Constrictive pericarditis
Septal shift, preserved medial e′, expiratory hepatic reversal — and how to separate it from restriction.
Numbers to remember
- Mayo criteria: respiration-related septal shift, medial e′ ≥9 cm/s, hepatic vein expiratory diastolic reversal ratio ≥0.79 [57]
- Septal shift plus either medial e′ ≥9 or HV ratio ≥0.79: sensitivity 87%, specificity 91% [57]
- Mitral E respiratory variation ≥25% [178]
- Annulus reversus: lateral e′ < medial e′ [179]
Questions echo must answer
Constrictive pericarditis is a stiff pericardium that limits total cardiac filling. It dissociates intrathoracic from intracardiac pressures and exaggerates ventricular interdependence. It is curable by pericardiectomy, and transient inflammatory forms respond to anti-inflammatory therapy, so missing it is costly [31,125]. The central differential is restrictive cardiomyopathy, where the myocardium is stiff and relaxation is impaired [57,178].
- InterdependenceRespiratory septal shift (septal bounce) and inflow variation [57,178].
- Myocardial relaxation preserved?Medial e′ normal or high; annulus reversus [57,179].
- Venous patternExpiratory hepatic vein diastolic reversal; plethoric IVC [57].
- PericardiumThickening, calcification, effusion (effusive-constrictive).
- InflammationTransient constriction? CRP and CMR LGE [31,125].
Acquisition protocol
- PLAX / PSAX M-modeEarly-diastolic septal notch and respirophasic septal shift. Look for posterior wall flattening in mid–late diastole.
- A4CWatch the septum move towards the LV with inspiration. Use a slow sweep with a respiratory trace.
- Mitral inflow PWMeasure the maximal (expiration) and minimal (inspiration) E. Variation = (exp − insp)/exp [178].
- Tricuspid inflowReciprocal inspiratory increase.
- Tissue DopplerMedial and lateral e′ [57,179].
- Hepatic vein PW (subcostal)Diastolic forward and reverse velocities in expiration → reversal ratio [57].
- IVCPlethora with little collapse.
- TR velocityUsually <3 m/s in constriction; high in restriction.
- PericardiumThickness and brightness; effusion.
- Septal bounce and respiratory shift
- Mitral E variation (%)
- Medial e′ (cm/s)
- Lateral vs medial e′ (annulus reversus)
- Hepatic vein expiratory reversal ratio
- IVC
- TR velocity / PASP
- Pericardial thickening, calcification, effusion
Diagnosis & severity
Mayo Clinic echo criteria (130 surgically confirmed constriction vs restriction or severe TR) [57]
| Criterion | Sensitivity | Specificity |
|---|---|---|
| Respiration-related ventricular septal shift | 93% | 69% |
| Medial e′ ≥9 cm/s | 83% | 81% |
| Hepatic vein expiratory diastolic reversal ratio ≥0.79 | 76% | 88% |
| Septal shift and (medial e′ ≥9 or HV ratio ≥0.79) | 87% | 91% |
Constriction vs restriction
| Feature | Constriction | Restrictive cardiomyopathy |
|---|---|---|
| Septal shift with respiration | Present | Absent |
| Mitral E respiratory variation | ≥25% [178] | <10–15% |
| Medial e′ | Preserved (≥9 cm/s) | Reduced (often <6 cm/s) |
| Medial vs lateral e′ | Medial > lateral (annulus reversus) [179] | Lateral ≥ medial |
| Hepatic vein reversal | Expiratory | Inspiratory |
| PASP | Usually <50 mmHg | Often >50 mmHg |
| Wall thickness, atria | Normal walls | Thick walls (amyloid); very large atria |
Thresholds that change management
- Echo suggests constriction → CT for calcification and pericardial thickness; CMR for inflammation (LGE, oedema) and real-time septal motion; right-and-left-heart catheterisation with simultaneous pressures if still uncertain [31,125].
- Raised CRP and pericardial LGE on CMR → transient inflammatory constriction is possible; try anti-inflammatory therapy before surgery [125].
- Chronic constriction with NYHA class III–IV symptoms → pericardiectomy at an experienced centre [31].
- Effusive-constrictive → RA pressure stays high after pericardiocentesis. Follow up for evolution [31].
Pitfalls & mimics
PitfallRespiratory variation is not specific. COPD, asthma, obesity, PE and tamponade all exaggerate inflow variation. In COPD, SVC flow varies widely with respiration, whereas in constriction it does not [178].
- Atrial fibrillation: measure beats after similar RR intervals and look for the septal shift on 2D.
- Post-cardiac surgery septum moves abnormally anyway. Rely on e′ and hepatic veins.
- Normal pericardial thickness does not exclude constriction. Thickness on TTE is unreliable.
- Mixed disease: radiation injury can cause both constriction and restrictive myocardial disease.
- E/e′ is paradoxically low in constriction (annulus paradoxus). Do not call it "normal filling pressure".