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Interventions on the pericardium are to be included among the first intrathoracic operations. They have greatly benefited from the advances made by modern intrathoracic surgery. Anesthesia is not effected any more by local infiltration of the walls, but by intratracheal general narcosis. The former horseshoe shaped incision, resecting 3–4 ribs, is now rectilinear and intercostal: the deformation of the thorax is considerably reduced. Decortication is effected on the two-thirds of the heart circumference, and only of the ventricles. As inner pleuro-pericardic drainage is made; effusions are aspired by pleural puncture. The results although satisfactory, are not always immediate.

Though the exact mechanism of radiation pericarditis has not been resolved and controversy still exists among the various medical disciplines, sufficient cases have now been reported to justify its classification as a clinical entity. This report describes a case of chronic constrictive pericarditis with the unusual feature of becoming symptomatic 45 years after radiation therapy to the mediastinum as a child, the longest latent period that has as yet been reported in the literature.

During the past ten years twenty-six patients have been operated upon at the Cleveland Clinic Hospital for the surgical correction of chronic constrictive pericarditis. There has been considerable variation in technical features of the operation, but with increasing experience the trend is toward one of two basic incisions: (1) the median sternotomy (sternal-splitting) or (2) the transverse sternotomy (sternal transection). Either incision provides excellent exposure of the anterior aspect of the pericardial sac and its contents. Successful decortication is dependent upon the surgical exposure; however, other factors may be of equal significance. The most important of these is the character of the pericardial disease in the patient. The ability to establish a cleavage plane is usually dependent upon the pathologic process itself. Other reasons for failure are myocardial disease and postoperative complications. The cause of chronic constrictive pericarditis is still a matter of interest. Although tuberculous pericarditis was originally presumed to be the responsible cause of constrictive pericarditis, it now appears that this may be comparatively rare. Comparison of a sizable series of patients with acute pcricardial effusion treated during the same time interval suggests a possible relationship between acute hemorrhagic pericarditis and chronic constrictive pericarditis. The investigative problem remains to establish the common cause of acute pericardial hemorrhage and the factors that allow intrapericardial blood to incite a possible constrictive pericarditis.

ACUTE benign pericarditis is a well recognized clinical syndrome, but its relation to chronic constrictive pericarditis is still a matter of dispute. Pathological studies of autopsy and operative material obtained from patients with constrictive pericarditis have shown some variation in the etiology, but in all the series reported, a large percentage of cases have been placed in the group with no specific cause (Table 1). There is evidence that many of these cases are the end result of so-called acute benign pericarditis. The case reported below represents typical acute pericarditis with massive effusion that failed to respond to medical management. . . .

A case of chronic constrictive pericarditis following uremic pericarditis is reported. Physicians caring for patients who have survived episodes of uremic pericarditis should be alert for the signs of a restrictive cardiac disorder.

Objective Prognosis after pericardiectomy remains to be clearly elucidated, especially in Asian countries, where the causes of constrictive pericarditis differ from those in Western countries. We aimed to investigate the preoperative prognostic factors and clinical outcomes after pericardiectomy in patients with chronic constrictive pericarditis. Methods Preoperative clinical and imaging characteristics were evaluated in 85 consecutive patients with chronic constrictive pericarditis without other valvular or ischemic heart diseases who underwent pericardiectomy. Causes were idiopathic in 49 patients (57.6%) and tuberculous in 36 patients (42.4%). All-cause death was observed for a median of 38.5 months. Results Of 85 patients, 15 (17.6%) died during follow-up. These 15 patients who died during follow-up had higher aspartate aminotransferase, smaller left ventricular end-systolic dimension index, and higher early diastolic mitral inflow velocity before pericardiectomy than the 70 patients who survived. Multivariate Cox proportional analysis showed that diabetes mellitus (hazard ratio, 4.610; P = .024) and high early diastolic mitral inflow velocity (hazard ratio, 1.050/cm/s; P = .002) before pericardiectomy were independent predictors of mortality after pericardiectomy. The preoperative cutoff value for early diastolic mitral inflow velocity in predicting mortality after pericardiectomy was 71 cm/s (sensitivity of 84.6% and specificity of 52.2%), and there was a significant difference in survival between groups divided by this cutoff value of early diastolic mitral inflow velocity ( P = .029). Conclusions Preoperative high early diastolic mitral inflow velocity and diabetes mellitus were predictors of poor prognosis after pericardiectomy in patients with chronic constrictive pericarditis. These results suggest that preoperative Doppler echocardiographic evaluation may be valuable not only for diagnosing constrictive pericarditis but also for predicting prognosis after pericardiectomy.

