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Chapter: Medicine and surgery: Cardiovascular system

Constrictive pericarditis - Disorders of the pericardium

A condition in which reduced elasticity of the pericardium results in poor cardiac output.- Definition, Incidence, Aetiology, Pathophysiology, Clinical features, Complications, Investigations, Management, Prognosis.

Constrictive pericarditis

 

Definition

A condition in which reduced elasticity of the pericardium results in poor cardiac output.


Aetiology

 

Haemopericardium, tuberculous pericarditis and acute pericarditis may result in constrictive pericarditis. In many cases there is no identifiable cause.

 

Pathophysiology

 

Chronic inflammation, or healing after acute pericarditis may cause the pericardium to become thick, fibrous and calcified. This surrounds and constricts the ventricles such that the heart cannot fill properly, hence causing a reduction in cardiac output.

 

Clinical features

 

The predominant features are of right-sided heart failure:

 

Raised jugular venous pressure, ascites, hepatomegaly, ankle and sacral oedema.

 

The JVP has a steep y descent (Friedreich’s sign). During inspiration there is an increase in pressure and hence neck vein distension (Kussmaul’s sign).

 

Pulsus paradoxus may occur, this is a greater than normal fall in pulse volume during inspiration. This is due to the transient reduction in left ventricular filling, which occurs as a result of reduction in pulmonary venous return to the left atrium during inspiration.

 

There is initially sinus tachycardia and atrial fibrillation may develop. Auscultation reveals soft S1 and S2 with a loud diastolic (early third) heart sound or pericardial knock due to rapid but abbreviated ventricular filling.

 

Investigations

 

Chest X-ray is frequently normal but may show a relatively small heart. There may be a shell of calcified pericardium particularly on the lateral film.

 

ECG shows low QRS voltages with flat or inverted T waves.

 

Echocardiogram can sometimes show thickening of the pericardium and an abnormal ventricular filling pattern. However, it may be normal even in the presence of the disease.

 

MRI is the investigation of choice to define the location of pericardial thickening and also may evaluate ventricular and valvular function.

 

Management

Medical intervention is of little value except for digoxin to control atrial fibrillation. The treatment of choice is surgical removal of a substantial proportion of the pericardium (pericardectomy). This is also helpful diagnostically, particularly for tuberculosis.

 

Prognosis

 

The majority of patients respond well to surgery. The exceptions are if there is coexistent atrial fibrillation, valve disease or left ventricular dysfunction.

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Medicine and surgery: Cardiovascular system : Constrictive pericarditis - Disorders of the pericardium |


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