Management of constrictive pericarditis in the 21st century

Definitive treatment for constrictive pericarditis is surgical pericardiectomy. Because constriction may be transient in a small proportion of patients, particularly those with exudative effusions, the initial treatment for constrictive pericarditis should be conservative, with loop diuretic therapy to manage volume expansion and edema and the use of colchicine, nonsteroidal anti-inflammatory agents, or, if necessary, glucocorticoid therapy for active inflammation. For subjects with persisting evidence of constriction, symptomatic management is advised for those with only minimal symptoms. Surgical pericardiectomy is advised for subjects with New York Heart Association class II or III symptoms and persisting evidence of constriction at echocardiography and cardiac catheterization and with associated pericardial abnormality on CT or MRI. Complete resection of the pericardium and, where possible, the diseased epicardium via a midline sternotomy is the favored approach, although a video-assisted thoracoscopic approach may be suitable in some subjects. Lateral thoracotomy should be used for suppurative pericarditis to avoid sternal infection. Because of higher mortality, increased complication rates, and suboptimal clinical outcomes, pericardiectomy should be avoided in older patients or those with radiation-induced disease, very advanced symptoms, or evidence of myocardial fibrosis.