Constrictive Pericarditis

In a patient with systemic venous congestion, ascites, edema, elevated jugular venous pressure, a pericardial knock, or otherwise unexplained right-sided heart failure, obtain transthoracic echocardiography (TTE) promptly to assess pericardial effusion and constrictive hemodynamics. Distended neck veins with a prominent y descent, ascites, and lower-extremity edema support the clinical phenotype; a pericardial effusion may coexist with constriction as effusive-constrictive pericarditis. ACC+1ACCTreatment of Tuberculous Constrictive Pericarditis with Pericardiectomy - American College of Cardiologyjacc2025 Concise Clinical Guidance: An ACC Expert Consensus ... - JACC

Do not equate pericardial thickening or calcification alone with hemodynamically significant constriction. The diagnostic target is ventricular interdependence caused by a noncompliant pericardium, integrated with symptoms, examination, and imaging. TTE is the recommended noninvasive hemodynamic test for both constrictive pericarditis and effusive-constrictive pericarditis. jacc+1jacc2025 Concise Clinical Guidance: An ACC Expert Consensus ... - JACCScienceDirectReview Constrictive pericarditis in the new millennium

If volume overload is present, use diuretic therapy to restore euvolemia while diagnostic testing proceeds. This is symptomatic treatment only: it does not change the natural history of constrictive physiology and should not substitute for anti-inflammatory treatment in active disease or for surgical assessment in irreversible disease. PubMed+1PubMedPericardial DiseasesPubMedPerioperative and Surgical Management of Constrictive Pericarditis - PMC

Use TTE as the first-line imaging modality because it evaluates constrictive hemodynamics noninvasively. Findings that support constriction include interventricular septal bounce and tissue-Doppler annulus reversus, in which lateral annular movement is lower than medial annular movement because the abnormal pericardium constrains lateral mitral annular motion. ScienceDirect+1ScienceDirectReview Constrictive pericarditis in the new millenniumACCTreatment of Tuberculous Constrictive Pericarditis with Pericardiectomy - American College of Cardiology

Order CMR when TTE is nondiagnostic or discordant with the clinical phenotype. CMR is reasonable for supportive evidence of constrictive pericarditis and is recommended to identify active pericardial inflammation as the cause of constriction. That distinction changes management because inflammatory constriction may be reversible with medical therapy, whereas fibrosis and calcification favor surgery. jacc+2jacc2025 Concise Clinical Guidance: An ACC Expert Consensus ... - JACCOxford Academic2025 ESC Guidelines for the management of myocarditis and ...PubMedPerioperative and Surgical Management of Constrictive Pericarditis - PMC

Use cardiac CT as an adjunct, not a physiologic replacement for echocardiography. CT can identify pericardial calcification and is reasonable for preoperative mapping before pericardiectomy. CT is especially useful when chronic calcific disease is suspected or when operative anatomy must be defined. jaccjacc2025 Concise Clinical Guidance: An ACC Expert Consensus ... - JACC

Proceed to invasive cardiac catheterization when TTE, CMR, and clinical data remain nondiagnostic or equivocal and the result will determine whether to pursue pericardiectomy. Invasive catheterization is recommended in this setting because differentiating constrictive pericarditis from restrictive cardiomyopathy is essential: constriction is often surgically treatable, whereas restrictive myocardial disease is not corrected by pericardiectomy. jacc+2jacc2025 Concise Clinical Guidance: An ACC Expert Consensus ... - JACCBMJDiVerential diagnosis of restrictive cardiomyopathy and ... - HeartScienceDirectReview Constrictive pericarditis in the new millennium

Obtain a focused history for prior cardiac surgery, mediastinal radiation, previous pericarditis, tuberculosis exposure or disease, connective-tissue disease, trauma, myocardial infarction, and drug exposure. Frequently reported causes include mediastinal radiation, chronic idiopathic pericarditis, prior cardiac surgery, and tuberculous pericarditis; prior surgery, irradiation, infarction, and idiopathic disease have also been prominent causes in surgical series. AHA Journals+2AHA JournalsPericardial Disease | CirculationAHA JournalsConstrictive Pericarditis in 26 Patients With Histologically Normal ...jaccPericardial Diseases and Best Practices for Pericardiectomy: JACC State-of-the-Art Review

Classify patients with CMR or other evidence of active pericardial inflammation as inflammatory or potentially transient constriction. Current guidance supports empirical anti-inflammatory therapy for constrictive pericarditis, with serial symptom assessment, inflammatory markers, and repeat imaging to determine whether constrictive physiology resolves. Oxford Academic+2Oxford Academic2025 ESC Guidelines for the management of myocarditis and ...PubMedPerioperative and Surgical Management of Constrictive Pericarditis - PMCPubMedPericardial Diseases

