Recurrent pericarditis and constrictive pericarditis — practice case: constriction after cardiac surgery

Presentation

Practice case (not a real patient). A 58-year-old man in Sydney had coronary bypass surgery 10 weeks ago. Over 6 weeks he has developed ankle swelling, abdominal distension and breathlessness on exertion.^[1] His jugular venous pressure is raised, he has ascites, and he is haemodynamically stable. NT-proBNP is near normal, C-reactive protein is raised, and left and right ventricular systolic function are preserved on echocardiography.^[1]

Step 1 — Is this constriction?

Discussion:

• ESC 2025 describes the classic clinical picture of constriction as usually characterized by isolated right heart failure with normal or nearly normal natriuretic peptide levels; venous congestion, hepatomegaly, pleural effusions and ascites may occur.^[1]
• Post-cardiac surgery accounts for 11%–37% of reported constriction in developed countries.^[1]
• Multimodality imaging is recommended in all patients with suspected constrictive pericarditis to make the diagnosis and assess pericardial thickening, calcifications and active inflammation (Class I, Level C).^[1]
• Echocardiography shows septal bounce, medial e' of 12 cm/s and a hepatic vein expiratory diastolic reversal ratio of 0.82, which meet the Mayo Clinic criteria quoted by ESC 2025 (septal bounce or septal shift with medial e' >8 cm/s or reversal ratio >0.78).^[1]
• In a retrospective New South Wales cohort of all hospitalized patients with pericardial disease from 2004 to 2021, the median time from cardiac surgery to a diagnosis of constriction was 6 months.^[22]

Step 2 — Is it inflamed?

CMR shows pericardial thickening with oedema and late gadolinium enhancement.^[1]

• Pericardial LGE may imply ongoing inflammation and neovascularization rather than simple scarring.^[1]
• Anti-inflammatory therapy is recommended in haemodynamically stable patients with a transient or new diagnosis of constriction and evidence of pericardial inflammation (C-reactive protein elevation or pericardial enhancement on CMR), to prevent progression to constriction and avoid pericardiectomy (Class I, Level C).^[1]
• Transient constriction resolves with anti-inflammatory therapy in >50% of cases, and ESC 2025 Table 18 gives a 3–6 month course of empirical anti-inflammatory medical therapy.^[1]
• Colchicine is recommended as first-line therapy in patients with pericarditis as an adjunct to aspirin/NSAID or corticosteroid therapy to reduce subsequent recurrences (Class I, Level A); the ESC 2025 Table 13 footnote says aspirin is the preferred choice for patients with ischaemic heart disease.^[1]

Step 3 — Four months later

His symptoms have improved only partly. C-reactive protein is now normal and CMR shows no pericardial enhancement, but constrictive physiology persists. Echocardiography now shows severe tricuspid regurgitation. He has no cirrhosis, sepsis or life-limiting illness.^[1]

• Pericardiectomy is recommended in permanent constriction if there is no active inflammation or anti-inflammatory treatment is not successful after 3–6 months (Class I, Level C).^[1]
• Surgical pericardiectomy is also recommended for persistent constrictive pericarditis despite medical therapy to improve symptoms and survival (Class I, Level C).^[1]
• It should be complete rather than partial anterior or anterophrenic, at a high-volume centre with the required expertise.^[1]
• Tricuspid valve repair is recommended in pericardial constriction with severe tricuspid regurgitation to improve symptoms and survival (Class I, Level C).^[1]
• CT before surgery evaluates the anatomy and extent of calcification.^[1]

Step 4 — Outcome and follow-up

• ESC 2025 gives a historical operative mortality of 6%–10% for pericardiectomy, with better results for early surgery in high-volume centres and the lowest risk (<1.5%) with idiopathic causes.^[1]
• In a 163-patient single-centre series, 7-year survival after pericardiectomy was 66% for post-surgical constriction, against 88% for idiopathic and 27% for post-radiation constriction.^[20]
• Cases of constriction after pericardiectomy have been reported, especially after partial pericardiectomy.^[1]

Examiner criteria

• Pass: recognises constriction from right heart failure with a near-normal natriuretic peptide; asks for multimodality imaging and applies the Mayo criteria; treats the inflamed constriction first; refers for complete pericardiectomy at an experienced centre when constriction persists without inflammation; repairs severe tricuspid regurgitation at the same operation.^[1]
• Fail: sends a stable patient with active pericardial inflammation straight to pericardiectomy, excludes constriction on a normal natriuretic peptide, or delays surgery in persistent constriction.^[1]