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Constrictive Pericarditis – Causes and Treatment

Constrictive pericarditis is a chronic heart condition in which the pericardium becomes scarred and thickened, restricting the heart from filling properly.

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Things worth knowing about "Constrictive Pericarditis"

Constrictive pericarditis is a chronic heart condition in which the pericardium becomes scarred and thickened, restricting the heart from filling properly.

What is Constrictive Pericarditis?

Constrictive pericarditis is a chronic condition of the pericardium – the fibrous sac surrounding the heart – in which scarring, thickening, and often calcification of the pericardial layers occur. These structural changes prevent the heart from expanding and filling normally with blood during each heartbeat, leading to progressively impaired cardiac function. Unlike acute pericarditis, constrictive pericarditis develops slowly over months to years.

Causes

In many cases, no specific cause can be identified (idiopathic form). Known causes include:

Previous pericarditis (inflammation of the pericardium) – the most common cause in developed countries
Tuberculosis – the leading cause worldwide, particularly in developing countries
Cardiac surgery or procedures (post-operative pericarditis)
Radiation therapy to the chest area (e.g., for lymphoma or breast cancer)
Autoimmune diseases such as systemic lupus erythematosus or rheumatoid arthritis
Infections caused by viruses, bacteria, or fungi
Renal failure (uremic pericarditis)
Malignancies involving the pericardium

Symptoms

Symptoms arise from restricted cardiac filling and the resulting backup of blood in the venous circulation:

Shortness of breath (dyspnea), especially during physical activity
Fatigue and weakness
Fluid retention in the abdomen (ascites) and legs (edema)
Distended neck veins (elevated venous pressure)
Enlarged liver (hepatomegaly)
Weight gain due to fluid accumulation
Kussmaul sign: a paradoxical rise in venous pressure during inhalation (clinically characteristic)

Diagnosis

Diagnosing constrictive pericarditis requires a combination of clinical assessment and imaging studies:

Physical Examination

Typical findings include distended neck veins, peripheral edema, abdominal swelling, and a characteristic early diastolic sound known as a pericardial knock heard on cardiac auscultation.

Imaging Studies

Echocardiography: Identifies pericardial thickening, restricted cardiac filling, and characteristic filling patterns
CT (Computed Tomography): Best method for visualizing pericardial thickening and calcifications
MRI (Magnetic Resonance Imaging): Helps differentiate constrictive pericarditis from restrictive cardiomyopathy
Chest X-ray: May reveal pericardial calcifications
Cardiac catheterization: Demonstrates characteristic hemodynamic patterns (equalization of filling pressures)

Laboratory Tests

Blood tests can provide information about underlying inflammation, renal function, or associated diseases, but are not specific to diagnosing constrictive pericarditis.

Treatment

Conservative Management

In mild or early cases, anti-inflammatory medications such as colchicine, NSAIDs, or corticosteroids may be used to reduce inflammation. Diuretics help manage fluid retention and relieve symptoms.

Surgical Treatment: Pericardiectomy

The only curative treatment for advanced constrictive pericarditis is surgical removal of the thickened pericardium, known as pericardiectomy. During this procedure, the scarred pericardial tissue is largely or completely removed to relieve the mechanical restriction on the heart. The operation is typically performed via median sternotomy and carries a mortality rate of approximately 5–10%, depending on disease severity and the overall condition of the patient. Full recovery of cardiac function after surgery may take several months.

Prognosis

The prognosis depends on the underlying cause, disease severity, and timing of treatment. Early surgical intervention significantly improves long-term outcomes. Without treatment, cardiac function deteriorates progressively over time.

References

Adler Y et al. - 2015 ESC Guidelines for the diagnosis and management of pericardial diseases. European Heart Journal, 2015; 36(42): 2921-2964.
Imazio M, Brucato A, Mayosi BM et al. - Medical therapy of pericardial diseases. Journal of Cardiovascular Medicine, 2010; 11(10): 712-722.
Bertog SC, Thambidorai SK, Parakh K et al. - Constrictive pericarditis: etiology and cause-specific survival after pericardiectomy. Journal of the American College of Cardiology, 2004; 43(8): 1445-1452.

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