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cardio.cardiac-tamponade.radiation-late-effusive-constrictive.v1

Cardiac tamponade — late post-radiation effusive-constrictive pericarditis

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Phase E variant of cardio.cardiac-tamponade.core.v1 — narrowed to LATE post-radiation effusive-constrictive pericarditis (5-20+ years after mediastinal radiation for Hodgkin lymphoma mantle field, left-sided breast cancer, lung cancer, esophageal cancer). Distinct from sibling cardio.cardiac-tamponade.radiation-induced.v1 (broader spectrum including acute pericarditis weeks post-RT and subacute effusion <1 year) and cardio.cardiac-tamponade.effusive-constrictive.v1 (broader physiology across all etiologies). Pathognomonic feature: pericardiocentesis FAILS to relieve elevated right atrial pressure / JVP — visceral pericardial fibrotic constriction persists after parietal effusion drainage (Sagristà-Sauleda NEJM 2004 PMID 14749453). HF-mimic differential mandatory — must distinguish from radiation-induced restrictive cardiomyopathy, primary HFpEF, valvular radiation disease, and metastatic recurrence using CMR (pericardial thickening >4 mm + LGE + tethering) + RH cath (square root sign + ventricular interdependence + dip-and-plateau) + tissue Doppler (annulus reversus, e′ >7 cm/s) per Talreja Circulation 2003 + ESC 2015. Treatment: Step 1 diuretic bridge (furosemide ± spironolactone ± metolazone) to euvolemia; Step 2 NSAID + colchicine for active inflammatory component on CMR (per ICAP PMID 23992557); Step 3 pericardiocentesis if effusion component significant (counsel that JVP will not normalize); Step 4 PERICARDIECTOMY (radical preferred over partial) as definitive — ≥80% surgical success when complete per Welch Mayo Clin Proc 2008 + Murashita Ann Thorac Surg 2017, but operative mortality 10-20% in radiation-damaged tissue per Bertog EHJ 2004 PMID 15010459 (refer to high-volume cardiothoracic center); Step 5 rilonacept for refractory inflammatory recurrence per RHAPSODY PMID 33999548; AVOID corticosteroids in radiation tissue (impairs wound healing); goals-of-care + palliative care if active cancer recurrence + limited prognosis. Cancer survivorship long-term cardiology surveillance per Lyon EHJ 2022 PMID 35993161 (annual echo + comprehensive cardiac MRI q3-5 yr in high-risk cohorts: mantle radiation, mean heart dose >15 Gy). Multidisciplinary cardiology + oncology + cardiothoracic + palliative care + anesthesiology coordination essential. Comorbidities common: radiation-induced premature CAD (Hancock JAMA 1993 PMID 8455714), valvular disease, restrictive CMP, AF (atrial fibrosis), lung fibrosis. Manifest pointer reuses cardio.cardiac-tamponade.core.v1 manifest. Design-brief pointer reuses parent (late effusive-constrictive specific differences documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute (Phase E wave 25).

Entry points (6)

  • history
    Cancer survivor (Hodgkin lymphoma mantle field, left-sided breast, lung, esophageal) 5-20+ years post-mediastinal radiation presenting with insidious progressive dyspnea + peripheral edema + ascites + fatigue (ESC 2015 §Effusive-Constrictive + §Radiation-Induced; Lyon EHJ 2022 PMID 35993161)
    hodgkin_breast_lung_survivor_5_to_20_yr_post_radiation_progressive_dyspnea_edema
  • imaging
    Echo with pericardial effusion + septal bounce + tissue Doppler annulus reversus + dilated IVC + Kussmaul respiratory variation in radiation survivor (Talreja Circulation 2003; ESC 2015)
    echo_effusion_with_septal_bounce_kussmaul_in_radiation_survivor
  • imaging
    Cardiac MRI showing pericardial thickening >4 mm + late gadolinium enhancement + tethering of pericardium to myocardium in patient 5+ years post-radiation (Lyon EHJ 2022; Heidenreich JACC 2010)
    cmr_pericardial_thickening_lge_in_late_radiation_survivor
  • symptom
    Persistent elevated JVP and right atrial pressure after apparently successful pericardiocentesis in radiation survivor — PATHOGNOMONIC for effusive-constrictive (Sagristà-Sauleda NEJM 2004 PMID 14749453)
    persistent_jvd_after_pericardiocentesis_in_radiation_survivor
  • history
    HF-like presentation (dyspnea + edema + ascites) in radiation survivor with PRESERVED LVEF + normal valves on echo — must rule in constrictive vs restrictive cardiomyopathy (ESC 2015; Heidenreich JACC 2010)
    hf_workup_negative_in_radiation_survivor
  • lab_abnormality
    Low/discordantly normal BNP relative to clinical congestion in radiation survivor — supports constrictive over restrictive/HF (ESC 2015 §Constrictive)
    low_bnp_with_high_jvp_pattern_radiation_survivor

