Constrictive pericarditis occurs when a thickened fibrotic pericardium impedes normal diastolic filling of the heart. Common causes include uremia, neoplasm, radiation, and surgery. The noncompliant pericardium interferes with filling of all cardiac chambers during diastole while systolic function remains normal. This reduces cardiac output and elevates venous pressures, causing symptoms like dyspnea, edema, and hepatomegaly. Diagnosis involves echocardiogram, ECG, CT/MRI and cardiac catheterization. Definitive treatment is pericardiectomy though medical management may help in early or inflammatory cases.

1. Constrictive
pericarditis
Constrictive pericarditis occurs when a thickened fibrotic pericardium, of whatever
cause, impedes normal diastolic filling.
uremia neoplasm radiation
by Marwan Nassar

2. normal

3. Functions of the Pericardium
Although surgical removal of the pericardium (pericardiectomy)
and congenital absence of the pericardium are well tolerated
1.Stabilization of the heart within the thoracic cavity by virtue of
its ligamentous attachments.
2. Protection of the heart from mechanical trauma and infection
from adjoining structures. The pericardial fluid functions as a
lubricant and decreases friction of cardiac surface during systole
and diastole.
3. Prevention of excessive dilation of heart especially during
sudden rise in intracardiac volume e.g. acute aortic or mitral
regurgitation.

4. Etiology
Common* *
*
*
*
Uremia *
Surgery*

5. PATHOPHYSIOLOGY
Noncompliant pericardium interferes with diastolic filling of all
cardiac chambers. Systolic function is normal.
filling in the early (1/3) diastolic phase is normal until abruptly
encounters the rigid pericardium and filling stops in later (2/3)
part of diastole
Although systolic function is normal, decrease in ventricular
filling reduces cardiac output. Elevation of right heart diastolic
pressure raises systemic venous pressure, which leads to jugular
venous distention, hepatomegaly, and edema.

6. Clinical Presentation
develop slowly over a number of years, so that patients may not be
aware of all of their symptoms until questioned. similar to
those
associated with CHF.
-Dyspnea**
-Lower-extremity edema and abdominal swelling and discomfort *
-Nausea, vomiting, and right upper quadrant pain, if present, are
thought to be due to hepatic congestion, bowel congestion, or both.
-The initial history may be more compatible with liver disease
(cryptogenic cirrhosis)
Less common Chest pain, presumably due to active inflammation
Easy fatigability Fever Tachycardia Palpitations
Paroxysmal nocturnal dyspnea Diaphoresis

7. Physical Examination
In more advanced stages, the patient may appear ill, with marked
muscle wasting, cachexia, or jaundice
Cardiovascular findings
-Elevated JVP
-Sinus tachycardia is common while the BP normal or low.
-The apical impulse is often impalpable, and the patient may have
distant or muffled heart sounds.
-A friction rub is usually not found.
-A pericardial knock
-Pulsus paradoxus is a variable finding.
-Kussmaul sign (ie, elevation of systemic venous pressures with
inspiration) is a common nonspecific finding

8. Physical Examination
Gastrointestinal, pulmonary, and other organ system findings
-Hepatomegaly with prominent hepatic pulsations in 70% of
patients.
-ascites, -spider angiomata, -and palmar erythema, Peripheral
(dependent) edema is a common finding

9. DIAGNOSIS
**Echocardiogram is useful in providing key hemodynamic
findings. The presence of pericardial effusion indicates effusive
constrictive pericarditis and may reveal thick pericardium.
*ECG is abnormal but nonspecific atrial fibrillation is common.
Chest x-ray may show evidence of pericardial calcification.
*CT and MRI are most helpful in differentiating constrictive
pericarditis from restrictive cardiomyopathy with which it
resembles so closely both hemodynamically and clinically.
*Cardiac catheterization shows the typical dip-plateau pattern
and equalization of diastolic pressures.

11. TREATMENT
The most definitive therapy consists of pericardiotomy. in the early stage of the disease and
hence the importance of early recognition. Individuals with significantly advanced symptoms
related to constriction may derive little benefit from pericardiectomy particularly how has
high surgical risk.
medical management is ineffective unless a prominent inflammatory component is present.
Transient constrictive pericarditis who are medically stable may be given a trial of conservative
treatment for 2-3 months (using NSAIDs and/or steroids).
Subacute constrictive pericarditis may respond to steroids if treated before pericardial fibrosis
occurs
Diuretics are the mainstay to relieve congestion and optimize clinical volume status.
medications used to treat patients specific to the underlying cause of the pericardial disease
directed toward the causative disease (eg, antituberculosis medication) is appropriate
Complications (eg, atrial arrhythmias) require their own therapy as appropriate
beta-blockers and calcium channel blockers should be avoided

12. Summery