Constrictive Pericarditis

Constrictive Pericarditis

• A fibrotic, thickened and adherent pericardium

  • restricts diastolic ventricular filling

Constrictive pericarditis is a result of:

• chronic pericardial inflammation

• fibrosis

• calcification

Common causes of constrictive pericarditis include:

• TB

  • extension from lungs / lymph nodes

• chronic renal failure

• lupus

• s/p cardiac surgery

• s/p MI

• s/p pericardial effusion

• idiopathic

The most common cause of constrictive pericarditis in underdeveloped countries:

Tuberculosis (TB)

What is the most common cause of constrictive pericarditis in the US?

Idiopathic

Symptoms of constrictive pericarditis:

• exertional dyspnea

• JVD

• hepatomegaly

• peripheral edema

• ascites

• tachycardia

• chronic fatigue

Constrictive Pericarditis Auscultation

diastolic pericadial “knock”

constrictive pericarditis CXR finding:

pericardial calcification

constrictive pericarditis EKG finding:

A-fib

constrictive pericarditis Cath lab findings:

• “square root” sign

• simultaneous R&L ventricular diastolic pressure recording w/ a “dip and plateau” pattern

  • early diastolic dip: period of excessively rapid filling

  • plateau: mod to late diastole where there’s little additional ventricular vol expansion

Constrictive pericarditis 2D findings:

• thick calcific pericardium

• normal size ventricle

• enlarged atria

• septal (IVS + IAS) bulge**

  • toward left during inspiration

• “bound down” appearance of free walls

  • best seen A4C

• dilated IVC + HV’s

  • no collapse w/ inspiration

  • Goose Foot Sign**

Normal IVC

• 1.2 - 2.3 cm

• collapse >50%

What view is constrictive pericardial septal bulging best seen in?

A4C & Subcostal

Constrictive pericarditis m-mode findings:

• thick calcific pericardium

• rapid, early ventricular filling may cause:

  • flattening of the LV free wall during mid-late diastole

  • sharp downward motion of the posterior Ao root in early diastole

  • increased / steep E-F slope of the MV

  • exaggerated anterior motion of the IVS

    • “Spanish notch”

• abnormal systolic SM

  • PSM, hypokinetic, akinetic

• premature PV opening

  • seen mid-diastole w/ an increase in RVDP

Why does the IVS have exaggeration motion w/ constrictive pericarditis in m-mode?

b/c the posterior free wall of the LV is unable to expand properly, an increase in LV volume w/ atrial systole produces an anterior displacement of the septum toward the lower pressure RV, following by a brisk posterior rebound (“Spanish notch”)

What helps explain the doppler findings of constrictive pericarditis?

Cardiac Tamponade

Treatment of constrictive pericarditis:

• Pericardectomy

  • partial / complete surgical removal of the pericardium

    • often performed when pericardium is scarred

    • may stabilize heart location

      • hrt shifts left

      • more RV seen in PLAX

    • will not affect hrt function

  • may be congenital

    • absent pericardium

What may a pericardectomy cause?

excessive LVPW motion & chamber dilation

Absent Pericardium

• may be congenital

  • partial → usually lt sided

  • complete → rare