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  • Review Article
  • Published:

Constrictive pericarditis—a curable diastolic heart failure

Nature Reviews Cardiology volume 11, pages 530–544 (2014)Cite this article

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An Erratum to this article was published on 06 October 2015

This article has been updated

Key Points

  • The most-common aetiologies of constrictive pericarditis in developed countries are cardiac surgery and idiopathic pericarditis, whereas in developing countries with high tuberculosis prevalence, tuberculous pericarditis is most common

  • Constrictive pericarditis should be suspected in any patient for whom the severity of heart failure is disproportional to the degree of myocardial dysfunction

  • Echocardiography is the initial investigation of choice, with cardiac MRI and CT being alternative or complementary imaging modalities

  • Cardiac catheterization can be used when echocardiography, cardiac MRI, and CT provide equivocal results or when a mixed cardiac pathology requires further evaluation

  • Patients with ongoing pericardial inflammation should initially receive anti-inflammatory therapy; those with noncalcific tuberculous constrictive pericarditis should be treated with antituberculous antimicrobial and steroid therapy to reverse the condition

  • Pericardiectomy is curative with symptomatic improvement in most patients, but some develop late recurrence of symptoms; mortality is highest in patients with radiation pericarditis and associated myocardial disease

Abstract

Constrictive pericarditis can result from a stiff pericardium that prevents satisfactory diastolic filling. The distinction between constrictive pericarditis and other causes of heart failure, such as restrictive cardiomyopathy, is important because pericardiectomy can cure constrictive pericarditis. Diagnosis of constrictive pericarditis is based on characteristic haemodynamic and anatomical features determined using echocardiography, cardiac catheterization, cardiac MRI, and CT. The Mayo Clinic echocardiography and cardiac catheterization haemodynamic diagnostic criteria for constrictive pericarditis are based on the unique features of ventricular interdependence and dissociation of intrathoracic and intracardiac pressures seen when the pericardium is constricted. A complete pericardiectomy can restore satisfactory diastolic filling by removing the constrictive pericardium in patients with constrictive pericarditis. However, if inflammation of the pericardium is the predominant constrictive mechanism, anti-inflammatory therapy might alleviate this transient condition without a need for surgery. Early diagnosis of constrictive pericarditis is, therefore, of paramount clinical importance. An improved understanding of how constrictive pericarditis develops after an initiating event is critical to prevent this diastolic heart failure. In this Review, we discuss the aetiology, pathophysiology, and diagnosis of constrictive pericarditis, with a specific emphasis on how to differentiate this disease from conditions with similar clinical presentations.

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Figure 1: Pathology findings in constrictive pericarditis.
Figure 2: Ventricular interdependence and dissociation of intrathoracic and intracardiac pressures in patients with constrictive pericarditis.
Figure 3: Changes in left ventricular strain in a patient with constrictive pericarditis.
Figure 4: Pericardial calcification in constrictive pericarditis.
Figure 5: Doppler echocardiography diagnosis of constrictive pericarditis.
Figure 6: Echocardiography diagnostic criteria algorithm for constrictive pericarditis.
Figure 7: Cardiac catheterization in constrictive pericarditis to differentiate between restrictive cardiomyopathy and constrictive pericarditis.159
Figure 8: Intraoperative photographs during radical pericardiectomy.

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Change history

  • 06 October 2015

    In the version of this article initially published online and in print, the images in Figure 2c depicting interventricular septum movements and blood flow velocities during inspiration and expiration were swapped. This error has been corrected for the HTML and PDF versions of the article.

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Authors and Affiliations

  1. Division of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, 55905, MN, USA

    Faisal F. Syed & Jae K. Oh

  2. Department of Cardiovascular Surgery, Mayo Clinic, 200 First Street SW, Rochester, 55905, MN, USA

    Hartzell V. Schaff

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  1. Faisal F. Syed
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F.F.S. and J.K.O. researched data for the article. All the authors contributed substantially to discussion of its content, writing, reviewing, and editing the manuscript before submission.

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Correspondence to Jae K. Oh.

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Supplementary Table 1

Aetiology of constrictive pericarditis in contemporary pericardiectomy series (published 1999–present) (DOCX 26 kb)

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Syed, F., Schaff, H. & Oh, J. Constrictive pericarditis—a curable diastolic heart failure. Nat Rev Cardiol 11, 530–544 (2014). https://doi.org/10.1038/nrcardio.2014.100

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