We report a ease of recurrent calcified chronic constrictive pericarditis of 31 years' duration, complicated by the development of tuberculous meningitis two weeks after a third pericardiectomy. It is suggested that all patients undergoing pericardiectomy for constrictive pericarditis should have anti-tuberculous therapy even in the absence of an established tuberculous aetiology.

Delayed chronic constrictive pericarditis developed in seven patients 51 to 268 (mean 116) months after radiotherapy. Six of the seven complained of exertional dyspnea that was initially believed to be caused by mediastinal fibrosis. All patients had raised jugular venous pressure, although in two patients this finding was not appreciated by the primary physician. There were no consistent noninvasively identifiable features to allow prediction of constrictive pericarditis other than consideration of its existence and careful examination of the cardiovascular system. All patients had constrictive pericarditis proved at cardiac catheterization. Of the five patients who underwent pericardiectomy, two had an excellent functional result, one has residual pericardial constriction and two died of unrelated causes. Recommendations for the treatment of radiation-induced pericardial disease are given.

The mechanism by which atrial natriuretic factor (ANF) is released has been variably attributed to a number of stimuli including atrial distension,1,2 stretch,3 compliance4 and atria1 hypertension.5,6 In constrictive pericarditis, atrial pressures are markedly elevated in conjunction with fluid retention and diminished myocardial distensibility. Release of pericardial constriction would therefore allow increased distensibility at the same time atrial pressures are lowered. We describe a patient with severe calcific constrictive pericarditis in whom for the first time ANF levels and physiologic parameters were measured before and after pericardiectomy.

Chronic constrictive pericarditis may complicate both rheumatoid arthritis and systemic lupus erythematosus. To our knowledge, however, this is the first time it has been described in a patient with dermatomyositis. This association should be kept in mind as constrictive pericarditis should be considered in the differential diagnosis of liver cirrhosis and Budd-Chiari syndrome in rheumatic diseases.

A 34 year old woman with a history of self-mutilation developed severe constrictive pericarditis with sterile, calcified intrapericardial abscess cavities as a result of inserting sewing needles into her chest seven years previously. After pericardiectomy she made a good recovery.

In this chapter the important structural features of the pericardium that influence the anatomy and function of the right ventricle will be summarized. The subject of ventricular interaction will be dealt with only in so much as it is modulated by the pericardium, other aspects of this subject being covered by Dr. Smith and Tyberg in Chapter 3. Likewise, since certain aspects of infarction of the right ventricle may bear a striking resemblance to chronic constrictive pericarditis, this subject will not be dealt with in detail because it is the subject of Chapter 6 by Dr. Isner. The complex shape of the right ventricle complicates analysis of the influence of the pericardium on its size and function. The reader of this chapter therefore needs familiarity with the material contained in the first chapter of this book.

Left ventricular function in two cases of restrictive pericardial disease is described. In one, calcification of the pericardium was absent and the restrictive process, as judged by the response to atrial systole, was incomplete. In the other, calcification was extensive and the restrictive process was severe. Both patients had normal myocardial function in the presence of greatly depressed pump function. This apparent discrepancy may be explained on the basis of restriction of end-diastolic fiber stretch and reduction in the potential to augment stroke volume by way of the Frank-Starling mechanism.

