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.