What is Constrictive Pericarditis?

The pericardium is a flexible sac that surrounds and protects the heart, and it also influences how the heart works. Constrictive pericarditis is a condition where scar tissue forms in the pericardium, causing it to lose elasticity and makes it harder for the heart to fill with blood. This condition usually develops over time, but there are also instances where it can occur more quickly, temporarily, or without showing obvious symptoms.

What Causes Constrictive Pericarditis?

Across the world, tuberculosis is the biggest cause of a condition known as ‘constrictive pericarditis’, and this is the case for about half of all people with a tuberculosis-related heart problem, even if they’re receiving treatment for tuberculosis. However, in more developed countries, this condition usually results from an unidentified cause or follows a viral infection, making up 40% to 60% of all cases.

Constrictive pericarditis can even be a complication from a heart surgery or from radiation treatments to the chest area, which could affect 2% to 30% of people who undergo these treatments. It is also linked to diseases that affect the body’s connective tissues, like rheumatoid arthritis and systemic lupus erythematosus (SLE).

Although diagnosing constrictive pericarditis might be straightforward sometimes, it’s often hard to figure out what caused it. A large number of cases don’t have a clear cause and are thought to involve an unnoticed episode of viral infection in the pericardium, that’s the sac around the heart.

Risk Factors and Frequency for Constrictive Pericarditis

About 9% of people with acute pericarditis, a heart condition, can develop another condition called constrictive physiology. This is more common in developing countries, particularly due to infections such as tuberculosis. Although it’s rare in adults and even rarer in children, it’s more usual in people who have had heart surgery. The condition tends to happen more in males, with a 3:1 ratio of males to females, and it doesn’t seem to favor any particular race.

Signs and Symptoms of Constrictive Pericarditis

Chronic symptoms often characterize people suffering this condition. These symptoms could be related to too much fluid in the body, such as weight gain and swelling, or a weakened heart, like ongoing tiredness and shortness of breath during physical activity. They might also experience a growing waist size or abdominal discomfort. The latter is usually as a result of fluid build-up in the abdominal cavity or an enlarged liver due to congested blood flow.

During a physical check-up, doctors often notice an increased pressure in the jugular vein (a vein in the neck that helps return blood from the head to the heart). However, this might appear normal in the early stages of constrictive pericarditis, a heart condition. Something interesting to note is that the pressure in the jugular vein does not reduce when a person breathes in deeply – a condition known as Kussmaul’s Sign. This sign is also associated with a disease of the tricuspid valve (one of the four valves in your heart) and right-sided heart failure.

Another thing doctors might notice is pulsus paradoxus, where the blood pressure drops significantly when a person breathes in. This is seen more in patients experiencing cardiac tamponade, another heart condition. An unusual heart sound that comes earlier than the third heart sound – called a pericardial knock – could be heard in about half of the patients. An abdominal examination might reveal the presence of fluid in the abdominal cavity or an enlarged liver. Depending on the cause of these symptoms, signs of prolonged illness like muscle wasting might be evident. Swelling in the lower body, or peripheral edema, might also be present.

  • Weight gain and swelling
  • Ongoing tiredness
  • Shortness of breath during physical activity
  • Increasing waist size
  • Abdominal discomfort
  • Increased pressure in the jugular vein
  • Kussmaul’s Sign
  • Pulsus paradoxus
  • Pericardial knock (unusual heart sound)
  • Fluid in the abdominal cavity or enlarged liver
  • Signs of prolonged illness like muscle waste
  • Swelling in the lower body

Testing for Constrictive Pericarditis

The American College of Cardiology and the European Society of Cardiology both recommend using an echocardiogram, a type of ultrasound, to diagnose constrictive pericarditis (a condition where the pericardium, a thin sac that covers the heart, becomes tight and rigid) as well as other heart problems. This method can show changes in the pericardium, including thickening and calcification, and also spot abnormalities in the inferior vena cava, a large vein that carries deoxygenated blood from the lower part of the body to the heart.

