Medical Care:
" Medical management is generally ineffective in the vast majority of cases unless a prominent inflammatory component is present.
" This is in contrast with acute pericarditis (see Pericarditis, Acute), in which the use of nonsteroidal anti-inflammatory agents, cyclooxygenase-2 inhibitors, colchicine, corticosteroids, or a combination thereof may provide benefit. However, even after optimal therapy of acute pericarditis, over time, the possibility of developing constriction exists. Other medical considerations are as follows:
o Subacute constrictive pericarditis may respond to steroids if treated before pericardial fibrosis occurs.
o Diuretics are commonly used to relieve congestion if ventricular filling pressures are clinically elevated. However, this may decrease cardiac output and requires careful monitoring.
o Any therapy directed toward the causative disease is appropriate, such as antituberculosis medication.
o Complications, such as atrial arrhythmias, require their own therapy as needed.
o In general, beta-blockers should be avoided because the sinus tachycardia that commonly occurs in constrictive pericarditis is compensatory in nature.
Surgical Care:
" Complete pericardectomy is the definitive therapy and is a potential cure.
o Results are generally better if the procedure is performed earlier in the course, when less calcification is present and when the chance of abnormal myocardium or advanced heart failure is reduced.
o Some judgment is required because patients who are asymptomatic (NYHA class I) or who have early NYHA stage II symptoms may be clinically stable for years.
o Pericardial decortication should be as extensive as possible, especially at the diaphragmatic-ventricular contact regions.
o The surgical procedure can be long and is often technically complex. Complications may include excessive bleeding and atrial and ventricular arrhythmias.
o Poor surgical results are observed in patients with organ failure (especially renal and hepatic), ascites, uncorrected coronary artery disease, myocardial fibrosis, older age, NYHA class IV, or postradiation pericarditis.
o The published surgical mortality rates range from 5-15%. Significantly, 80-90% of patients who undergo pericardectomy postoperatively achieve NYHA class I or II.
o Even though the symptoms following a pericardiectomy are commonly improved, evidence of abnormal diastolic filling (which can be correlated with clinical status) often remains.
o A recent study found that some diastolic filling abnormalities remained in a substantial number of patients after pericardectomy for constriction.
o In 58 patients who underwent total pericardectomy for constriction, 30% still had some significant symptoms after 4 years. These patients were more likely to have a persistent restrictive or constrictive pattern to their transmitral and transtricuspid Doppler signals as determined by respiratory recording.
o Although some improved with time, persistent diastolic filling abnormalities tended to occur in patients who had a longer history of preoperative symptoms, supporting the concept of early operation in patients who are symptomatic.
" New experimental devices are being investigated to access the pericardial space, including in patients without significant effusion.
o One is the PerDUCER, which is a percutaneous sheath-needle pericardial access device.
o Hopefully, the development of such devices can improve diagnostic and therapeutic options in patients with pericardial disease.
Consultations:
" A cardiologist can assist with obtaining and interpreting echocardiographic imaging, hemodynamic measurements, and, if necessary, endocardial or pericardial biopsies.
" Consultation with a cardiothoracic surgeon is appropriate when a pericardial procedure is being considered.
Diet:
" No specific dietary recommendations are necessary.
Activity:
" Although no specific restrictions are needed, activity can often be severely limited by symptoms.
drug treatment : Surgical pericardectomy is clearly the treatment of choice for patients with constrictive pericarditis. Diuretics have been used in the early stages of the disease to improve pulmonary and systemic congestion. However, these should be used cautiously because any drop in intravascular volume may cause a corresponding drop in cardiac output.
DRUG TREATMENT : DRUGS THAT SLOW HEART RATE ARE POORLY TOLERATED.
1. DIURETICS :
- FRUSEMIDE