Constrictive Pericarditis: A Medical or Surgical Disease?

Abstract

Constrictive pericarditis is a disease of the pericardium resulting from chronic inflammation and/or scar responsible for a clinical feature of left and right ventricular failure. Although constrictive pericarditis has long been considered a surgical disease, a subset of patients experience reversibility of pericardial inflammation, a condition referred to as "transient constriction." Thus, after establishing the diagnosis of constrictive pericarditis, it is essential to evaluate the duration and potential for reversal to determine an appropriate treatment plan. Evidence of chronic disease can be acquired from the patient's clinical features and cardiac imaging, especially calcifications seen on computed tomography and chest X-ray. Transient constrictive pericarditis should be considered in cases without evidence of chronic disease, as active inflammation of the pericardium can be treated medically. Resolution of constrictive physiology can be evaluated using serial transthoracic 2-D Doppler echocardiography along with clinical examination. The potential for reversibility may also be assessed with multi-modality cardiac imaging to look for evidence of late enhancement on cardiac magnetic resonance and ¹⁸F-FDG PET/CT imaging.

Keywords: Constrictive pericarditis.

Figure 1. Calcification (yellow arrows) of the pericardium in simple chest X-ray (A, B) and CT (C).

Figure 2. Doppler examination using transthoracic echocardiography is helpful to assess constrictive physiology during treatment. At baseline, respiratory variation of mitral and tricuspid inflow was exaggerated, and diastolic flow reversal during expiration was prominent. After 3 months of steroid therapy, there was no evidence of constrictive physiology.

Figure 3. Use of cardiac magnetic resonance imaging to diagnose transient constrictive pericarditis. A 32-year-old man was diagnosed with tuberculous pericarditis. Prior to treatment, the pericardium was thickened (left upper panel) and exhibited signs of late enhancement (left lower panel). After steroid therapy and anti-tuberculous medication, the pericardial thickness normalized and late enhancement of the pericardium resolved.

Figure 4. FDG-PET. Maximum-intensity projection (upper row) and fused transaxial PET/CT (lower row) images of a 32-year-old male patient showing significant and diffuse high ¹⁸F-FDG uptake in the pericardium (left panel, SUV_max = 16.0). After steroid therapy, the patient was free of symptoms, and ¹⁸F-FDG uptake in the pericardium was markedly decreased (right panel, SUV_max = 3.5). CT: computed tomography, FDG: fluorodeoxyglucose, PET: positron emission tomography.