1. Anesthesia for constrictive pericarditis
Dr. S. Parthasarathy
MD., DA., DNB, Dip. Diab. DCA,
Dip. Software based statistics-
PhD ( physiology),
IDRA

2. What is pericardium ??
Two-layered sac that encircles the heart Inner serosal layer ( visceral pericardium ) adhering to the outer wall of the heart
Reflected at the level of the great vessels joins the tough fibrous outer layer ( parietal pericardium ).
50 ml fluid for frictionless movement

3. What does pericardium do ?
Fixes the heart within the mediastinum
When intracardiac volume rises suddenly , it prevents cardiac dilation
Infection spread from lungs
Without pericardium , can any one exist ?
Yes ,
so doubts about its real use ?

4. What is constrictive pericarditis ?
Constrictive pericarditis is a clinical syndrome defined by impaired expansion of the heart by a rigid, chronically inflamed/thickened pericardium.
Only ultra structural changes in 20 % cases
The predominant form is chronic constriction without pericardial effusion.
Effusive-constrictive forms are equally important

5. Why should it occur ?? Idiopathic - 50 %
Tuberculous % ( India - >??)
Post infarction
After viral pericarditis
Radiotherapy
Fungal - parasitic infections very rare

6. Clinical features fatigue, peripheral oedema, breathlessness ?
abdominal swelling. Ascitis ?
Pulmonary venous congestion (exertional dyspnea, cough and orthopnea)
Chest pain typical of angina may be related to ? underperfusion of the coronary arteries or
? compression of an epicardial coronary artery by the thickened pericardium.
Hemodynamic compromise may be there

7. Possible differential diagnosis
Restrictive cardiomyopathy
RV infarction
COPD
The catch
jugular venous distension
Friedrich’s sign - rapid Y decent in JVP
Kussmauls’s sign - increasing JVP with inspiration

8. Confirm with what investigations ?

9. X ray may show calcifications
From the internet for closed academic purpose only

10. Pleural effusions are present in about 60 %
Persistent unexplained pleural effusions can be the presenting manifestation
The ECG may show
low-voltage QRS complexes
nonspecific ST-T changes
Atrial arrhythmias

11. Echocardiography and other imaging
Right heart function
Effusion and tamponade
CT is diagnostic
MR scan will delineate constrictive pericariditis
A pericardial thickness of greater than 4 mm
( normal is 2 ) -- evidence of constrictive pericarditis in the clinical setting.
Absence of pericardial thickening does not exclude constrictive pericarditis

12. Dip and plateau sign
RV diastolic pressure, pulmonary artery diastolic pressure, right atrial pressure,and pulmonary capillary wedge pressures are equal.

13. Coronary angiography ?
In all patients over 35 years
in patients with a history of mediastinal irradiation, regardless of the age
Pulmonary veins are extra pericardial
Reciprocal filling of ventricles due to noncompliance
LV filling drops in systole

14. Fixed low output with noncompliant heart

15. Management Progressive disease Minority need diuretics
Steroids NSAIDs, ATT are options
Otherwise pericardiectomy ( both visceral and parietal)
No beta blockers or other ca channel blockers which affect heart rate
Rate dependent output

16. No routine pericardiectomy in
Cardiomegaly – suspicion of myocardial damage
Elderly patients with severe liver dysfunction
Cachexia
Densely calcified pericardium
Patients with ? life expectancy.

17. Preoperative considerations
Good diuretic dosage and relieve congestion
Pleural tap if needed
Antibiotic and ATT if its on
All routine investigations and LFT
Invasive lines and postoperative ICU care should be explained
Uremic pericarditis – leave alone upperlimb
Surgical challenge !! – 15 % mortality !!

18. Grid No brady No myocardial depression
Preload and afterload to be maintained
Difficult to titrate IVFluids – think of urine output
CPB Vs NO CPB
Comfort Vs bleeds
Sternotomy or PL thoracotomy

19. Induction Midaz and high doses of morphine and fentanyl
Low doses of ketamine
Maintain IV fluid volume
CVP may not be an indicator
Drop in CVP is more significant
Urine output and other routine monitors

20. Intraoperative considerations
Entry into chamber and bleeds
Ready for CPB
Arrhythmias – lignocaine infusion
Brady – beta agonists or pacing
Hypotension
Inotropes for low cardiac output state
Coronories – not damaged ??
Left thoractomy – lung compression ?

21. Decortication of the LV before RV is recommended by some.
theoretical possibility of producing sudden pulmonary edema if the RV is freed first.

22. Lateral thoracotomy
Para vertebral or epidural can be given for perioperative analgesia.
Postoperative decrease in CVP is more important than intraop increase
Symptomatic improvement in 90 % but hemo dynamics will be normalized in 60 % only.

23. Low cardiac output 70 % don’t improve immediately – not like tamponade
Need mechanical ventilation for a few days
Need inotropes for a few days
The possible causes of low CO are injury to coronary arteries, residual pericardial scar, constrictive epicardium or underlying myocardial disease

24. Summary Definition Anatomy Clinical features Preop management
Intraop management
Post op care