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Abstract & Commentary
Synopsis: Effusive-constrictive pericarditis is an uncommon syndrome in patients with pericarditis that often progresses to persistent constriction, although spontaneous resolution can occur.
Source: Sagrista-Sauleda J, et al. N Eng J Med. 2004; 350:469-475.
Effusive-constrictive pericarditis is characterized by persistently elevated right atrial pressure after intrapericardial pressure has been normalized by removal of pericardial fluid. The constriction is due to visceral pericardial disease, which has been confirmed in surgical cases. However, little is known about this entity in nonsurgical patients. Thus, Sagrista-Sauleda and colleagues studied 190 patients with clinical evidence of cardiac tamponade who underwent pericardiocentesis and cardiac catheterization for a 16-year period. After pericardiocentesis, constriction was diagnosed if the right atrial pressure failed to decrease by 50% or to a level < 10 mm Hg, after pericardial pressure was normalized (near zero). By these criteria, 15 patients had effusive-constrictive disease. Further treatment was based upon a complete medical evaluation and often included oral nonsteroidal anti-inflammatory drugs. Corticosteroids were not used. Surgery for constriction was considered for severe and persistent heart failure after a trial of medical therapy. The 190 patients studied were derived from 218 patients with clinical tamponade among 1184 patients evaluated for pericarditis. In seven of the patients diagnosed with effusive-constrictive disease, constriction was suspected prepericardiocentesis because of abnormal left ventricular septal motion on echo and Doppler evidence of cardiac inflow abnormalities. After pericardiocentesis, pericardial pressure decreased from a median of 12 to -5 mm Hg, whereas right atrial and ventricular pressures decreased slightly but remained elevated with a dip and plateau pattern in left ventricular diastolic pressure. Pulsus paradoxus decreased from a median of 15 to 8 mm Hg. Cardiac index increased only slightly from 2.1 to 2.4 L/min. The etiology of pericarditis was diverse. Seven patients underwent pericardiectomy for persistent symptoms between 13 weeks and 4 months after pericardiocentesis, and all had thickening of both pericardial layers. Three subsequently died of their underlying disease, but 4 were well after 3-15 years of follow-up. Among the nonsurgical patients, 3 with idiopathic pericarditis resolved spontaneously; 4 with neoplastic disease responded to radiation therapy; and the final patient responded to therapy for severe left heart failure. Sagrista-Sauleda et al concluded that effusive-constrictive pericarditis is an uncommon syndrome in patients with pericarditis that often progresses to persistent constriction, although spontaneous resolution can occur.
Comment by Michael H. Crawford, MD
Several important points can be made from this report. Effusive-constrictive pericarditis is unusual, but not rare, probably occurring in 5-10% of patients with clinical evidence of pericardial tamponade. In this series, about half of the cardiac catheterization proven cases were suspected clinically. Thus, had catheterization not been done, half would have been initially missed, leading to delays or misdiagnosis with potentially serious consequences. This experience argues for performing pericardiocentesis in the catheterization laboratory whenever possible with careful hemodynamic measurements done before and after pericardicentesis to detect constriction. Bedside pericardiocentesis should be reserved for true life-threatening emergencies.
Once underlying constriction has been identified in patients with cardiac tamponade, conservative management should be attempted. In this series, the only nonspecific therapy used was nonsteroidal anti-inflammatory agents. Corticosteroids were avoided, probably because of their known propensity to increase the frequency of relapse upon withdrawal and the possibility that an undiagnosed infectious etiology such as tuberculosis would be worsened. Most of the patients in this series died of their underlying disease rather than recurrent tamponade or constriction, and several improved spontaneously.
About half eventually required surgical pericardiectomy. There were no recurrences noted after surgery. Of note, echocardiography was not particularly useful in identifying effusive-constrictive patients, but some believe that transesophageal echocardiography may be superior in this regard, because characteristics of the pericardial space are more clearly seen. It was not reported in this study and probably not widely used. I have been impressed that cardiac MRI is useful for detecting underlying visceral pericardial disease, but constriction is a hemodynamic diagnosis in the final analysis. So no matter what sophisticated imaging technique is used, cardiac catheterization should always be done.
Dr. Crawford, Professor of Medicine, Associate Chief of Cardiology for Clinical Programs University of California San Francisco, is Editor of Clinical Cardiology Alert.