Role of Echocardiography in the Diagnosis of Constrictive Pericarditis

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The clinical recognition of constrictive pericarditis (CP) is important but challenging. In addition to Doppler echocardiography, newer echocardiographic techniques for deciphering myocardial deformation have facilitated the noninvasive recognition of CP and its differentiation from restrictive cardiomyopathy. In a patient with heart failure and a normal ejection fraction, echocardiographic demonstration of exaggerated interventricular interdependence, relatively preserved left ventricular longitudinal deformation, and attenuated circumferential deformation is diagnostic of CP. This review is a concise update on the pathophysiology and hemodynamic features of CP, the transmural and torsional mechanics of CP, and the merits and pitfalls of the various echocardiographic techniques used in the diagnosis of CP.

Section snippets

Pathophysiology of Constrictive Pericarditis

In CP, the visceral pericardium and the parietal pericardium are fibrosed and fused together,2 although not necessarily always thickened (Figure 2A).12 Calcification can result in the formation of pericardial calcium plaques (eggshell appearance), which may penetrate into the myocardium.2 The incidence and prevalence of pericardial calcification is dependent on the underlying cause of CP and is less commonly encountered in developing nations as the incidence of tuberculous pericarditis has

Echocardiographic Diagnosis of Constrictive Pericarditis

The echocardiographic diagnosis of CP was originally based on M-mode echocardiographic findings and subsequently on 2-dimensional echocardiography and Doppler hemodynamics in response to the respiratory cycle. More recently, newer echocardiographic techniques, such as pulsed tissue Doppler, color Doppler tissue imaging (DTI), and speckle-tracking imaging, have been used to assess the unique changes in global and regional myocardial function seen in CP. However, while interpreting the role of

Pericardium

The detection of increased pericardial thickness may be of help in making a diagnosis of CP,35 but M-mode38 and 2-dimensional echocardiography62 show poor sensitivity and correlation with pathologic specimen measurements. Transesophageal echocardiography, on the other hand, because of superior resolution, showed high sensitivity (95%) and specificity (86%) to detect a pericardium ≥3 mm thick.63 Nevertheless, about 1 in 5 patients with CP have normal pericardium,12 and the isolated finding of

Conclusion

Multiple echocardiographic findings are used to confirm a diagnosis of CP, but demonstration of enhanced cardiac intracavitary blood flow variations during respiration, abnormal interventricular septal motion, and normal longitudinal mitral annular velocity provide the greatest diagnostic yield. In the presence of a mixed physiology (pericardial constraint combined with myocardial dysfunction), the diagnosis and therefore referral for pericardiectomy remain challenging. In such patients, the

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    This work was supported in part by a grant-in-aid to Dr Sengupta from the American Society of Echocardiography (Morrisville, NC).

    Drs Dal-Bianco and Sengupta contributed equally to this work.

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