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Pericardial effusion, acute and chronic pericarditis – treatment

Pericarditis is an inflammation of the pericardium. The most common causes of pericarditis with effusion formation are acute myocardial infarction and viral infections. While tuberculosis used to be considered the main cause of pericarditis, viral pericarditis is now the primary cause.

Overview

Already, cases of pericarditis after COVID-19 infection have also been reported in the literature. Other possible causes include diseases of the immune system, rheumatologic and oncologic diseases, and conditions following extensive radiation to the chest.

Drug treatment

In the early stages of the disease, there is usually an accumulation of fluid in the pericardium. Pericardial effusion is not infrequently observed even after unproblematic heart surgery. With early drug therapy, excessive fluid accumulation in the pericardium can be prevented. If this is not the case, the accumulation of fluid in the pericardium can lead to impaired pumping function (pericardial tamponade) of the heart due to the impeded filling. In this case, the effusion must be relieved by drainage (using ultrasound guidance or surgically through a small incision at the lower end of the sternum). If the pericardium fills up again after a single drainage, a so-called pericardial fenestration into the chest cavity or into the abdominal cavity is performed at best – so that the fluid does not cause compression of the heart and is better reabsorbed in the long term.

Surgical treatment

Regardless of the etiology, the inflammatory process leads to adhesions between the epicardium and the pericardium and to increasing fibrotic thickening of the pericardial tissue. In the chronic stage, it is not uncommon for calcifications to occur that are visible on conventional chest radiographs (see Figure). These changes lead to obstruction of diastolic ventricular filling, resulting in venous backflow and reduced cardiac output.  The scarring can constrict the pericardium to such an extent that the heart cannot expand sufficiently. In this case, the heart is referred to as an armored heart (chronic constrictive pericarditis). In this form of chronic pericarditis with the corresponding symptoms of reduced performance (accompanied by shortness of breath, arrhythmia, feeling of fullness in the upper abdomen), pericardectomy (removal of the pericardium) is the only effective therapy.

The procedure is usually performed through a sternotomy and can usually be done without a heart-lung machine. An alternative approach considered is the lateral approach through the ribs. However, this approach does not allow complete release of the constriction in the area of the right atrium and the confluence of the vena cavae. In older and less symptomatic patients, conservative and drug therapy with diuretics is the main approach. Removal of the thickened pericardium results in a decrease in filling pressures; this may occasionally lead to a transient deterioration of ventricular pump function. The short-term collapse in circulatory function can be counteracted perioperatively with drugs to counteract the risk of excessive dilatation of the heart.

Typical picture of calcified chronic pericarditis
Typical picture of calcified chronic pericarditis

For patients

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For referrals

University Hospital Zurich
Universitäres Herzzentrum Zürich
Rämistrasse 100
8091 Zürich

Tel. +41 44 255 15 15