From Diagnosis to Definitive Surgical Therapy: An Approach to Constrictive Pericarditis and Pericardiectomy

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Constrictive pericarditis is a challenging clinical condition in which the pericardium becomes thickened, fibrotic, and often calcified, resulting in impaired diastolic filling and progressive symptoms of right-sided heart failure. This video demonstrates the step-by-step diagnostic and surgical approach to treating a patient with advanced constrictive pericarditis. 
 
The diagnostic workup integrated physical examination, multimodality imaging, and invasive hemodynamic assessment. Echocardiography revealed characteristic features, including a septal bounce, exaggerated respiratory variation in inflow velocities, biatrial enlargement, and impaired ventricular strain patterns. Catheterization confirmed the diagnosis by demonstrating near-equalization of diastolic pressures, an elevated central venous pressure, and the classic dip-and-plateau (square root) sign. Computed tomography further delineated the extent of pericardial calcification and associated effusion. 
 
Surgical pericardiectomy remains the only definitive therapy and should be performed thoroughly to achieve meaningful symptom relief. In this case, a complete pericardiectomy was carried out, beginning between the phrenic nerves and extending across the anterior, diaphragmatic, and lateral surfaces to the posterior left ventricular region. Dense calcified plaques were removed meticulously in small pieces, ensuring protection of the atrial walls, coronary arteries, and phrenic nerves. Adequate decompression was confirmed by visual improvement in ventricular filling and by intraoperative hemodynamic changes. 
 
The patient’s postoperative course was notable for rapid diuresis, resolution of venous congestion, and significant improvement in functional capacity. Follow-up echocardiography demonstrated restored atrial septal motion and reduced tricuspid regurgitation. 

References

1. The Society of Thoracic Surgeons. (2024). STS Cardiothoracic Surgery E-Book. Unbound Medicine / Society of Thoracic Surgeons.
2. Sellke, F. W., del Nido, P. J., & Swanson, S. J. (Eds.). (2024). Sabiston and Spencer surgery of the chest (10th ed.). Elsevier.
3. Schulz-Menger, J., Collini, V., Gröschel, J., Adler, Y., Brucato, A., Christian, V., ... & Imazio, M. (2025). 2025 ESC Guidelines for the management of myocarditis and pericarditis: Developed by the task force for the management of myocarditis and pericarditis of the European Society of Cardiology (ESC) Endorsed by the Association for European Paediatric and Congenital Cardiology (AEPC) and the European Association for Cardio-Thoracic Surgery (EACTS). European heart journal, 46(40), 3952-4041.
4. Matshela, M. R. (2017). Constrictive pericarditis: prevention and treatment. European Society of Cardiology, 15, 24.

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