An M-mode echocardiogram, which provides a single-dimensional view of the heart, can help rule out constrictive pericarditis. If certain features usually linked with the condition are absent in the result, then it’s very likely that the patient does not have constrictive pericarditis.

A Doppler ECHO, which shows how blood flows within the heart, can also provide helpful information. For example, it can show unusual patterns in how the heart ventricles fill with blood as well as abnormal changes in blood flow speed across the tricuspid valve and pulmonary veins.

An electrocardiogram (ECG), a test that measures the electrical activity of the heartbeat, might also be used but it doesn’t reveal specific signs of constrictive pericarditis. Although, in severe or long-term cases, it may show irregular heartbeat due to high atrial pressures.

Additional imaging tests, like CT scans and cardiac MRI, are often done, especially before surgery. CT scans can reveal calcifications or thickening in the pericardium more clearly. On the other hand, cardiac MRI is great for differentiating between small fluid buildups and pericardial thickening. Any signs of myocardial fibrosis or atrophy—conditions where the heart muscle becomes scarred or wastes away—seen on these tests could mean a poorer surgical outcome.

In some cases, right heart catheterization might be performed to study the heart’s blood flow and pressure. This can reveal increased pressure in the right atrium and right ventricle, distinct fluid-pressure patterns, and a larger than normal drop in pulmonary capillary wedge pressure compared to the left ventricular diastolic pressure during inhalation.

Treatment Options for Constrictive Pericarditis

Pericardiectomy, the procedure of removing the pericardium (a protective layer surrounding the heart), is the ultimate treatment for chronic constrictive pericarditis, a heart condition where this layer becomes thick and rigid. Doctors aim to remove as much of the pericardium as they can during this surgery. However, the presence of extensive fibrous tissue and calcium build-up in the heart muscle itself can make the chances of a successful outcome less likely. The risk of death from the surgery varies widely, from as high as 55% to as low as 10%.

Therefore, this procedure should be undertaken with great caution in patients who either have less severe symptoms or are affected by advanced illnesses along with this condition because of the high risk related to the procedure. Water pills, known as diuretics, can be used either before surgery to reduce swelling or high blood pressure, or to manage symptoms in patients who are not good candidates for surgery.

That said, some patients may see their disease resolve on its own or react positively to medicines alone. This situation is referred to as transient constrictive pericarditis. Stable patients recently diagnosed with constrictive pericarditis who don’t show symptoms of chronic disease may be treated with anti-inflammatory medications for up to three months while being closely monitored. If these patients start showing symptoms of advancing disease and become unstable, surgery should be promptly considered.

  • Heart tumor (Cardiac sarcoma)
  • Pressure on the heart due to fluid accumulation (Cardiac tamponade)
  • Heart enlargement that affects its functioning (Dilated cardiac myopathy)
  • HIV and AIDS infections
  • Iron overload disorder (Hemochromatosis)
  • Kidney disorder marked by excess protein in urine (Nephrotic syndrome)
  • Ovarian cancer
  • Fluid around the heart (Pericardial effusion)
  • An inflammatory disease that affects many organs (Sarcoidosis)
  • Backflow of blood into the right upper heart chamber (Tricuspid regurgitation)

Possible Complications When Diagnosed with Constrictive Pericarditis

Here are some serious conditions that could result:

  • High blood pressure in the lungs (Pulmonary hypertension)
  • Enlarged liver (Hepatomegaly)
  • Failure of the kidneys to function properly (Renal failure)
  • A chemical imbalance in the body caused by too much acid in the blood (Metabolic acidosis)
  • Not enough oxygen reaching the body’s tissues (Hypoxia)
  • A severe drop in blood pressure leading to inadequate blood flow to the body (Shock)
  • Death
Frequently asked questions

Constrictive pericarditis is a condition where scar tissue forms in the pericardium, causing it to lose elasticity and makes it harder for the heart to fill with blood.

