Constrictive Pericarditis: Key Radiographic Features and Clinical Insights

Constrictive pericarditis is a chronic condition characterized by thickening and scarring of the pericardium, which restricts the heart's ability to expand normally. Radiographic imaging plays a crucial role in identifying this condition, with several key X-ray findings being particularly indicative of the disease.

Typical X-Ray Findings in Constrictive Pericarditis

1. Triangular or Flask-Shaped Cardiac Silhouette

One of the hallmark signs of constrictive pericarditis on chest X-ray is a heart that appears triangular or flask-like in shape. This is due to the rigid pericardium limiting normal cardiac expansion, often resulting in straightened or irregular cardiac borders.

2. Narrowed Aortic Arch with Superior Vena Cava Dilation

Another notable radiographic feature is a narrowed aortic arch, which may be accompanied by dilation of the superior vena cava. This combination can suggest elevated venous pressure and impaired cardiac filling, both commonly seen in constrictive pericarditis.

3. Reduced Cardiac Pulsation and Pulmonary Congestion

Diminished cardiac motion is frequently observed on fluoroscopy or dynamic X-ray imaging. In addition, signs of pulmonary congestion may be present due to increased pressure in the pulmonary circulation, reflecting impaired left ventricular filling.

4. Pericardial Thickening and Calcification

Pericardial thickening is a key diagnostic clue and may appear as focal or diffuse density changes. Importantly, the presence of patchy or speckled pericardial calcification is highly suggestive of chronic constrictive pericarditis, often indicating long-standing inflammation.

Pathophysiology and Clinical Implications

Constrictive pericarditis typically develops as a sequel to chronic inflammation of the pericardium, often following an episode of pericardial effusion. One of the most common causes is prior infection, particularly tuberculous pericarditis, which can lead to fibrosis and calcification over time.

The thickened pericardium restricts the heart's ability to relax and fill properly, impairing both diastolic and systolic function. This results in reduced cardiac output and systemic hypoperfusion, alongside increased pressure in the pulmonary veins, leading to symptoms such as fatigue, edema, and dyspnea.

Management and Treatment Options

While medical management may offer temporary relief of symptoms, the definitive treatment for severe constrictive pericarditis is surgical pericardiectomy—removal of the thickened pericardium. This procedure can significantly improve cardiac function and quality of life for patients, especially when diagnosed early.