Constrictive Pericarditis

Constrictive Pericarditis

Constrictive pericarditis (CP) is a chronic condition where the pericardium becomes fibrotic, thickened, and non-compliant, leading to impaired diastolic filling with equalization of diastolic pressures and ventricular interdependence.

Etiology

Cause	Important Points
Idiopathic / Viral	Most common in developed world
Tuberculosis	Most common in India
Post-cardiac surgery	Increasing cause
Radiation-induced	Delayed, associated with myocardial fibrosis
Connective tissue disease	SLE, RA
Malignancy	Rare but aggressive
Uremia	Chronic inflammation
Purulent pericarditis	Leads to fibrosis
Trauma	Post-hemorrhagic

Pathophysiology

1. Loss of pericardial compliance

Thickened ± calcified pericardium → fixed cardiac volume

2. Rapid early diastolic filling + abrupt halt

Early filling normal → “dip”
Sudden stop → “plateau”

Classic: Dip-and-plateau (square root sign)

3. Ventricular interdependence

Inspiratory ↑ RV filling → septal shift → ↓ LV filling
Expiration opposite

Hallmark of constriction (vs restrictive cardiomyopathy)

4. Dissociation of pressures

Intrathoracic pressure ↓ in inspiration
But intracardiac pressure does NOT fall → impaired LV filling

5. Equalization of diastolic pressures

RA ≈ RVEDP ≈ LVEDP ≈ PCWP (within 5 mmHg)

Hemodynamic Signature

Feature	Finding
RA pressure	Elevated
RV/LV diastolic pressures	Equalized
Ventricular tracing	Dip-and-plateau
Respiratory variation	Prominent

Clinical Features

1. Right-sided heart failure dominates

Pedal edema
Ascites (often massive)
Hepatomegaly

2. Classical signs

Kussmaul’s sign-↑ JVP during inspiration
Due to inability of RV to accommodate venous return

Pericardial knock-Early diastolic sound (earlier than S3)

Elevated JVP with prominent y descent(Rapid early filling)

Cachexia (“cardiac cirrhosis”)

Investigations

Chest X-ray

Pericardial calcification (suggestive, not always present)

Echocardiography (MOST IMPORTANT)

Septal bounce (shudder)
Respiratory variation in mitral/tricuspid flow (>25%)
Annulus reversus

e’ medial > e’ lateral

Hepatic vein expiratory diastolic reversal

CT / MRI

Pericardial thickness >4 mm
Calcification
MRI: inflammation vs fibrosis (important for reversibility)

Cardiac Catheterization (Gold Standard if doubt)

Hemodynamic hallmarks:

Dip-and-plateau
Equalization of diastolic pressures
Discordant LV/RV systolic pressures with respiration

Differential Diagnosis

Condition	Key Difference
restrictive cardiomyopathy	No ventricular interdependence
cardiac tamponade	No y descent, pulsus paradoxus
Cirrhosis	Low JVP
Pulmonary HTN	RV failure dominant

Constrictive Pericarditis vs Restrictive Cardiomyopathy

Feature	Constrictive Pericarditis	Restrictive Cardiomyopathy
Cause	Pericardium	Myocardium
Ventricular interdependence	Present	Absent
Respiratory variation	Present	Minimal
e’ velocity	Normal/high	Reduced
Annulus reversus	Present	Absent
BNP	Mild ↑	Markedly ↑
CT/MRI	Thick pericardium	Normal pericardium

Types of Constriction

Type	Description
Chronic	Fibrotic, irreversible
Subacute / transient	Inflammatory → reversible
Effusive-constrictive	Tamponade + constriction

Management

1. Medical (limited role)

Indications:

Transient/inflammatory constriction

Drugs:

NSAIDs
Steroids
Colchicine

2. Diuretics

Symptomatic relief (reduce congestion)
Avoid overdiuresis → ↓ preload → hypotension

3. Definitive: Pericardiectomy

Indications:

Symptomatic CP (NYHA II–IV)
Chronic constriction

Procedure:

Complete pericardial stripping

Outcomes:

Dramatic improvement if:

Early surgery
No myocardial fibrosis

Decision Algorithm

Patient with:

Ascites + raised JVP + normal EF

Step:

Do echo
If constriction suspected → REFER CARDIOLOGY EARLY
If diagnostic doubt → Cath (gold standard)
If confirmed + symptomatic → Pericardiectomy