Pericardite cronica costrittiva
Table of Contents
Definizione
La pericardite cronica costrittiva è una conseguenza rara, fortemente invalidante, di un processo infiammatorio cronico del pericardio, che porta a una riduzione del riempimento ventricolare e della gittata cardiaca. La pericardite cronica rappresenta generalmente l’esito di una pericardite di lunghissima durata.
Eziologia
La causa resta spesso ignota. La pericardite costrittiva di origine tubercolare è divenuta rara nei paesi industrializzati nei quali le cause più frequenti sono il cancro (seno, polmone, linfoma maligno), contusione del cuore, radioterapia.
Anatomia patologica
Ispessimento fibroso o fibrocalcare (soprattutto nella forma tubercolare) del sacco pericardico che può raggiungere 1 cm di spessore. Il cuore è costretto in una gabbia rigida inestensibile; gli strati miocardici sotto- epicardici possono atrofizzarsi. Un versamento sieroso separa i due foglietti del pericardio nella forma subacuta. Fegato, rene e milza vanno incontro a stasi venosa (pseudo cirrosi-pericardica)
Fisiopatologia
Il riempimento diastolico è rapido all’inizio delle diastole e fortemente limitato alla fine delle diastole, mentre nel tamponamento diastolico è limitato durante tutta la diastole. La pressione telediastolica aumenta fortemente; ne risulta una stasi venosa con congestione delle giugulari, epatomegalia ed edemi periferici.
Manifestazioni cliniche
Il quadro clinico è dominato dai segni e sintomi di scompenso destro, in presenza di una contrattilità ventricolare sinistra normale o solo lievemente ridotta.
Nella fase iniziale della patologia è frequente riscontrare edemi agli arti inferiori e lieve fastidio addominale da stasi epatica.
In una fase più avanzata si rende evidente il quadro di ascite e di congestione venosa del circolo polmonare con dispnea da sforzo, tosse e ortopnea. Possono insorgere anche fibrillazione atriale e insufficienza della tricuspide.
Le fasi tardive sono caratterizzate dai segni e sintomi di bassa gittata periferica, che si sovrappongono a quelli dello scompenso destro; il paziente lamenta facile affaticabilità, danno muscolare e calo ponderale.
Negli stadi terminali le manifestazioni cliniche sono sovrapponibili a quelli dello scompenso cardiaco destro e dell’epatopatia terminale. All’esame obiettivo il paziente appare deperito, subitterico. L’addome è spesso globoso per e la presenza di ascite, sono presenti edemi periferici.
Diagnosi
La diagnosi viene posta attraverso l’integrazione di dati clinici, ecocardiografici ed emodinamici.
ECG
Non vi sono segni patognomonici; è possibile riscontrare soltanto alterazioni aspecifiche dell’onda T in molte derivazioni e una riduzione diffusa dei voltaggi dei complessi QRS.
Radiografia del torace
Mostra ingrandimento dell’atrio destro; l’ombra cardiaca nel complesso non è ingrandita, tranne nei casi in cui concomita un versamento pericardico. E’ possibile osservare (soprattutto nei casi di pericardite tubercolare) la presenza di calcificazioni pericardiche, che di per sé non è un segno specifico di pericardite costrittiva in quanto le calcificazione non sono necessariamente correlata alle modificazioni emodinamiche che questa condizione comporta.
Ecocardiogramma
L’ecocardiogramma bidimensionale e M-mode evidenziano soprattutto l’ispessimento e la rigidità del pericardio, che si configurano come un segnale ben definito con una ridotta escursione diastolica, all’esterno della parete ventricolare.
Decorso e prognosi
La pericardite cronica costrittiva è una patologia evolutiva a esito infausto in assenza di terapia.
Terapia
Data la gravità del quadro clinico e la prognosi della patologia, è necessario intervenire il prima possibile una volta fatta la diagnosi. L’unico approccio terapeutico efficace e risolutivo è l’asportazione chirurgica del pericardio o pericardiectomia. La terapia medica con diuretici e la restrizione salina è utile per migliorare la sintomatologia riducendo il sovraccarico idrico e gli edemi periferici, ma a lungo termine comporta l’insorgenza di un certo grado di refrattarietà.
Ti potrebbero interessare:
- Pericardite acuta
- Fibrillazione atriale
- Insufficienza tricuspidale
- Tubercolosi (TBC)
- Scompenso cardiaco o insufficienza cardiaca
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References:
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