The early and late results of total pericardiectomy performed during a 30-year period in 34 patients with chronic constrictive pericarditis are presented. The overall hospital mortality was 8.8%. The cumulative 5-, 10-, and 30-year survival rates were 79%, 65% and 53%, respectively. Preoperatively, 94% of the patients were classified in functional class III or IV (NYHA classification). After 3 months' follow-up, 94% of the surviving patients were in functional class I or II. After an average 14.2 year follow-up period, 94% of the surviving patients were in functional class I, and of these 72% were in fulltime jobs. It is concluded that the tendency towards early surgery should be encouraged, especially because the chronic state is accompanied by deleterious effects.

The diagnosis of constrictive pericarditis is frequently confused with that of mitral stenosis as well as other diseases. This paper presents clues for the early recognition of constrictive pericar...

A case of classic chronic calcific constrictive pericarditis had a benign 11-year course until appearance of an intercurrent lymphoma. Following treatment of the lymphoma there was a remission in the hemodynamic abnormalities caused by the pericarditis. It is important to consider complicating factors in the evaluation of constrictive pericarditis.

A case report of a patient with clinical and x-ray evidence of chronic constrictive pericarditis with a calcific pericardium is presented. The patient had negative tuberculin and positive histoplasmin skin tests. This suggests, along with a previous report, 6 that cases of pericardial calcification should include histoplasmin skin testing when the etiology is in doubt.

The hemodynamic findings in five patients are presented in order to demonstrate the variability in the clinical and physiologic patterns that may be encountered in restrictive disease of the pericardium. The mechanical effects of pericardial encasement previously described were confirmed. Furthermore, it was found that myocardial insufficiency and hypervolemia were not only important causative agents in the circulatory dysfunction but were in some measure reversible, thus permitting resolution of the congestive state and disappearance of the "typical" hemodynamic findings of constrictive pericarditis.

The “flat top and V” pattern of the electrokymogram in chronic constrictive pericarditis is discussed, as well as the different opinions expressed by the various authors in regard to this finding. The findings obtained by analytic roentgenkymography in 16 cases of chronic constrictive pericarditis are reported. Such findings may be classified into two main types: a first type, which consists of a straight line due to standstill of the ventricular border, and a second type, trapezoid in form, due to partial rigidity of the walls. It is suggested that the discrepancies in the electrokymographic findings may be explained by the kymoanalytic results with two reasons: (1) The trapezoid pattern is not constant but only statistically prevalent. (2) Even in cases having a trapezoid type of movement, the electrokymogram may be deformed by variations in density of the paracardiac shadows.

Sixty-one patients with chronic cardiac compression were studied critically, the largest series in the literature. All patients had pericardiectomy performed. The operative mortality was 18 per cent. Satisfactory result was obtained 72.1 per cent of the patients operated. Tuberculosis was the cause in 28.2 per cent. In most of the remaining cases the etiology was obscure. The symptoms, physical signs, and laboratory examinations are reported. The physiologic studies after operation demonstrate improved cardiac filling and emptying. The importance of diagnosis and the desirability of pericardiectomy are stressed. With antibiotic therapy there is less risk in operating patients with active infection and the compression syndrome.

chronic constrictive pericarditis have long been known, but not until the advent of refined examination methods, particularly heart catheterization, was it possible to clarify the hemodynamic disturbance in this disease. Thanks to these methods it has been possible to form a clear conception of the patho-physiologic features of constrictive pericarditis and to offer adequate surgical treatment.

1. 1. In a series of eighteen cases of chronic constrictive pericarditis, five had coexisting rheumatic valvular disease and are reported in detail. 2. 2. If constrictive pericarditis is suspected in patients with heart disease who have an atypical course, more cases will be discovered. 3. 3. Cardiac enlargement, normal intensity of heart sounds, and normal cardiac pulsations are not rare in patients with constrictive pericarditis. 4. 4. The presence of definite rheumatic heart disease does not exclude the existence of associated chronic constrictive pericarditis although there is no evidence that the two conditions are causally related. 5. 5. It is of significance that in three of the five cases in which constrictive pericarditis was associated with rheumatic heart disease, there was a history of another etiologic factor which may have played a role in the development of the disease.

