Constrictive Pericarditis
Definition
Loss of pericardial elasticity causing impaired diastolic ventricular filling, presenting as a heart failure syndrome typically with preserved ejection fraction. Can be transient/subacute (predominantly inflammatory, potentially reversible) or chronic (often fibrotic/calcified, irreversible).
Key Concepts
Pathophysiology
- Pericardial inelasticity dissociates intrathoracic and intracardiac pressures during respiration, causing accentuated interventricular dependence and elevated bilateral diastolic filling pressures sources/pericarditis-acc-2025 (very high)
- Two distinct forms with fundamentally different prognosis and treatment:
- Transient/inflammatory constrictive pericarditis: significant pericardial inflammation; may resolve spontaneously or with anti-inflammatory therapy over 3–6 months
- Chronic constrictive pericarditis: irreversible pericardial thickening and fibrosis (often calcified); requires surgical radical pericardiectomy
Etiology
Outside TB-endemic areas (most common to less common) sources/pericarditis-acc-2025 (very high):
- Idiopathic (most common)
- Post-cardiac surgery
- Prior mediastinal radiation
- In TB-endemic areas: tuberculosis is the most common cause
Effusive Constrictive Pericarditis
- Distinct entity: persistent constrictive pathophysiology after drainage of pericardial effusion sources/pericarditis-acc-2025 (very high)
- Attributed to marked inflammation of the visceral pericardium
- Classically diagnosed invasively (RA pressure fails to decrease after pericardiocentesis); now often diagnosed by constrictive features on TTE post-drainage
Diagnosis — Multimodality Imaging
TTE (Primary and Initial Modality)
sources/pericarditis-acc-2025 (very high):
- Respirophasic ventricular interdependence/septal shift (E-wave mitral inflow variation >25%; tricuspid >40%)
- E-wave predominant LV filling pattern
- Elevated medial mitral annular e' velocity (>8 cm/s) — key differentiator from restrictive cardiomyopathy
- Annulus reversus: medial > lateral mitral e' annular velocity
- Dilated IVC (<50% collapse)
- Hepatic vein end-diastolic expiratory reversal/forward flow velocity ≥0.8
- No single isolated finding is diagnostic; constellation of findings + clinical features required
CMR (Complementary — Most Comprehensive for Inflammation)
sources/pericarditis-acc-2025 (very high):
- Pericardial thickness (increased)
- Respirophasic ventricular interdependence on free-breathing cine white-blood sequences
- Wall tethering and conical deformity of ventricle
- LGE + T2-STIR: identifies active pericardial inflammation (transient CP) — indicates potential response to anti-inflammatory therapy
- Mild LGE may be present with fibrosis; significant LGE + T2-STIR suggests transient/inflammatory CP
CCT (Supplementary)
- Best modality for pericardial calcifications — present in ~1/3 of chronic cases sources/pericarditis-acc-2025 (very high)
- Essential for preoperative evaluation of pericardiectomy (defines anatomy, relationship to sternum)
Invasive Cardiac Catheterization (When Noninvasive Data Incongruent)
sources/pericarditis-acc-2025 (very high):
- Elevated and equalized right- and left-sided diastolic pressures
- Rapid x and y descent (Kussmaul's sign); dip-and-plateau waveforms
- Respirophasic ventricular interdependence; intrathoracic-intracardiac dissociation
- Systolic area index (LV/RV systolic pressure discordance) confirms constrictive physiology
Differentiation from Cardiac Tamponade and Restrictive Cardiomyopathy
Key distinguishing features from restrictive cardiomyopathy sources/pericarditis-acc-2025 (very high):
| Feature | Constrictive Pericarditis | Restrictive Cardiomyopathy |
|---|---|---|
| Mitral annular e' | Normal/increased (>8 cm/s) | Reduced |
| Annulus | Reversus (medial > lateral) | Normal (lateral > medial) |
| Myocardial LGE | Absent (pericardial LGE in transient) | Abnormal myocardial pattern |
| Ventricular interdependence | Present | Absent |
| Pericardial thickness | Increased | Normal |
| Hepatic vein reversals | Expiratory | Inspiratory |
Management
Transient/Inflammatory Constrictive Pericarditis
sources/pericarditis-acc-2025 (very high):
- First-line: anti-inflammatory therapy (NSAIDs + colchicine ± anti-IL-1 agents) for 3–6 months before considering pericardiectomy
- Resolves constrictive physiology in many cases; if pericardiectomy still required, less-inflamed pericardium facilitates more successful surgery
- In tuberculous constrictive pericarditis: antituberculous therapy; adjunctive corticosteroids may enhance improvement
Chronic Constrictive Pericarditis
sources/pericarditis-acc-2025 (very high):
- Diuretics: symptomatic relief of volume overload; does not alter natural history
- Radical pericardiectomy: preferred definitive treatment
- Resection of entire pericardium (anterior + diaphragmatic + posterior segments) on cardiopulmonary bypass
- Must be performed at experienced tertiary surgical centers for optimal outcomes
- Partial anterior/diaphragmatic pericardiectomy alone: not recommended
- Goal-directed heart failure therapy: limited evidence
Contradictions / Open Questions
- Distinction between transient and chronic constrictive pericarditis can be challenging without CMR; the presence and extent of LGE/T2-STIR guides this distinction sources/pericarditis-acc-2025 (very high)
- Optimal anti-inflammatory regimen for transient CP not established by RCT
Connections
- Related to concepts/Pericarditis — constrictive pericarditis as a complication
- Related to concepts/Pericardial-Effusion — effusive constrictive pericarditis
- Related to entities/Heart-Failure — presents as HF with preserved EF
Sources
- sources/pericarditis-acc-2025 — Primary source; 2025 ACC Expert Consensus Statement