Constrictive Pericarditis, restrictive pericarditis

1. CONSTRICTIVE
PERICARDITIS

3. EFFUSION SEQUEL
• Cardiac tamponade: acute or
subacute(Variants include low
pressure (occult) and regional
tamponade.
• Constrictive pericarditis: chronic,
subacute, transient, and occult
constriction.
• Effusive-constrictive pericarditis
– a mixed hemodynamic picture with
features of both constriction and
tamponade.

4. CAUSES
• Idiopathic or viral  42 - 49 %
• Post-cardiac surgery  11 to 37 %
• Post-radiation therapy  9 to 31 %, (Hodgkin or breast ca.)
• Connective tissue disorder  3 to 7 %
• Postinfectious (tuberculous or purulent)  3 to 6 %
• Miscellaneous causes  1 to 10 %
– (malignancy, trauma, drug-induced, asbestosis, sarcoidosis, uremic pericarditis)

5. PREVELANCE
• Idiopathic/viral – 0.76 cases per 1000 person/yr
• Connective tissue/pericardial injury syndrome
– 4.40 cases per 1000 person/yr
• Neoplastic– 6.33 cases per 1000 person/yr
• Tuberculous– 31.65 cases per 1000 person/yr
• Purulent– 52.75 cases per 1000 person/yr

6. PRESENTATION
• Symptoms related to fluid
overload, ranging from peripheral
edema to anasarca
• Symptoms related to diminished
cardiac output in response to
exertion, such as fatigability and
dyspnea on exertion

7. Physical examination
• Elevated JVP has been reported in 93%
• Pulsus paradoxus 20%
• Kussmaul's sign 13%-21%
• A pericardial knock 47%
• Profound cachexia, peripheral edema, ascites,
pulsatile hepatomegaly and pleural
effusion are common findings .

8. EVALUATION
• Electrocardiography (no
pathognomonic findings.)
• Chest radiograph
• Echocardiography
– M Mode
– 2 dimensional ECHO
– Doppler
• CT scan (>4 mm) in 72 %
• MRI *
• Pro BNP (less than in other
types of cardiomyopathy)

9. CONSTRICTIVE VS. RESTRICTIVE
constrictive pericarditis restrictive cardiomyopathy
Doppler ECHO Respiratory
variation in ventricular
inflow velocities
increase in respiratory
variation of the ventricular
inflow velocities in patients
with compared to a in
patients
normal pattern
Hepatic venous flow
reversal
usually reverses during
expiration in constrictive
pericarditis
reverses during inspiration
in restrictive
cardiomyopathy.
Ventricular end-diastolic
pressures
(RVEDP and LVEDP) are
equal or nearly equal
LVEDP is usually higher
than RVEDP in restrictive
cardiomyopathy.

10. OCCULT CONSTRICTIVE
PERICARDITIS
Chest Pain,
Dyspnea
Fatigue
reported in 1977 described 19 patients with a syndrome
called occult constrictive pericardial disease

11. • history of acute pericarditis in 12 patients (which was recurrent in five),
pericardial calcification in 2 patients, and nonspecific repolarization
changes in 16 patients. A plausible cause for pericardial disease was
present in 10
• Saline infusion caused an elevation and equalization of ventricular filling
pressures, and development of pressure waveforms in diastole
characteristic of constrictive pericarditisin the patients presumed to have
occult constriction.
• Ventricular filling pressures and diastolic waveform were unaltered in the
subjects free from heart disease.
• The patients with myocardial disease developed elevated ventricular filling
pressures, but unequally on the two sides.
• Eleven of the symptomatic patients underwent pericardiectomy with
dramatic improvement. All 11 cases had mild gross or histologic evidence
of pericardial disease. The fluid challenge was repeated postoperatively in
five of the patients, with normal hemodynamic findings.
OCCULT CONSTRICTIVE
PERICARDITIS

12. Treatment
• newly diagnosed hemodynamically stable + No chronic
constriction  may be given a trial of conservative
management for 2-3(Grade 2C).
• No chronic constriction (ie, no evidence of cachexia, weight
loss, reduced cardiac output at rest, or hypoalbuminemia
due to protein losing enteropathy and/or impaired hepatic
function due to chronic congestion or cardiogenic cirrhosis
• Treatment had included NSAIDs , steroids, antibiotics,
chemotherapy, and ACEi plus diuretics.

13. • Transient > review of 212 patients with
echocardiographic findings of constrictive
pericarditis, 17 percent had follow-up studies
showing resolution at an interval ranging from
two months to two years
• Chronic symptyomatic  Pericardiectomy
Treatment