Chronic Constrictive Pericarditis

Background

• Due to progressive thickening, fibrosis and calcification of the pericardium, causing a restricting filling and ejection defect of the myocardium.
• Often a consequence of TB pericarditis, but can also be caused by/secondary to
  • Haemopericardium
  • Viral pericarditis
  • Purulent pericarditis
  • Rheumatoid arthritis
• Can be idiopathic

Clinical features

• Signs of right heart failure e.g. hepatomegaly, splenomegaly and ascites are common
  • NB Breathlessness is rare (lungs rarely congested)
  • Fatigue is also common
• The JVP is abnormal
  • Raised with abrupt waveform descents (y > x).  May rise further (paradoxically) with inspiration (as in tamponade- Kussmaul’s sign)
• Paradoxical Pulse (abnormal decrease in pulse strength (SBP) during inspiration); pulse will usually be rapid and low
• Auscultation may reveal a ‘pericardial knock’ (early S3).
• A friction rub is actually relatively rare (cf acute disease)

Investigations

• Pericardial calcification may be seen on CXR.  There may also be left and right atrial enlargement.
• Echocardiography (heart function)

NB Can be difficult to differentiate from restrictive cardiomyopathy and further testing e.g. doppler echo or catheter tests may be required to do this

Management

• Pericardectomy is the only definitive treatment.  However, mortality and complication rate is high and it may not benefit every patient.
• Otherwise, treatment is largely supportive