CardiologyTier 2Disease (DEADMAN)

Pericardial disease - constrictive pericarditis

Description

Fibrotic, thickened +/- calcified pericardium -> fixed total cardiac volume
Three consequences:
- Rapid early diastolic filling then abrupt cessation
- Dissociation of intrathoracic from intracardiac pressures
- Ventricular interdependence - one ventricle fills at the other's expense
Presents as right heart failure with clear lungs - the classic trap

Cause	Share of developed-country series
Idiopathic / post-viral	~60%
Post-cardiac surgery	~35%
Post-mediastinal radiotherapy	~30%
Connective tissue disease	~7%
TB or purulent pericarditis	3-15%

Radiation cases follow Hodgkin lymphoma and breast cancer treatment - ask the oncology history
TB dominates in high-burden settings globally

Causes

Mechanism

Rigid pericardial shell -> total cardiac volume fixed
- Inspiration: inc systemic venous return
- -> RV can only fill by displacing the septum leftwards
- -> dec LV filling -> dec LV stroke volume on inspiration
- -> ventricular interdependence
Intrathoracic pressure no longer transmitted to the chambers
- -> Kussmaul's sign (JVP rises on inspiration)

Clinical

Right heart failure with clear lungs
Raised JVP, ascites often out of proportion to peripheral oedema, hepatomegaly
Kussmaul's sign
Pericardial knock - early diastolic, sudden cessation of filling
Pulsus paradoxus is uncommon - that is tamponade

The three-way discrimination

Investigations

Echo: septal bounce, respirophasic septal shift, dilated non-collapsing IVC
- Tissue Doppler e' preserved or high in constriction, low in restriction (annulus paradoxus)
CT/CMR: pericardial thickening >4 mm, calcification, tethering
- Normal pericardial thickness does not exclude constriction
Cath: equalisation of end-diastolic pressures, dip-and-plateau (square root sign), discordant RV/LV systolic pressures on respiration
BNP typically low or normal in constriction, high in restriction

Transient / inflammatory constriction

Trial of anti-inflammatory therapy for 2-3 months - NSAID + colchicine +/- corticosteroid
- Especially if raised CRP or pericardial LGE on CMR
- Can resolve completely without surgery

Symptomatic relief

Chronic established constriction

Pericardiectomy is the only definitive treatment
High perioperative mortality, worst after radiation and in advanced disease - refer early, not late

Avoid

Beta blockers and other rate-slowing drugs
- Stroke volume is fixed - cardiac output is rate-dependent

Transient constriction after acute pericarditis resolves in a minority - worth a trial before operating
Chronic constriction is progressive
Late features: cardiac cachexia, hepatic congestion -> cardiac cirrhosis, protein-losing enteropathy
Pericardiectomy outcomes good if done before end-stage; radiation-associated disease does worst

Monitor

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