Required inputs (11)

  • agerequired
    demographic • used at CONTEXT
    Late effusive-constrictive presents 5-20+ years post-radiation; median patient age 50-70 at presentation per Aleman JCO 2003 PMID 12586791
  • radiation_dose_field_timing_latencyrequired
    history • used at CONTEXT
    Mediastinal radiation specifics: dose (>30 Gy mantle for Hodgkin or mean heart dose >5 Gy per Darby NEJM 2013 PMID 23484825), field, latency 5-20+ years from completion; cancer type and current oncologic status
  • jvprequired
    vital • used at INITIAL_WORKUP
    Markedly elevated JVP with Kussmaul sign (paradoxical inspiratory rise) is hallmark; persists after pericardiocentesis if effusive-constrictive (Sagristà-Sauleda NEJM 2004)
  • sbprequired
    vital • used at RED_FLAGS
    BP often preserved in chronic effusive-constrictive (low-output but compensated); pulsus paradoxus may be present from effusion component (ESC 2015)
  • hrrequired
    vital • used at CONTEXT
    Sinus tachycardia compensatory; AF common in long-term radiation survivors (Lyon EHJ 2022)
  • echorequired
    imaging • used at INITIAL_WORKUP
    TTE with septal bounce + tissue Doppler annulus reversus + respiratory variation in mitral inflow (>25%) + dilated non-collapsing IVC + tethering — distinguishes constrictive from restrictive (Talreja Circulation 2003; ESC 2015 Class I)
  • cardiac_mrirequired
    imaging • used at INITIAL_WORKUP
    Cardiac MRI — pericardial thickening >4 mm, late gadolinium enhancement, tethering, real-time cine for septal bounce; gold standard differentiating constrictive vs restrictive (Lyon EHJ 2022; ESC 2015)
  • chest_ct
    imaging • used at INITIAL_WORKUP
    CT for pericardial calcification (highly specific for late radiation pericarditis) + thickness measurement + co-existing radiation lung/mediastinal pathology (Lyon EHJ 2022; Heidenreich JACC 2010)
  • bnp_or_nt_probnprequired
    lab • used at INITIAL_WORKUP
    Discordantly low/normal BNP relative to clinical congestion supports constrictive over restrictive/HF; BNP <100 with NYHA III-IV congestion is classic (ESC 2015)
  • creatininerequired
    lab • used at CONTEXT
    Renal function for diuretic + drug dosing + contrast-enhanced CMR/CT decisions; KDIGO 2026 race-free eGFR (Inker NEJM 2021)
  • cancer_status_remission_or_recurrencerequired
    history • used at CONTEXT
    Active vs remission cancer drives differential (radiation late effect vs metastatic recurrence) and goals of care for high-risk pericardiectomy (Lyon EHJ 2022)

12-phase flow (9)