Constrictive pericarditis is common and can be caused by various factors such as tuberculosis, viral infections, heart surgery, radiation treatments, and diseases affecting connective tissues.

Signs and symptoms of Constrictive Pericarditis include: - Weight gain and swelling - Ongoing tiredness - Shortness of breath during physical activity - Increasing waist size - Abdominal discomfort - Increased pressure in the jugular vein - Kussmaul's Sign (pressure in the jugular vein does not reduce when breathing in deeply) - Pulsus paradoxus (significant drop in blood pressure when breathing in) - Pericardial knock (unusual heart sound) - Fluid in the abdominal cavity or enlarged liver - Signs of prolonged illness like muscle wasting - Swelling in the lower body (peripheral edema)

Constrictive pericarditis can be caused by tuberculosis, unidentified causes or viral infections, heart surgery or radiation treatments, diseases affecting connective tissues, and unnoticed episodes of viral infection in the pericardium.

The doctor needs to rule out the following conditions when diagnosing Constrictive Pericarditis: 1. Heart tumor (Cardiac sarcoma) 2. Pressure on the heart due to fluid accumulation (Cardiac tamponade) 3. Heart enlargement that affects its functioning (Dilated cardiac myopathy) 4. HIV and AIDS infections 5. Iron overload disorder (Hemochromatosis) 6. Kidney disorder marked by excess protein in urine (Nephrotic syndrome) 7. Ovarian cancer 8. Fluid around the heart (Pericardial effusion) 9. An inflammatory disease that affects many organs (Sarcoidosis) 10. Backflow of blood into the right upper heart chamber (Tricuspid regurgitation)

The types of tests that are needed for Constrictive Pericarditis include: 1. Echocardiogram (ultrasound) to diagnose and show changes in the pericardium, as well as abnormalities in the inferior vena cava. 2. M-mode echocardiogram to rule out constrictive pericarditis by checking for certain features associated with the condition. 3. Doppler ECHO to show abnormal blood flow patterns and changes in blood flow speed across the tricuspid valve and pulmonary veins. 4. Electrocardiogram (ECG) to measure the electrical activity of the heartbeat, although it doesn't reveal specific signs of constrictive pericarditis. 5. Additional imaging tests like CT scans and cardiac MRI to reveal calcifications, thickening, and differentiate between fluid buildups and pericardial thickening. 6. Right heart catheterization to study blood flow and pressure in the heart. 7. In some cases, surgery called pericardiectomy may be performed to remove the pericardium.

Constrictive pericarditis can be treated through a procedure called pericardiectomy, which involves removing the pericardium, the protective layer surrounding the heart. This surgery aims to remove as much of the pericardium as possible. However, the presence of extensive fibrous tissue and calcium build-up in the heart muscle can make the chances of a successful outcome less likely. Therefore, the procedure should be undertaken with caution, especially in patients with less severe symptoms or advanced illnesses. Water pills, or diuretics, can be used to manage symptoms or reduce swelling and high blood pressure before surgery. In some cases, the disease may resolve on its own or respond well to medications alone, known as transient constrictive pericarditis. Stable patients recently diagnosed with constrictive pericarditis may be treated with anti-inflammatory medications while closely monitoring their condition. Surgery should be considered promptly if symptoms worsen and the patient becomes unstable.

The side effects when treating Constrictive Pericarditis can include: - High blood pressure in the lungs (Pulmonary hypertension) - Enlarged liver (Hepatomegaly) - Failure of the kidneys to function properly (Renal failure) - A chemical imbalance in the body caused by too much acid in the blood (Metabolic acidosis) - Not enough oxygen reaching the body's tissues (Hypoxia) - A severe drop in blood pressure leading to inadequate blood flow to the body (Shock) - Death

The prognosis for constrictive pericarditis can vary depending on the underlying cause and the severity of the condition. In some cases, treatment with medications or surgery can provide relief and improve symptoms. However, if left untreated or if the condition is severe, it can lead to complications such as heart failure and a poor prognosis.

A cardiologist.

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