Korean Circ J.  2012 Mar;42(3):143-150. 10.4070/kcj.2012.42.3.143.

Constrictive Pericarditis as a Never Ending Story: What's New?

• Sohn DW

• KMID: 2225027
• DOI: http://doi.org/10.4070/kcj.2012.42.3.143

Abstract

Nowadays, we have a better understanding of the natural history of constrictive pericarditis such as transient constriction. In addition, we have acquired the correct understanding of hemodynamic features that are unique to constrictive pericarditis. This understanding has allowed us to diagnose constrictive pericarditis reliably with Doppler echocardiography and differentiation between constrictive pericarditis and restrictive cardiomyopathy is no longer a clinical challenge. The advent of imaging modalities such as CT or MR is another advance in the diagnosis of constrictive pericarditis. We can accurately measure pericardial thickness and additional information such as the status of coronary artery and the presence of myocardial fibrosis can be obtained. We no longer perform cardiac catheterization for the diagnosis of constrictive pericarditis. However, these advances are useless unless we suspect and undergo work-up for constrictive pericarditis. In constrictive pericarditis, the most important diagnostic tool is clinical suspicion. In a patient with signs and symptoms of increased systemic venous pressure i.e. right sided heart failure, that are disproportionate to pulmonary or left sided heart disease, possibility of constrictive pericarditis should always be included in the differential diagnosis.

Keyword

Pericarditis, constrictive; Echocardiography, Doppler; Hemodynamics

MeSH Terms

Cardiac Catheterization
Cardiac Catheters
Cardiomyopathy, Restrictive
Constriction
Coronary Vessels
Diagnosis, Differential
Echocardiography, Doppler
Fibrosis
Heart Diseases
Heart Failure
Hemodynamics
Humans
Natural History
Pericarditis, Constrictive
Venous Pressure

Figure

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  Fig. 1 Pericardial calcification in a patient with constrictive pericarditis. In this patient with end-stage renal disease with multiple physical signs of increased systemic venous pressure, we can come to the diagnosis of constrictive pericarditis for sure with this chest X-ray finding even in the absence of further diagnostic tests.

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  Fig. 2 Increase in pericardial thickness seen in a computed tomographic image. Arrows: thickened pericardium.

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  Fig. 3 Classic cardiac hemodynamic findings in constrictive pericarditis. When the pericardial pressure is increased above the left atrial pressure, both left and right atrial pressure increase to the level of the pericardial pressure, resulting in the equalization of the left and right atrial pressures. During diastole, as the mitral and tricuspid valves are opened, this equalization in both atrial pressures results in equalization of four chamber pressures. In constrictive pericarditis, ventricular filling is not limited during early diastole but is limited during mid to late diastole. This feature results in dip and plateau patterns in both ventricular pressure waveforms and rapid Y descent in atrial pressure waveforms. In the atrial pressure waveforms, in association with the preserved X descent, this prominent Y descent results in M or W shaped atrial pressure waveforms.

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  Fig. 4 Schematic representation of the mechanism of respiratory variations in the mitral inflow and hepatic venous flow. BA: right atrium, RV: right ventricular, LA: left atrium, LV: left ventricular, PV: pulmonary vein, HV: hepatic venous flow. Reprinted from Oh JK et al. J Am Coll Cardiol 23:154-62, 1994 with permission.15)

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  Fig. 5 A: mitral inflow finding in constrictive pericarditis. Prominent increase in mitral E velocity during expiration is seen. B: hepatic vein flow. Diastolic flow reversal during expiration (arrows) is seen. MV: mitral inflow, HV: hepatic venous flow, insp: inspiration, exp: expiration.

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  Fig. 6 In a relatively volume depleted state, respiratory variation in the mitral inflow may not be present, and can be elicited when the intracardiac volume is increased by leg raising. A: respiratory variation in the mitral inflow is absent in the resting state. B: respiratory variation is manifested after leg raising.

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  Fig. 7 Hepatic vein flows obtained in a single patient. A: expiratory diastolic flow reversal characteristic feature in constrictive pericarditis is suspected. B: absence of increase in diastolic flow reversal during expiration. Only prominent A waves are seen in every cardiac cycle. Insp: inspiration, Exp: expiration.

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  Fig. 8 Although timing of respiratory change from inspiration to expiration may not be accurately reflected in the respirometer, (A) shows every cardiac cycle located during one phase of respiration, while (B) shows that respiratory change from inspiration to expiration or vice versa occur in the midst of every cardiac cycle. Insp: inspiration, Exp: expiration.

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  Fig. 9 Mitral annulus velocity in a patient with constrictive pericarditis before (A) and after (B) pericardiectomy. Mitral annulus velocity decreased after pericardiectomy when the constrictive physiology was relieved.

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  Fig. 10 Respiratory variation of the left ventricular size. Note the increase in dimension during expiration and opposite phenomenon during inspiration. insp: inspiration, exp: expiration.

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