  1. 1FRAME
    Late post-radiation effusive-constrictive pericarditis — combined effusion + visceral pericardial fibrotic constriction 5-20+ years after mediastinal radiation; pericardiocentesis fails to relieve elevated atrial pressures (pathognomonic); pericardiectomy preferred for symptomatic disease (high-risk in radiation tissue) (ESC 2015 §Effusive-Constrictive + §Radiation-Induced; Sagristà-Sauleda NEJM 2004 PMID 14749453)
    inputs: radiation_dose_field_timing_latency
    advance: late radiation effusive-constrictive context confirmed
  2. 2ENTRY
    Recognize cancer survivor 5-20+ years post-mediastinal radiation with insidious progressive dyspnea + edema + ascites + Kussmaul sign; HF-mimic differential mandatory (ESC 2015; Lyon EHJ 2022)
    inputs: age
    advance: late radiation survivor with constrictive symptoms identified
  3. 3CONTEXT
    Document radiation specifics (dose, field, mean heart dose, latency 5-20+ yr), cancer status, comorbidities (radiation-related premature CAD per Hancock JAMA 1993 PMID 8455714, valvular disease, restrictive CMP), prior pericardial procedures, functional status (predicts surgical candidacy)
    inputs: radiation_dose_field_timing_latency, cancer_status_remission_or_recurrence, creatinine
    advance: survivor + radiation + comorbidity context captured
  4. 4RED_FLAGS
    Acute decompensation triggers: NYHA IV congestion, hypotension, pre-renal AKI from low-output, atrial arrhythmias with RVR, refractory ascites + hepatic congestion (cardiac cirrhosis); tamponade physiology if effusion component dominant (ESC 2015)
    inputs: sbp, hr, jvp
    advance: decompensation severity stratified → admission level determined
  5. 5INITIAL_WORKUP
    TTE with tissue Doppler (annulus reversus, e′ >7 cm/s, septal bounce, respiratory variation), cardiac MRI (pericardial thickening >4 mm + LGE + tethering + real-time cine), CT (calcification + thickness), discordantly low BNP, ECG (low voltage, AF common), CBC + BMP + LFTs (cardiac cirrhosis), pericardial fluid analysis if drained (cytology + chemistry to rule out malignant recurrence) (Talreja Circulation 2003; Lyon EHJ 2022)
    inputs: echo, cardiac_mri, bnp_or_nt_probnp
    actions: panel.cardiac, panel.cbc
    advance: imaging + labs define effusive-constrictive pattern + bleeding/surgical risk quantified
  6. 6DIFFERENTIAL
    Differentiate: radiation-induced effusive-constrictive (this engine — LGE + thickening + calcification + cancer hx) vs radiation-induced restrictive cardiomyopathy (myocardial fibrosis without pericardial thickening) vs primary HFpEF (no pericardial pathology) vs radiation valvular disease vs metastatic recurrence (cytology + tumor markers + PET-CT) vs constrictive pericarditis from other etiology — RH cath with simultaneous LV/RV pressures (square root sign + ventricular interdependence + dip-and-plateau) is gold standard (ESC 2015 Class I; Talreja 2003)
    advance: diagnosis confirmed; effusive-constrictive vs restrictive distinguished
  7. 7TREATMENT
    Step 1 diuretic titration (furosemide ± spironolactone) for volume overload — bridge to surgery; Step 2 NSAID + colchicine for any inflammatory component on CMR (per ICAP PMID 23992557); Step 3 pericardiocentesis if effusion component significant (recognize that JVP will NOT fully normalize — pathognomonic); Step 4 pericardiectomy (radical preferred over partial) for symptomatic effusive-constrictive — definitive but high-risk in radiation tissue (operative mortality 10-20% per Bertog EHJ 2004 PMID 15010459; ≥80% surgical success when complete per Welch Mayo Clin Proc 2008); Step 5 rilonacept for refractory inflammatory recurrence per RHAPSODY PMID 33999548; AVOID corticosteroids as they impair healing in radiation tissue and rarely indicated; goals-of-care + palliative care discussion mandatory if active cancer recurrence + limited prognosis
    advance: multidisciplinary treatment plan including pericardiectomy decision finalized
  8. 8DISPOSITION
    CCU/floor admission for diuretic optimization + pre-operative workup; cardiothoracic surgery referral to high-volume center for pericardiectomy decision (radiation tissue surgery requires expertise); oncology + cardiology + cardiothoracic + palliative care multidisciplinary tumor board (Lyon EHJ 2022; Murashita Ann Thorac Surg 2017)
    advance: multidisciplinary disposition + surgical center identified
  9. 9MONITORING
    Diuretic response (weight, BMP daily); echo at 24-48h post-pericardiocentesis to confirm persistent constrictive physiology; CMR pre-op for surgical planning; long-term cancer-survivorship cardiac surveillance per Lyon 2022 (annual echo + CMR q3-5 yr in high-risk cohorts: mantle radiation, mean heart dose >15 Gy)
    advance: stable + surveillance plan documented