Restrictive pericarditis

BACKGROUND—Pericardial thickening is an uncommon complication of cardiac surgery.
OBJECTIVES—To study pericardial thickening as the cause of severe postoperative venous congestion.
SUBJECTS—Two men, one with severe aortic stenosis and single coronary artery disease, and one with coronary artery disease after an old inferior infarction. Both had coronary artery bypass grafting surgery.
METHODS—Magnetic resonance imaging (MRI), Doppler echocardiography, and cardiac catheterisation.
RESULTS—Venous pressure was raised in both patients. MRI showed mildly thickened pericardium, and cardiac catheterisation indicated diastolic equalisation of pressures in the four chambers. Jugular venous pulse showed a dominant "Y" descent coinciding with early diastolic flow in the superior vena cava, and mitral and tricuspid Doppler forward flow proved restrictive physiology. The clinical background suggested pericardial disease so both patients had pericardiectomy. This proved the pericardium to be thickened; the extent of fibrosis also involved the epicardium.
CONCLUSIONS—Although rare, restrictive pericarditis (restrictive ventricular physiology resulting from pericardial disease) should be considered to be a separate diagnostic entity because its pathological basis and treatment are different from intrinsic myocardial disease. This diagnosis may be confirmed by standard investigational techniques or may require diagnostic thoracotomy.


Keywords: restrictive pericarditis; pericardial disease     

Effusive-constrictive pericarditis

Effusive-constrictive pericarditis (ECP) is an increasingly recognized clinical syndrome. It has been best characterized in patients with tamponade who continue to have elevated intracardiac pressure after the removal of pericardial fluid. The disorder is due to pericardial inflammation causing constriction in conjunction with the presence of pericardial fluid under pressure. The etiology is diverse with similar causes to constrictive pericarditis and the condition is more prevalent with certain etiologies such as tuberculous pericarditis. The diagnosis is most accurately made using simultaneous intrapericardial and right atrial pressure measurements with pericardiocentesis, although non-invasive Doppler hemodynamic assessment can assess residual hemodynamic findings of constriction following pericardiocentesis. The clinical presentation has considerable overlap with other pericardial syndromes and as yet there are no biomarkers or non-invasive findings that can accurately predict the condition. Identifying patients with ECP therefore requires a certain index of clinical suspicion at the outset, and in practice, a proportion of patients may be identified once there is objective evidence for persistent atrial pressure elevation after pericardiocentesis. Although a significant number of patients will require pericardiectomy, a proportion of patients have a predominantly inflammatory and reversible pericardial reaction and may improve with the treatment of the underlying cause and the use of anti-inflammatory medications. Patients should therefore be observed for the improvement on these treatments for a period, whenever possible, before advocating pericardiectomy. Imaging modalities identifying ongoing pericardial inflammation such as contrast-enhanced magnetic resonance imaging or nuclear imaging may identify those subsets more likely to respond to medical therapies. Pericardiectomy, if necessary, requires removal of the visceral pericardium.     

Tramadol-associated pericarditis

Tramadol, marketed as Ultram in the United States, is as a non-scheduled narcotic analgesic based on its low abuse liability. It is indicated for the treatment of moderately severe pain; however, multiple adverse effects have been reported with its use including seizures, anaphylaxis, angioedema, bronchospasm, and serotonin syndrome. An association between tramadol and pericarditis has not been previously reported. We describe the case of an 88 year-old male who developed acute pericarditis 2 days following tramadol initiation. The temporal relationship between drug initiation and pericarditis as well as the resolution of symptoms upon drug discontinuation suggested a potential association. Although pericarditis has not been described with tramadol administration, clinicians should be aware of a possible association.     

Acute pericarditis

Most patients with severe acute pericarditis should be hospitalized for complete diagnosis and observation for complications, particularly effusion and tamponade. Therapy should be directed at a specific inciting etiologic agent, if identified. In all patients, anti-inflammatory and symptomatic treatment should aim at alleviating pain, fever, and malaise, using nonsteroidal anti-inflammatory drugs (NSAIDs) as the mainstays. Choice of treatment should be individualized, but indomethacin should be avoided in adults, if possible, because of its deleterious effect on coronary flow. Colchicine added to NSAIDs or as monotherapy is effective both for the initial attack and to prevent recurrences. Corticosteroids should be used only as a last resort (eg, for severe illness resistant to NSAIDs) or to treat specific inciting illnesses.