Sections View Full Chapter Figures Tables Videos Full Chapter Figures Tables Videos Supplementary Content + Print Section ++ For further information, see CMDT Part 10-52: Constrictive Pericarditis + Key Features Print Section ++ ++ Generally caused by inflammation leading to a thickened, fibrotic, adherent pericardium that restricts diastolic filling and produces chronically elevated venous pressures Other causes include post cardiac surgery, radiation therapy and connective tissue disorders. A small number of cases are secondary to trauma, drug induced, asbestosis, sarcoidosis or uremia Causes Cardiac surgery Radiation therapy Connective tissue disorders Some cases secondary to Trauma Drugs Asbestosis Sarcoidosis Uremia May coexist with pericardial tamponade, a condition also referred to as effusive-constrictive pericarditis + Clinical Findings Print Section ++ ++ Slowly progressive dyspnea, fatigue, and weakness Chronic edema, hepatic congestion, and ascites out of proportion to degree of peripheral edema Elevated jugular venous pressure with a rapid y descent Failure of jugular venous pressure to fall during inspiration (Kussmaul sign) Pericardial knock in early diastole Atrial fibrillation is common Pulsus paradoxus is unusual + Diagnosis Print Section ++ ++ Chest radiograph Normal heart size or cardiomegaly Pericardial calcification is rare since TB is cause less often; best seen on lateral view Echocardiography Rarely demonstrates thickened pericardium Septal bounce, respiratory fall in mitral Doppler filling pattern useful CT and MRI may be more sensitive than echocardiography, but can only identify a thickened pericardium when it is > 4 mm Cardiac catheterization: Right atrium (RA) Elevated pressure with y descent > x descent Kussmaul sign (lack of fall of RA pressure with inspiration) “Square root" diastolic pressures in both RV and LV Equalization of diastolic pressures RV end-diastolic pressure > one-third of RV systolic pressure Evidence of RV-LV interaction (discordance in RV/LV systolic pressures with inspiration) Area of RV/LV pressure tracing ratio that decreases with inspiration The only definitive way to diagnose effusive-constrictive pericarditis is to reveal the underlying constrictive physiology once the pericardial fluid is drained + Treatment Print Section ++ ++ Should be aimed at the specific etiology initially Anti-inflammatory medications may have a role if there is evidence of ongoing inflammation Diuretics Mainstay of treatment once hemodynamics are determined Should be aggressive, using loop diuretics (oral torsemide or bumetanide if bowel edema is suspected), thiazides, and aldosterone antagonists (especially in the presence of ascites and hepatic congestion) Pericardiectomy Should be recommended when diuretics are unable to control symptoms Removes only the pericardium between the phrenic nerve pathways However, most patients still require diuretics after the procedure, although symptoms are usually dramatically improved Morbidity and mortality are high (up to 15%) and are greatest in those with the most disability prior to the procedure