**4. Constrictive pericarditis**

Constrictive pericarditis is a result from inflammation and fibrosis of the pericardium leading to diastolic dysfunction and right heart failure. Generally speaking, constrictive pericarditis is irreversible, and once the diagnosis is made, surgical pericardiectomy is indicated in patients with symptoms of heart failure.

In Western countries, the etiology of constrictive pericarditis is mainly idiopathic, presumably unrecognized prior viral pericarditis. Previous cardiac surgery and prior mediastinal radiation therapy are becoming more popular. On the other hand, tuberculosis is a major cause of constrictive pericarditis in developing countries.

In constrictive pericarditis, Kussmaul sign and pericardial knock are common physical findings. Electrocardiogram may show low voltages, non-specific ST-T changes, or atrial fibrillation. Chest X-ray shows pericardial calcification in onethird of the cases.

**7**

logic study.

**5.2 Pericardiectomy**

tubes are placed in the pleural space.

*Prologue: Introduction to Advanced Concepts in Pericardial Disease*

medical therapy

3–6 months

*Definition and therapy for constrictive pericarditis.*

**Syndrome Definition Therapy**

Reversible pattern of constriction following spontaneous recovery or

Failure of the right atrial pressure to fall by 50% or to a level below 10 mmHg after pericardiocentesis

Persistent constriction after

pressures usually equal, and ventricular independence.

**5. Surgical treatment for pericardial disease**

**5.1 Pericardial window**

For the diagnosis of constrictive pericarditis, transthoracic echocardiography and chest X-ray with adequate technical characteristics are recommended in all patients with suspected constrictive pericarditis. Echocardiography may show septal bounce, pericardial thickening and calcifications, respiratory variation of the mitral peak E velocity of >25% and variation in the pulmonary venous peak D flow velocity of >20%, or color M-mode flow propagation velocity > 45 cm/s. Computed tomography and cardiac magnetic resonance imaging are indicated as second-level imaging techniques to assess calcifications, pericardial thickness (3–4 mm), degree, and extension of pericardial involvement (**Figure 2**). Cardiac catheterization may show "dip and plateau" sign, right ventricular diastolic and left ventricular diastolic

2–3 months of empiric anti-inflammatory

Pericardiocentesis followed by medical therapy. Surgery for persistent cases

Pericardiectomy, medical therapy for advanced cases or high risk of surgery, or mixed forms with myocardial involvement

drugs

The definitions and therapy of the main constrictive pericarditis are listed in **Table 3**.

A pericardial window is the procedure to create a communication from the pericardial space to the pleural space. The purpose of this procedure is to allow a pericardial effusion (usually malignant) to drain from the pericardial space into the chest cavity to prevent a large accumulation of pericardial fluid and cardiac tamponade. Subxiphoid pericardial window is done by either local or general anesthesia. A vertical incision about 4 cm is made over the xiphoid process and upper abdomen. The diaphragm is dissected away from the undersurface of the sternum and xiphoid, fat is removed from over the pericardium, and the pericardium is opened under direct vision. All fluid is aspirated, and loculations may be broken up gently with the sucker. As large a pericardial window as possible is made by excision of the pericardium. Pericardial tissue and fluid are sent for bacteriologic and histo-

Another way to do a pericardial window is via a left anterolateral approach. A small left anterolateral incision is made, and a simple pericardial window is created, usually of necessity anterior to the phrenic nerve. After evacuation of fluid, chest

Pericardiectomy is indicated in patients with symptomatic constrictive pericarditis, especially those patients requiring increasing doses of diuretics. It is also

*DOI: http://dx.doi.org/10.5772/intechopen.86164*

Transient constriction

Effusiveconstrictive pericarditis

Chronic constriction

**Table 3.**

**Figure 2.** *Cardiac magnetic resonance imaging shows thickening of the pericardium (arrow).*

*Prologue: Introduction to Advanced Concepts in Pericardial Disease DOI: http://dx.doi.org/10.5772/intechopen.86164*


**Table 3.**

*Inflammatory Heart Diseases*

pneumopericardium.

third of the cases.

**4. Constrictive pericarditis**

etiology in developing countries.

pericardiocentesis or pericardial window is indicated.

tissue diseases, trauma, and metabolic causes (e.g., hypothyroidism). In developed countries, over 50% of the etiology is idiopathic, whereas tuberculosis is the leading

It is recommended that the therapy of pericardial effusion is targeted at the etiology. When pericardial effusion is associated with systemic inflammation, aspirin/ NSAIDs/colchicine, and treatment of pericarditis are recommended. For cardiac tamponade, symptomatic moderate to large pericardial effusions not responsive to medical therapy, and suspicion of unknown bacterial or neoplastic etiology,

The common causes of cardiac tamponade include pericarditis, tuberculosis, iatrogenesis (invasive procedure-related, post-cardiac surgery), trauma, and neoplasm/malignancy. The other causes include autoimmune diseases (systemic lupus erythematosus, rheumatoid arthritis, scleroderma), radiation, post-myocardial infarction, uremia, aortic dissection, bacterial infection, and

Constrictive pericarditis is a result from inflammation and fibrosis of the pericardium leading to diastolic dysfunction and right heart failure. Generally speaking, constrictive pericarditis is irreversible, and once the diagnosis is made, surgical

In Western countries, the etiology of constrictive pericarditis is mainly idiopathic,

pericardiectomy is indicated in patients with symptoms of heart failure.

*Cardiac magnetic resonance imaging shows thickening of the pericardium (arrow).*

presumably unrecognized prior viral pericarditis. Previous cardiac surgery and prior mediastinal radiation therapy are becoming more popular. On the other hand, tuberculosis is a major cause of constrictive pericarditis in developing countries. In constrictive pericarditis, Kussmaul sign and pericardial knock are common physical findings. Electrocardiogram may show low voltages, non-specific ST-T changes, or atrial fibrillation. Chest X-ray shows pericardial calcification in one-

**6**

**Figure 2.**

*Definition and therapy for constrictive pericarditis.*

For the diagnosis of constrictive pericarditis, transthoracic echocardiography and chest X-ray with adequate technical characteristics are recommended in all patients with suspected constrictive pericarditis. Echocardiography may show septal bounce, pericardial thickening and calcifications, respiratory variation of the mitral peak E velocity of >25% and variation in the pulmonary venous peak D flow velocity of >20%, or color M-mode flow propagation velocity > 45 cm/s. Computed tomography and cardiac magnetic resonance imaging are indicated as second-level imaging techniques to assess calcifications, pericardial thickness (3–4 mm), degree, and extension of pericardial involvement (**Figure 2**). Cardiac catheterization may show "dip and plateau" sign, right ventricular diastolic and left ventricular diastolic pressures usually equal, and ventricular independence.

The definitions and therapy of the main constrictive pericarditis are listed in **Table 3**.
