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Constrictive Pericarditis

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Updated February 12, 2013

Written or reviewed by a board-certified physician. See About.com's Medical Review Board.

The pericardium (also called the pericardial sac) is the pouch of tissue that encloses the heart, and helps to protect it from infection and trauma. Normally the pericardium is a very elastic structure. This "stretchiness" allows it to expand along with the heart during diastole, (the phase of the heartbeat in which the ventricles fill with blood). In some medical conditions the pericardium loses this normal elasticity, and it can no longer stretch as the heart fills. The "stiff" pericardium can constrict the normal filling of the heart. This condition is called constrictive pericarditis.

What Causes Constrictive Pericarditis?

Any disease process that affects the pericardium can lead to a loss of elasticity and produce constrictive pericarditis. This is especially true for conditions that produce acute pericarditis. The most common conditions that may cause constrictive pericarditis include:
  • Infection. Viral infections are the most common cause of acute pericarditis, but tuberculosis, or bacterial or fungal infections can also produce this condition. Any of these infections involving the pericardium can lead to constrictive pericarditis.
  • Collagen vascular diseases, such as lupus, can produce constrictive pericarditis.
  • Cardiac surgery. Surgical procedures can lead to scarring of the pericardial sac, producing constrictive pericarditis.
  • Radiation therapy. Radiation therapy to the chest area - usually in the treatment of Hodgkin disease or breast cancer - can cause constrictive pericarditis.
  • Other conditions that can occasionally produce constrictive pericarditis include cancer, asbestosis, chest trauma, kidney failure, or sarcoidosis.

What Are The Symptoms Of Constrictive Pericarditis?

With constrictive pericarditis, cardiac filling is restricted. When the heart is unable to fill completely, two general kinds of problems may result:

First, the amount of blood pumped with each heart beat is diminished. This causes the heart to beat faster in an attempt to keep up with the body's needs. The resulting tachycardia can produce palpitations. Further, because the amount of blood being pumped with each heart beat is reduced, patients with constrictive pericarditis become tired and fatigued more easily, their energy is reduced, and they often experience dyspnea (shortness of breath).

Second, because the heart is constricted, the blood being returned to the heart tends to "dam up" in the veins, and consequently the pressure within the veins becomes elevated. This elevation in venous pressure leads to fluid retention and to edema (swelling), most often in the legs. However, this elevated venous pressure also causes a back-up of blood in the liver, which can lead to fluid accumulation in the belly - a condition called ascites. If the elevated pressure in the liver is persistent enough and severe enough, liver failure may eventually occur. (For this reason, constrictive pericarditis should be considered a possibility any time unexplained ascites or reduced liver function is present.)

How Is Constrictive Pericarditis Diagnosed?

Doctors usually are alerted to the possibility of constrictive pericarditis by the patient's symptoms, and by exposure to any of the medical problems known to produce this condition. Once the constrictive pericarditis is suspected, usually it can be readily diagnosed by performing an echocardiogram. Especially if surgical treatment is being contemplated (see below), a heart catheterization and/or an MRI study can not only help to pin down the diagnosis, but also can reveal the nature and degree of damage to the pericardium.

There are at least two other medical conditions - cardiac tamponade, and restrictive cardiomyopathy - whose symptoms can closely mimic the symptoms of constrictive pericarditis. Because the treatments used in these three conditions are quite different from one another, it is important for the doctor to make a definitive diagnosis. Usually, a carefully performed echocardiogram can clearly differentiate among these three conditions.

How Is Constrictive Pericarditis Treated?

In people who have mild to moderate constrictive pericarditis which is of recent onset, the elasticity of the pericardial sac can return toward normal when the underlying disease process is adequately treated. These "reversible" forms of constrictive pericarditis require an underlying cause that is potentially treatable - such as infection, collagen vascular disease, or cancer. If the underlying cause can be adequately treated, mild constrictive pericarditis is likely to resolve over a period of weeks to months.

For many people who have constrictive pericarditis, however, especially if symptoms are significant, surgical treatment is necessary. This surgery - called pericardiectomy - involves removing all or most of the pericardium in order to relieve the constriction of the heart. Pericardiectomy is a major surgical procedure, and because of the extent of the surgery required it can carry significant risk. In patients with severe and long-lasting constrictive pericarditis, especially if liver failure is already evident, the risk of surgery can be prohibitive. However, in patients with less severe constrictive pericarditis, the pericardiectomy can entirely relieve this condition and its symptoms.

Summary

Constrictive pericarditis is a serious medical condition that can affect both the heart and the liver. It is critical to make the correct diagnosis as early as possible, while treatment can still prevent irreversible damage.

Sources:

Ling LH, Oh JK, Schaff HV, et al. Constrictive pericarditis in the modern era: evolving clinical spectrum and impact on outcome after pericardiectomy. Circulation 1999; 100:1380.

Maisch B, Seferovic PM, Ristic AD, et al. Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology. Eur Heart J 2004; 25:587.

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