12-phase flow (10)

1. 1FRAME
   Effusive-constrictive pericarditis = effusion + tamponade + persistent constrictive physiology after drainage; pericardiocentesis relieves the effusion but residual visceral constriction persists; definitive therapy is anti-inflammatory + etiology-specific Rx OR pericardiectomy if chronic/refractory (Sagristà-Sauleda NEJM 2004 PMID 15128896; ESC 2015)
   inputs: sbp
   advance: effusive-constrictive physiology suspected on echo
2. 2ENTRY
   Recognize tamponade clinically (Beck triad + pulsus); echo confirms effusion; SPECIFIC features hinting at underlying constriction (septal bounce, mitral E-wave variation >25%, IVC plethora) (Klein JASE 2013)
   inputs: age
   advance: tamponade + constriction features documented
3. 3CONTEXT
   Etiology screen — TB exposure + HIV, prior cardiac surgery, mediastinal radiation history, malignancy, rheumatologic disease, recurrent pericarditis history; CRP/ESR for active inflammation
   inputs: etiology_screen_tb_radiation_malignancy_autoimmune_post_surgical, crp_esr
   advance: etiology hypotheses framed
4. 4RED_FLAGS
   Tamponade obstructive shock (SCAI C+); cardiogenic decompensation post-drainage from residual constriction; concurrent disseminated TB if TB suspected (ESC 2015)
   inputs: sbp, hr
   advance: shock + post-drain decompensation risk stratified
5. 5INITIAL_WORKUP
   STAT echo, ECG, CXR, troponin, BMP, CBC, CRP, ESR, baseline ALT/Cr; HIV test if TB suspected; etiology-specific labs (autoimmune panel, tumor markers, IGRA) (ESC 2015)
   inputs: echo_pre_drainage, creatinine, crp_esr
   actions: cardiac_tamponade, panel.cardiac, panel.renal
   advance: echo confirms tamponade + initial etiology workup launched
6. 6BRANCHING_WORKUP
   Cardiac MRI (pericardial thickness, late gadolinium enhancement = active inflammation vs fibrosis); right heart catheterization if equivocal hemodynamics; pericardial fluid analysis post-drain (cell count, cytology, ADA, IGRA, Xpert, AFB, glucose, LDH, protein); pericardial biopsy if etiology unclear (ESC 2015; Klein JASE 2013)
   inputs: cardiac_mri_for_pericardial_thickness_and_inflammation
   advance: fluid + biopsy specimens analyzed + MRI characterizes constriction substrate
7. 7TREATMENT
   Step 1 echo-guided pericardiocentesis (diagnostic + therapeutic); Step 2 INVASIVE pre-/post-drain hemodynamics — RA fails to fall ≥50% or to <10 mmHg confirms effusive-constrictive (Sagristà-Sauleda); Step 3 NSAID + colchicine per ICAP for inflammatory etiology; Step 4 etiology-specific Rx (RIPE for TB; immunosuppression for autoimmune; oncology for malignancy); Step 5 PERICARDIECTOMY (visceral + parietal stripping) if chronic refractory constriction persists despite medical therapy 3-6 mo OR if radiation/calcific substrate (ESC 2015 Class IIa)
   inputs: invasive_hemodynamics_pre_post_drain, sbp
   advance: drainage performed + post-drain hemodynamics captured + medical therapy initiated + pericardiectomy decision documented
8. 8DISPOSITION
   CCU/ICU post-drainage with hemodynamic monitoring (post-drain decompensation possible from residual constriction); cardiothoracic surgery consult if pericardiectomy considered; multidisciplinary pericardial team (cardiology + cardiothoracic surgery + ID if TB + rheumatology if autoimmune)
   advance: multidisciplinary disposition confirmed
9. 9MONITORING
   Re-accumulation surveillance (echo q24-48h × 7d then weekly); CRP trend (target normalisation per ICAP); MRI repeat at 3 mo to assess inflammation resolution vs fibrotic progression; serial RHC if symptomatic constriction develops
   actions: panel.cardiac
   advance: inflammation + constriction surveillance plan documented
10. 10FOLLOWUP
    Long-term cardiology + cardiothoracic surgery + etiology-specific specialist follow-up; pericardiectomy if symptomatic constriction persists at 6 mo despite optimal medical therapy (ESC 2015 Class IIa)
    advance: long-term follow-up plan + pericardiectomy decision documented