Constrictive Pericarditis and Its Echocardiographic Features

Constrictive pericarditis is a condition characterized by the thickening, fibrosis, and often calcification of the pericardium, which can also be accompanied by pericardial effusion. This pathological change restricts normal cardiac filling, leading to a range of clinical manifestations and hemodynamic abnormalities.

Clinical Presentation

Patients often experience symptoms such as chest tightness, shortness of breath, fatigue, and exertional dyspnea. Physical examination may reveal elevated jugular venous pressure, with a positive Kussmaul's sign — an increase in jugular venous pressure during inspiration. Other signs include hepatomegaly, splenomegaly, a positive hepatojugular reflux, and the presence of shifting dullness indicating fluid accumulation. A pericardial knock, an early diastolic sound, may also be audible upon auscultation.

Echocardiographic Evaluation

Echocardiography plays a crucial role in diagnosing constrictive pericarditis. Using multiple imaging planes, two-dimensional echocardiography can reveal significant pericardial thickening, increased echogenicity, and calcifications, particularly in the atrioventricular groove region. The presence of pericardial effusion along with these findings further supports the diagnosis.

Key Two-Dimensional Findings

Typical echocardiographic features include enlargement of both atria, a smaller than normal ventricular cavity resembling a "water bottle" or "flask" shape, and abnormal septal motion. The interventricular septum may exhibit a respiratory pattern known as "septal bounce," moving toward the right ventricle during expiration and toward the left ventricle during inspiration.

M-Mode Echocardiography Insights

M-mode imaging may show a characteristic "V-shaped" indentation of the interventricular septum during diastole. This is due to increased end-diastolic pressure and reduced ventricular filling. Another notable sign is a reversed E/F slope of the mitral valve, which is considered a specific indicator of constrictive physiology.

Doppler Echocardiography Characteristics

Doppler assessment reveals distinct patterns at the atrioventricular valves. In constrictive pericarditis, pulsed-wave Doppler across the mitral valve typically shows a tall E wave, a reduced A wave, and a decreased E-F slope. During inspiration, flow velocities at the tricuspid valve increase, while those at the mitral valve decrease — a phenomenon known as "respiratory discordance."

Diagnostic Criteria

The key echocardiographic criteria for diagnosing constrictive pericarditis include pericardial thickness greater than 3 mm, increased echogenicity, calcification, and the presence of mild pericardial effusion. If significant thickening and calcification are observed specifically in the atrioventricular groove, constrictive pericarditis should be strongly considered.