like sac that encloses the heart), becomes stiffened and inelastic. As a result, cardiac function deteriorates. This condition, which thankfully is quite uncommon, always has serious consequences.
Unfortunately, constrictive pericarditis can “hide” from detection for a long time. The symptoms it produces can develop very gradually, and when they are finally perceived they tend to be similar to symptoms seen with other kinds ofheart disease.
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The pericardial sac—or pericardium—is the fibrous, elastic, fluid-filled sac that encloses and protects the heart. The pericardium limits excessive movement of the beating heart in the chest, lubricates the heart to reduce friction as it works, and protects it from infection.
Certain diseases can produce inflammation within the pericardium (a condition calledpericarditis). If the inflammation persists long enough or becomes particularly severe, eventually the pericardial sac may become scarred and thickened, causing it to lose its elasticity. The stiffened pericardial sac can have the effect of “squeezing” the heart, thus restricting its ability to fill with blood. This condition is called constrictive pericarditis.
With constrictive pericarditis, the amount of blood the heart is able to pump with each heartbeat can become significantly limited, due to the heart’s inability to fill completely. This tends to cause the blood returning to the heart to become “backed up” within the vascular system. For this reason people with constrictive pericarditis often develop significant fluid retention and severeedema(swelling).
Constrictive pericarditis is usually a chronic, progressive disorder; that is, it begins relatively gradually and becomes worse over time. So its symptoms also tend to worsen gradually and can be ignored or written off (say, as “old age”), for months or even years. However, the symptoms become relentlessly worse as time passes and eventually a doctor will hear about them.
Constrictive pericarditis can result from almost any disease or disorder that can cause inflammation in the pericardium. In particular, just about any medical problem that can cause acute pericarditis can also result in constrictive pericarditis. However, constrictive pericarditis is not a common consequence of acute pericarditis—in a study of 500 people who had acute pericarditis, only 1.8 percent of them developed constrictive pericarditis during six years of follow-up.
For reasons that are not at all clear, constrictive pericarditis appears to be a rare event in people who have chronic or recurrent pericarditis. When it occurs, it appears to follow an episode of acute pericarditis.
Thesymptoms of constrictive pericarditistend to feature symptoms common withheart failure, especiallydyspnea(shortness of breath),paroxysmal nocturnal dyspnea, poor exercise tolerance and easy fatiguability, rapid heart rate (tachycardia), andpalpitations. People with constrictive pericarditis can also develop chest pain, steering doctors toward a diagnosis ofcoronary artery diseasewithangina.
Constrictive pericarditis can also produce fluid retention, which can become quite severe. This fluid retention often causes edema in the legs and abdomen. The abdominal edema may become severe enough to cause nausea, vomiting, and liver dysfunction, sending the doctor in the direction of trying to diagnose a gastrointestinal disorder. In fact, there have been cases in which patients referred for liver transplantation because of presumed primary liver failure turned out to have undiagnosed constrictive pericarditis as the underlying cause.
As we have seen, constrictive pericarditis is pretty rare and its onset is often gradual, so it is common for doctors to think first of other medical problems that can cause the same kinds of symptoms, such as heart failure, coronary artery disease, liver disease, or other gastrointestinal conditions.
To complicate things even further, when the doctor becomes focused on the idea that restricted cardiac filling may be the main issue, it turns out that there are several other cardiac conditions that also restrict cardiac filling. These conditions can be quite difficult to distinguish from constrictive pericarditis. They includediastolic heart failure,restrictive cardiomyopathy, andcardiac tamponade.
The real key to diagnosing constrictive pericarditis is, first, for the doctor to think of the possibility in the first place, and then to do the necessary testing to specifically look for it.
CT scanningis useful in clinching the diagnosis. Thickening of the pericardium is easier to detect with a CT scan than with echocardiography. Also, the CT scan often provides information that can be quite useful in planning surgical treatment.
In some cases, however, even with the availability of modern non-invasive techniques, acardiac catheterizationmay be necessary to help confirm the diagnosis of constrictive pericarditis.
Again, the main point is that constrictive pericarditis is correctly diagnosed when the right tests are done, and the doctors performing the tests are alerted to the suspicion that constrictive pericarditis may be present.
However, in some cases, constrictive pericarditis is diagnosed very early in its course. When this is the case, the possibility exists that aggressively treating the underlying cause of the problem can reverse the constrictive pericarditis, and render it a transient condition.
So, if constrictive pericarditis is newly diagnosed in a person whose cardiac symptoms appear to be mild and stable, and in whom the underlying medical condition producing the constrictive pericarditis is judged to be treatable, surgical therapy can be delayed for a few months, while aggressive treatment of the underlying medical disorder is undertaken.
When this course of action is undertaken, with luck the damage to the pericardium can be stopped and even reversed. However, during this period of time, the patient needs to be carefully monitored for signs of deterioration. And, if no improvement is seen within two or three months, surgery should be done. The longer surgery is delayed, the more difficult the treatment is likely to become.
The only effective treatment for most people who have constrictive pericarditis is to surgically remove a substantial portion of the thickened, fibrous pericardial sac—a procedure called pericardiectomy. By removing the thickened pericardium, the heart is no longer constricted, the restriction on cardiac filling is relieved, and the heart itself is freed to begin functioning normally again.
Pericardiectomy surgery also tends to be difficult because the diagnosis of constrictive cardiomyopathy is often missed until the patient is extremely sick, and therefore has a greatly elevated surgical risk. In fact, in people who have end-stage constrictive pericarditis, surgery is more likely to hasten death than to improve things.
Because pericardiectomy is so difficult to perform, and because it is a relatively uncommon procedure, whenever possible it ought to be performed in major cardiac centers where the surgeons have substantial experience with this challenging procedure.
A Word From Verywell
2 Sources
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Imazio M, Brucato A, Maestroni S, et al.Risk of Constrictive Pericarditis After Acute Pericarditis. Circulation 2011; 124:1270. DOI:10.1161/CIRCULATIONAHA.111.018580Vistarini N, Chen C, Mazine A, et al.Pericardiectomy for Constrictive Pericarditis: 20 Years of Experience at the Montreal Heart Institute.Ann Thorac Surg 2015; 100:107. DOI: :10.1016/j.athoracsur.2015.02.054
Imazio M, Brucato A, Maestroni S, et al.Risk of Constrictive Pericarditis After Acute Pericarditis. Circulation 2011; 124:1270. DOI:10.1161/CIRCULATIONAHA.111.018580
Vistarini N, Chen C, Mazine A, et al.Pericardiectomy for Constrictive Pericarditis: 20 Years of Experience at the Montreal Heart Institute.Ann Thorac Surg 2015; 100:107. DOI: :10.1016/j.athoracsur.2015.02.054
Szabó G, Schmack B, Bulut C, et al. Constrictive Pericarditis: Risks, Aetiologies And Outcomes After Total Pericardiectomy: 24 Years Of Experience. Eur J Cardiothorac Surg 2013; 44:1023. doi:10.1093/ejcts/ezt138
Welch TD. Constrictive pericarditis: diagnosis, management, and clinical outcomes. Heart 2018; 104:725. doi:10.1136/heartjnl-2017-311683
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