In the “primary” type of protein-losing gastroenteropathy, the anatomical abnormality in the parietal lymphatic system has been clearly shown by lymphangiography (5). Among the “secondary” types of protein-losing gastroenteropathies, it is now recognized that hypoproteinemia due to excessive protein loss from the digestive tract has been associated with chronic constrictive pericarditis. In protein-losing gastroenteropathy secondary to pericarditis, intestinal lymphangiectasia has been observed on jejunal biopsy (8), and thoracic duct hypertension has been proved by means of thoracic duct cannulation (4). But pathological conditions of the remainder of the lymphatic system in this disease have not been described. The purpose of this paper is to clarify the extent to which parietal lymphatic abnormalities exist in patients with protein-losing gastroenteropathy secondary to constrictive pericarditis. To this end, one such patient was studied with lymphography performed before and after pericardiectomy. Case...

Non-diagnostic electrocardiographic tracings are encountered frequently which do not coincide with the criteria of established picture. They are occasionally confused with more characteristic patterns. Such variations which are included in this discussion are found in neurocirculatory asthenia, acute nonspecific myocarditis or pericarditis, chronic constrictive pericarditis, thyroid dysfunctions, beriberi, and various electrolyte imbalances. Recognition of suggestive patterns in conjunction with a careful history, examination, and other laboratory studies may prove vital since most of these conditions are reversible with appropriate therapy.

Excerpt The purpose of this paper is to present the clinical syndrome of chronic constrictive pericarditis as it occurred in two patients on whom a total of three pericardial resections was done. S...

A series of 102 therapeutic pericardiectomies is presented. Although the majority were performed for tuberculosis, those performed in the most recent decade have mainly been for effusion due to a variety of causes. Because of the lower operative mortality (11 vs. 18%) and relative ease of the procedure, operation during the effusion stage is encouraged. Wide pericardiectomy for effusion pericarditis is recommended to decrease the likelihood of the patient's developing delayed chronic constrictive pericarditis.

Chronic constrictive pericarditis impairs normal diastolic filling of the heart and usually results in the classic clinical triad of increased venous pressure, ascites and a small quiet heart.1 Occasionally, however, this process may simulate other cardiac abnormalities, as illustrated by the following case.

Chronic constrictive pericarditis, being an uncommon disease, may present problems in diagnosis, especially in cases without pericardial calcification. Consequently, there is frequently a prolonged interval between the onset of symptoms and eventual diagnosis, and it is probable that the condition occasionally escapes diagnosis completely. The diagnostic difficulties are of two types. At one level, the relative rarity of the disease leads to a lack of awareness on the part of the examiner. This is generally the main source of difficulty. Less frequently, there is an awareness of the possibility of constriction but there is difficulty in distinguishing it from restrictive cardiomyopathy. This differentiation can frequently be made by special techniques,1-3 but it may also be possible to do so by careful bedside examination. An analysis of a series of cases of constrictive pericarditis seen during the past 25 years directed attention to two clinical signs with a high level of specificity. These are precordial systolic retraction and a third sound accentuated by inspiration. The majority of previous publications have not referred to these signs; a minority have done so but in a cursory fashion .1,4 In one instance only has a frequency level been provided for one of the signs.5 Of a consecutive series of 34 cases of chronic constrictive pericarditis of a fibrotic or fibrocalcific type, 28 provided information on one or both of these signs. The value of the signs came to be appreciated only gradually so that both were not always assessed in earlier patients. Of the 28 patients, 17 had pericardial calcification on x-ray examination and in these the diagnosis presented little difficulty. Eleven patients lacked calcification and in these the mean interval between the onset of symptoms and final diagnosis was 3.4 years (11 years in one instance). Six patients had been diagnosed as definite cases of cardiomyopathy of unknown cause

In Reply.— Paradoxical pulse undoubtedly does occur in some instances of inactive chronic constrictive pericarditis. Dr Sasse makes an interesting and useful point that analysis of the respiratory changes in timing of A2and P2may show correlations with various degrees of paradoxical pulse. The relationship of inspiratory variations in venous return to paradoxical pulse in various types of pericardial disease is not completely elucidated and should be studied further, perhaps with Doppler flow-pattern studies and with echocardiographic studies of cardiac dimensions.