Classify patients with persistent symptoms, objective constrictive physiology, absent inflammatory features, and fibrotic or calcific pericardial disease as chronic constriction. In this phenotype, diuretics may improve congestion but definitive reversal of pericardial noncompliance is unlikely with medical therapy alone; refer early to a multidisciplinary pericardial and cardiac-surgery team for pericardiectomy assessment. PubMed+1PubMedPerioperative and Surgical Management of Constrictive Pericarditis - PMCPubMedPericardial Diseases

When tuberculosis is a plausible cause, pursue etiologic confirmation when tissue becomes available. Pericardial tissue obtained at pericardiectomy should undergo acid-fast bacilli staining and assessment for granulomatous inflammation. Cause-directed therapy remains necessary even when surgery relieves mechanical constriction. ACC+1ACCTreatment of Tuberculous Constrictive Pericarditis with Pericardiectomy - American College of CardiologyBMJPericarditis - Symptoms, diagnosis and treatment | BMJ Best Practice US

For inflammatory or transient constrictive pericarditis, initiate anti-inflammatory therapy before surgery when there is evidence of active inflammation and no immediate indication for definitive operative treatment. Contemporary management describes colchicine with or without an NSAID when not contraindicated, and corticosteroids with consideration of IL-1 inhibition in selected cases; treatment is guided by symptoms, CRP, and imaging evidence of pericardial inflammation. PubMed+1PubMedPerioperative and Surgical Management of Constrictive Pericarditis - PMCPubMedPericardial Diseases

Do not infer a specific drug dose or duration from constrictive physiology alone. The cited management approach describes a 3- to 6-month period of anti-inflammatory therapy to evaluate resolution of inflammation and constrictive physiology, with serial CRP monitoring and repeat echocardiography at 8 to 12 weeks. PubMed+1PubMedPerioperative and Surgical Management of Constrictive Pericarditis - PMCPubMedPericardial Diseases

Escalate toward surgery when congestion and objective constrictive physiology fail to improve despite an appropriate anti-inflammatory course, or when imaging indicates predominantly chronic noninflammatory fibrosis or calcification. Further prolonged medical treatment in that setting risks deferring the only definitive therapy. PubMed+1PubMedPerioperative and Surgical Management of Constrictive Pericarditis - PMCPubMedPericardial Diseases

Refer for pericardiectomy when chronic constrictive pericarditis causes persistent symptoms with objective constrictive physiology, especially when there is no evidence of reversible pericardial inflammation or when anti-inflammatory treatment has failed. Pericardiectomy is the definitive reversal of pericardial noncompliance; diuretics alone are palliative in this setting. PubMed+2PubMedPerioperative and Surgical Management of Constrictive Pericarditis - PMCPubMedPericardial DiseasesACCTreatment of Tuberculous Constrictive Pericarditis with Pericardiectomy - American College of Cardiology

Preoperative assessment should include TTE-based hemodynamics, CMR when inflammatory activity or myocardial involvement needs clarification, and cardiac CT for calcification and surgical planning. Lower right atrial pressure with diuresis as tolerated and control active pericardial inflammation before surgery when possible, because inflammatory activity can increase operative complications such as bleeding and injury to coronary structures. jacc+1jacc2025 Concise Clinical Guidance: An ACC Expert Consensus ... - JACCPubMedPerioperative and Surgical Management of Constrictive Pericarditis - PMC

Discuss meaningful operative risk explicitly. Across reported pericardiectomy series, operative mortality ranges from 0% to 18.6%; older surgical literature reports operative risk of 5% to 10%, with long-term outcomes varying substantially by etiology and comorbidity. Postradiation constriction carries particularly unfavorable prognosis. jacc+1jaccPericardial Diseases and Best Practices for Pericardiectomy: JACC State-of-the-Art ReviewPubMedSurgical Treatment of Constrictive Pericarditis - PMC

Pericardiectomy is commonly performed through median sternotomy, which permits access to the right-sided cardiac structures, great vessels, and caval-right atrial junctions and can facilitate removal of diseased pericardium from phrenic nerve to phrenic nerve. Surgical approach should be individualized in experienced centers; left anterior thoracotomy may be preferred for infected-purulent pericarditis to reduce concern for sternal infection. PubMedPubMedSurgical Treatment of Constrictive Pericarditis - PMC