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Image of the month : Different forms of constrictive pericarditis

idiopathic, tuberculous, post-radiotherapy

Different forms of constrictive pericarditis share a common physiopathology but anatomy is quite different, much more than what can be anticipated by imaging studies






Panel A (top left)- Idiopathic constrictive pericarditis. Visceral epicardium is mildly inflammed, not removed since it does not interfere with myocardial function. Parietal pericardium is thickened (6-8 mm), and inestensible. Prognosis is generally very good.
Panel B (top right)- Constrictive tuberculous pericarditis. Typical caseum, that in this case is sterile, negative for M.Tuberculosis. Wide areas of calcification are mechanically removed (Panel C, bottom left).
Panel D (bottom right)
- Constrictive pericarditis following radiotherapy. Visceral pericardium is tenacioulsy adherent to the myocardium. Removal is very difficult and technically demanding. Prognosis especially depends on the degree of myocardial involvement.

 

Questions:

Answers will be given in the next newsletter and on the web site

1. Is pericardial thickening essential for the diagnosis of constrictive pericarditis?
2. What is the risk of developing constrictive pericarditis in a patient with acute viral or idiopathic pericarditis?
3. What is the risk of developing constrictive pericarditis in a patient with recurrent idiopathic pericarditis?
4. How does the risk change if the patient has tuberculous pericarditis?

 

 

Conclusion:

Different forms of constrictive pericarditis share a common physiopathology but anatomy is quite different, much more than what can be anticipated by imaging studies. In the previous image of the month, 3 different cases of constriction were depicted: idiopathic, tuberculous, and following radiotherapy.

The following questions were proposed:

1. Is pericardial thickening essential for the diagnosis of constrictive pericarditis?
No, pericardial thickening is not essential for the diagnosis of constrictive pericarditis. Pericardial thickness is not increased in 15-20% of patients with surgically proven constrictive pericarditis, although the histopathological appearance may be focally abnormal in all cases. When clinical, echocardiographic, or invasive hemodynamic features indicate constriction in patients with heart failure, pericardiectomy should not be denied on the basis of normal thickness as demonstrated by noninvasive imaging.

2. What is the risk of developing constrictive pericarditis in a patient with acute viral or idiopathic  pericarditis?
Data from a prospective color study of 500 consecutive cases of acute pericarditis of different aetiologies have been recently published. CP is a relatively rare complication of viral or idiopathic acute pericarditis (<0.5%) but, in contrast, is relatively frequent for specific aetiologies, especially bacterial.

3.What is the risk of developing constrictive pericarditis in a patient with recurrent idiopathic  pericarditis?
A systematic review of all publications on recurrent pericarditis from 1966 to 2006 has been published on this issue. Eight major clinical series including a total of 230 patients with idiopathic recurrent pericarditis (mean age 46 years, men/women ratio: 0.9) have been included. After a mean follow-up of 61 months, the complication rate was 3.5% cardiac tamponade and 0% constrictive pericarditis and left ventricular dysfunction. The overall life prognosis was excellent in idiopathic recurrent pericarditis and complications are uncommon. In conclusion constrictive pericarditis was never reported despite numerous recurrences, and the risk is lower than in idiopathic acute pericarditis (approximately 1%). Thus, it is important to reassure patients on their prognosis, explaining the nature of the disease, and the likely course. Therapeutic choices should take into account of the overall good outcome of these patients, including less toxic agents.
4. How does the risk change if the patient has tuberculous pericarditis?
Patients with tuberculous pericarditis have a substantial risk of developing constrictive pericarditis. In contemporary series from Western Europe this complication has been reported in about 20% of patients following acute tuberculous pericarditis.

References


1. Imazio M, Brucato A, Maestroni S, Cumetti D, Belli R, Trinchero R, Adler Y. Risk of constrictive pericarditis after acute pericarditis. Circulation. 2011;124:1270-5. Epub 2011 Aug 15.
2. Syed FF, Mayosi BM. A modern approach to tuberculous pericarditis. Prog Cardiovasc Dis. 2007;50:218-36.
3. Imazio M, Brucato A, Adler Y, Brambilla G, Artom G, Cecchi E, Palmieri G, Trinchero R. Prognosis of idiopathic recurrent pericarditis as determined from previously published reports. Am J Cardiol. 2007;100:1026-8. Epub 2007 Jul 6.
4. Hoit BD. Pericardial disease and pericardial tamponade. Crit Care Med. 2007;35:S355-64.
5. Mayosi BM, Burgess LJ, Doubell AF. Tuberculous pericarditis. Circulation. 2005;112:3608-16.
6. Bertog SC, Thambidorai SK, Parakh K, Schoenhagen P, Ozduran V, Houghtaling PL,Lytle BW, Blackstone EH, Lauer MS, Klein AL. Constrictive pericarditis: etiology and cause-specific survival after pericardiectomy. J Am Coll Cardiol. 2004;43:1445-52.
7. Sagristà-Sauleda J. Pericardial constriction: uncommon patterns. Heart. 2004;90:257-8.
8. Sagristà-Sauleda J, Angel J, Sánchez A, Permanyer-Miralda G, Soler-Soler J.Effusive-constrictive pericarditis. N Engl J Med. 2004;350:469-75.
9. Haley JH, Tajik AJ, Danielson GK, Schaff HV, Mulvagh SL, Oh JK. Transient constrictive pericarditis: causes and natural history. J Am Coll Cardiol. 2004;43:271-5.
10. Talreja DR, Edwards WD, Danielson GK, Schaff HV, Tajik AJ, Tazelaar HD, Breen JF, Oh JK. Constrictive pericarditis in 26 patients with histologically normal pericardial thickness. Circulation. 2003;108:1852-7.

Notes to editor


Presented by Paolo Ferrazzi, Caterina Simon, Samuele Pentiricci, Federica Bonomi,  Antonio Brucato.
Cardiac Surgery and Internal Medicine, Ospedali Riuniti, Bergamo, Italy
The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

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