C.Richard Conti,MD

1 University of Florida Medical School,Gainesville,FL,USA

Abstract

Keywords:chronic constrictive pericarditis;chronic effusive pericarditis;pericarditis;surgical treatment

Chronic pericarditis is inflammation that begins gradually,is long lasting,and results in fluid accumulation in the pericardial space or thickening of the pericardium.There are two main types of chronic pericarditis:1) chronic effusive pericarditis;fluid slowly accumulates in the pericardial space between the two layers of the pericardium,but,the visceral pericardium is constricting the heart and 2) chronic constrictive pericarditis;a rare disease that usually results when scar or fibrous tissue forms throughout the pericardium.The fibrous tissues tends to contract over the years compressing the heart,thus the heart as viewed on a chest X-Ray does not enlarge as it does in most types of heart diseases.

Etiology of Chronic Effusive Pericarditis and Chronic Constrictive Pericarditis

Usually the cause of chronic effusive pericarditis is unknown but it may be cancer,tuberculosis or hypothyroidism.The cause of chronic constrictive pericarditis is also unknown,the most common known causes are viral infection and radiation therapy for breast cancer or lymphoma.Previously tuberculosis was the most common cause of chronic pericarditis in the US but today tuberculosis accounts for only 2% of cases.In Africa and India,tuberculosis is still the most common cause of all forms of pericarditis.

Hemodynamics of Chronic Pericarditis

As virtually all filling of the ventricles,occur very early in diastole.In patients with chronic pericarditis the pattern of filling is a characteristic dip and plateau ( √) waveforms.The early diastolic dip corresponds to the period of rapid filling,while the plateau corresponds to the period of mid and late diastole when there is little additional ventricular volume expansion.In some patients,systemic venous pressure may actually increase with inspiration i.e.Kussmaul’ s sign.Talreja et al.[1]reported LV and RV high-fidelity manometer pressure traces in a patient with constrictive pericarditis.During inspiration there is an increase in the area of the RV pressure curve.The area of the LV pressure curve decreases during inspiration as compared with expiration.They also found a patient with restrictive myocardial disease who showed a decrease in the area of the RV pressure curve during inspiration as compared with expiration.The area of the LV pressure curve was unchanged during inspiration as compared with expiration.

Chest X-ray

On occasion,patients show calcium around the heart,best seen in the left lateral position.If fluid is removed by pericardiocentesis the cardiac silhouette may be normal is size.

Arrhythmias

Atrial fibrillation occurs in almost half the patients with chronic pericarditis and may be related to pericardial calcification or atrial myocardial inflammation.

Symptoms

Symptoms of chronic pericarditis include shortness of breath,coughing and fatigue.Coughing occurs because of high pressure in the pulmonary veins,fatigue occurs because of decreased cardiac output when the demand increases.Ascites and peripheral edema are common and related to increased RA pressure and protein loss.Pleural effusions occur occasionally.This condition may produce few symptoms if fluid accumulates slowly.The reason for slow accumulation of fluid is that the pericardium can stretch gradually.However if fluid accumulates rapidly,the heart can become compressed and cardiac tamponade may occur.

Physical Findings

Physical findings are often due to the insidious development of ascites and hepatomegaly.Patients with ascites are often mistakenly thought to have hepatic cirrhosis or intra-abdominal tumor.A summary of the physical findings in chronic pericarditis includes 1) elevated atrial venous pressure is almost the universal finding and 2) sinus arrhythmia or atrial fibrillation is often seen,3) hepstosplenomegaly with prominent hepatic pulsations,asities and peripheral edema is a common finding,4) Auscultation often reveals a characteristic diastolic pericardial “ Knock” (an early diastolic sound,heard along the left sternal border following S2).It represents the sudden cessation of ventricular diastolic filling imposed by the rigid pericardium.

Problems in Diagnosis

There are several reasons for missing the diagnosis of chronic pericarditis.These include

1.Diagnosis is not considered.

2.Primary manifestations of chronic pericarditis are obscured by secondary symptoms and physical findings.

3.Other cardiac disease obscuring the presence of chronic pericarditis.

Non-Surgical Therapy

For patients with any form of chronic pericarditis,bed rest,restriction of salt in the diet,anti- inflammatory agents and diuretics may diminish symptoms.However,the only cure is surgical removal of the pericardium,including the visceral pericardium when identified as the cause for constriction.

Surgery of Chronic Pericarditis

Surgery is not performed before significant symptoms appear.Surgery cures about 85% of people.However,the risk of death from surgery is 5- 15%.For this reason most do not have surgery unless the disease substantially interferes with daily activities.Whether surgery is recommended during the active effusive-constrictive phase or during the later chronic constrictive phase is not easily determined.The highest risk of pericardial surgery is associated with removing the visceral pericardium.

Contraindications to Surgery (Pericardiectomy)

Pericardiectomy probably should not be routinely attempted in very elderly patients with severe liver dysfunction,cachexia,densely calcified pericardium and massive cardiac enlargement indicative of underlying myocardial damage or in patients with limited life expectancy.Complete resection of the pericardium is usually attempted,(e.g.phrenic nerve to phrenic nerve).

In many patients,the return to improved hemodynamics may be delayed from weeks to months after surgery and can be attributed to incomplete pericardial resection,or myocardial atrophy or fibrosis caused by an inflammatory process.The easiest surgery probably involves removing the pericardium when there is fluid present in the pericardial sac and the patient is without the risk factors noted above.However the visceral pericardium may be the cause of the patient’ s symptoms and thus it must be removed as well as the parietal pericardium.

Chronic Effusive Pericarditis

This is a rare special type of pericarditis observed many years ago by Burchell [2],Spodick and Kumar [3]and later well characterized by Hancock [4],who reported 13 patients.These patients demonstrated a unique pathophysiologic form of compressive pericardial disease characterized by effusion into free pericardial space associated with constriction of the heart by the visceral pericardium.The natural history of effusive-constrictive pericarditis appears to progress on to non-effusive chronic constrictive pericarditis,usually in less than a year [5].However,some patients,especially those who received antiinflammatory therapy after pericardiocentesis can remain stable for many years.This suggests that these patients have a reversible inflammatory cause for the hemodynamic abnormalities seen in effusive constrictive pericarditis and may respond very well to medical therapy.Removing the constricted visceral pericardium is not as easy as removing the parietal pericardium.However,since the visceral pericardium may be the cause of the patient’ s symptoms it should be removed along with the parietal pericardium.