Chronic Constrictive Pericarditis Causes Diagnosis and Treatment

Causes Diagnosis and Treatment of Chronic Constrictive Pericarditis

Meaning of Chronic Constrictive Pericarditis:  Subacute exudative constrictive pericarditis refers to a special type of lesion in which the visceral layer of the pericardium is narrowed with a large amount of pericardial exudate. 

It can be caused by tuberculosis, recurrent nonspecific pericarditis, trauma, radiation, rheumatoid arthritis, uremia, and scleroderma. Some reasons are unknown. The clinical manifestations are both pericardial tamponade and constriction. Qimai is more common than constrictive pericarditis. The X-ray indicates that the heart shadow is obviously enlarged, and pericardial calcification is rarely seen. 

After injection of gas into the pericardium, the pericardial wall thickened and the heart shadow was normal or reduced. ECG diagram QRS wave low voltage, T wave low or inverted, after pericardial puncture and drainage, the central venous pressure and right atrial pressure remain at the original high level.

 The right atrial pressure curve has obvious X tilt or Y tilt equal. 

After the liquid is drained, Y tilts deeper. The disease often progresses to constrictive pericarditis within one year. 

Although treatment with hormones and pericardial puncture can achieve temporary results, it cannot prevent it from developing into constrictive pericarditis, so treatment mainly depends on pericardial dissection.

It is a disease caused by thickening, adhesion and even calcification of the pericardium caused by chronic inflammation of the pericardium, which restricts the relaxation and contraction of the heart, reduces cardiac function, and causes disorders of systemic blood circulation.

Pericarditis Reference

1. Etiology and pathology

Chronic constrictive pericarditis is mostly caused by tuberculous pericarditis. Acute suppurative pericarditis is about 10% of those who do not heal, and others can also be caused by rheumatism, trauma, and mediastinal radiotherapy.

Pathological changes occur in the pericardial wall and the visceral layer. As the lesion progresses, the pericardium adheres, thickens, and even calcifies. 

The generally thickened pericardium binds the heart. A narrow ring can be formed at the entrance of the vena cava, causing severe obstruction, and severe narrowing in the atrioventricular groove, causing patients to have symptoms and signs similar to atrioventricular valve stenosis. 

Due to limited cardiac activity, the myocardium undergoes disuse atrophy early, and myocardial fibrosis can occur later. 

Due to apparently limited diastole, reduced filling volume, weakened myocardial contractility, increased ventricular diastolic pressure, restricted venous return, and increased venous pressure, congestion of various organs throughout the body, jugular venous dilatation, hepatomegaly, ascites, and pleural effusion Wait for signs.

2. Clinical manifestations of Pericarditis

Tuberculous pericarditis can appear symptoms 3 to 6 months after the acute phase. The common ones are fatigue, shortness of breath, oliguria, abdominal distension, loss of appetite, ascites, and hepatomegaly, which lead to systemic edema.

3. Physical examination of Pericarditis

Those with narrowing and heavier constriction usually present with chronic disease, superficial neck veins dilate, apical beats weaken or disappear, fast heart rate, weak heart sounds, fine pulse and odd pulse. 

The abdomen is swollen and frog-shaped, the liver is enlarged, and the liver neck sign is positive. Blood pressure is at a low level, and the pulse pressure difference narrows. The central venous pressure can rise above 20cmH2O.

4. Auxiliary inspection for Pericarditis

X-ray: the heart shadow is normal or slightly enlarged, the left and right heart borders are straightened, the superior vena cava shadow is widened, the heart beat is weakened, and there may be signs of pericardial calcification or pleural effusion.

Electrocardiogram: QRS complex low voltage in each lead, T wave low or inverted. Atrial fibrillation can be seen in some patients.

Echocardiography: pericardial thickening, adhesions, effusion and calcification, enlarged atria, ventricular contraction, and decreased cardiac function.

Right heart catheterization: cardiac output is lower than normal. The pressure in various parts of the heart cavity is generally increased, the pulmonary capillary pressure is also increased, the right ventricular diastolic pressure is significantly increased, the early diastolic sagging, and the late increase.

5. Differential diagnosis

Chronic constrictive pericarditis is not difficult to diagnose based on medical history, symptoms and physical examination, but it is often necessary to distinguish between heart failure caused by cardiomyopathy, cirrhosis, and valvular disease.

6. Surgical Treatment of Pericarditis

 Once the diagnosis of chronic constrictive pericarditis is confirmed, surgical treatment should be performed as soon as possible. 

Before the operation, make preparations according to the patient's condition. Preparations should be like limiting sodium salt, proper application of diuretics, maintaining water and electrolyte balance, strengthening nutrition, supplementing protein, vitamins, small amounts of blood transfusion or plasma, anti-tuberculosis treatment for tuberculosis patients, and appropriate elimination of pleural effusion and ascites.

The surgical approach often uses longitudinal sternal approach or left anterior thoracic incision. Make a small incision in the thickened pericardium in front of the ventricle. Be careful when approaching the myocardium. 

When the pericardium wall and the visceral layer are between, the myocardium bulges slightly when the heart contracts, and the wall and the visceral layer are up and down and both sides Separation, the separation sequence is the left ventricle, then the right ventricular outflow tract, the right ventricular base, and finally the superior and inferior vena cava are released. 

Both sides of the pericardial resection range should reach the phrenic nerve, up to the root of the aorta, and down to most of the phrenic surface. Prevent damage to coronary arteries and myocardium during separation.

In critically ill patients, the surgical mortality rate is relatively high. About 75% of deaths are due to acute or subacute heart failure. Therefore, strict postoperative root volume and appropriate cardiac support are still an important part of ensuring successful surgery. 

Author's Bio

Name: Gwynneth May

Educational Qualification: MBBS, M.D. (Medicine) Gold Medalist

Profession: Doctor

Experience: 16 Years of Work Experience as a Medical Practitioner

About Me