**8. Surgical treatment**

*Inflammatory Heart Diseases*

index (CI): 2.3 l/min/m2

**7. Natural history**

1 month to 10 years even 25 years [2].

Generally, male gender predominance is noted (60–80%), patients have an average age below 40 years; for instance in Morocco (32 years) [18], Ghana (33 years) [22], Senegal (23 years) [20], Gabon (36 years) [23], Cote d'Ivoire (28.8 years) [21], and Ethiopia (24.3 years) [26]. Main clinical findings often due to severe constriction include: hepatomegaly (74–100%), raised jugular venous pressure (76–100%), hepato-jugular reflux (67–100%), ascite (50–76%), peripheral edema (46–79%), complete "Pick Syndrome"(50–76%). Kussmaul sign is less detected (9.8%). In African setting, frequent radiographical findings at chest X-ray are as follows: enlarged cardiothoracic ratio or cardiomegaly (88–47%), calcifications (36–52.5%), and pleural effusion (44–63%); electrocardiography shows invariable modifications such as low QRS voltage (32.5–82.5%), atrial fibrillation (18–46%), and T wave abnormality up to 87.5%. Echocardiography is largely available and is useful for accurate assessment in revealing in most cases a thickened pericardium (56 and 100%), pericardial calcifications in 30.2%, 47.4% of cases according to authors and left ventricular septal motion abnormality (63.6%) with reduced ejection fraction below 0.60 in Rabat, Morocco [19]; cardiac catheterization performed only in a very few centers [21, 24, 25, 27] documents elevation and equalization of diastolic heart pressures with the typical dip-plateau waveform of constrictive pericarditis and evaluate the stroke volume, cardiac output, and myocardial systolic function. It still prevails to be the most final diagnostic assessment in sub-Saharan Africa. In his study, Yangni-Angate et al. [21] reported that cardiac catheterization confirmed a dip-and-plateau (square root sign), an equalization of end-diastolic pressures in right and/or left cardiac chambers ranged between 10 and 40 mmHg, a mean cardiac

(extremes: 1.3–3.6). From this author, the constriction was

limited to the right cardiac cavities called right constriction (n = 54, 45%) or to the right and left cardiac cavities called bilateral constriction (n = 66, 55%) and hemodynamic parameters and cineangiograms confirmed the diagnosis of pericardial constriction in all the patients. Omboga in Nairobi [25] showed the same observation with elevation of intracardial pressures in all cases, raised mean right atrium, enddiastolic right and left ventricular, and elevated mean pulmonary artery pressures at 18, 18, 20, and 27mmHg, respectively. Other imaging studies such as computed tomography and magnetic resonance imaging are rarely prescribed because they are inexistent usually. Those modern imaging techniques could be heavily useful in diagnosing constrictive pericarditis. When done, pericardial biopsy can be contributive for constrictive pericarditis etiology. Laboratory investigations regarding protein-losing enteropathy in patients with chronic constrictive pericarditis are not yet done for Africans. Differential diagnosis is always considered, and distinction from both constrictive pericarditis and restrictive cardiomyopathy due to endomyocardial fibrosis is really the usual situation to be clarified. Endomyocardial fibrosis (EMF) is a tropical heart disease with fibrous endocardial lesions lying in the right and/or the left ventricle. Endoventricular fibrosis is shown and confirmed in all cases

by bi-dimensional echocardiography and angiocardiography [28].

Constrictive pericarditis occurs mostly in our African context after a nondiagnosed, untreated tuberculous or pyogenic pericarditis or even as a sequel of a treated tuberculous pericarditis. Constrictive process starts with an acute pericarditis; then a subacute and chronic pericarditis marked in most of the cases by a fusion of the two layers of the pericardium and an occlusion of the pericardial cavity [3]. The delay from onset clinical symptoms to constriction is widely flexible from

**44**

When diagnosis of constrictive pericarditis is confirmed and surgery is indicated, a pericardiectomy should not be delayed; surgery remains the only efficient and comprehensive treatment option. Pericardiectomy is frequently performed via a median sternotomy approach or a left anterolateral thoracotomy approach; it may be partial or complete. From the African teams' surgical experiences, cardiopulmonary bypass has not been used in all cases and excellent early surgical outcomes were reported.
