Multimodality Imaging of Constrictive Pericarditis: Pathophysiology and New Concepts

Abstract

Purpose of Review The unique pathophysiological changes of constrictive pericarditis (CP) can now be identified with better imaging modalities, thereby helping in its early diagnosis. Through this review, we outline the pathophysiology of CP and its translation into symptomology and various imaging findings which then are used for both diagnosis and guiding treatment options for CP. Recent Findings Multimodality imaging has provided us with the capability to recognize early stages of the disease and identify patients with a potential for reversibility and can be treated with medical management. Additionally, peri-procedural planning and prediction of post-operative complications has been made possible with the use of advanced imaging techniques. Summary Advanced imaging has the potential to play a greater role in identification of patients with reversible disease process and provide peri-procedural risk stratification, thereby improving outcomes for patients with CP.

My Approach to Echocardiographic Assessment for Constrictive Pericarditis

“…• During systole, restricted movement of the posterior wall of the left ventricle is observed due to pericardial adhesion. There is also an abrupt relaxation of the posterior wall with subsequent flattening of the endocardial movement during the rest of the diastole, which can be well observed in the M-mode; 6 • Mitral annulus reversus, present in 74% of patients with CP, which represents the reversal of the normal ratio of early diastolic myocardial velocities with lateral e' smaller than septal e'. 6 The septal e' / lateral e' ratio ≥ 0.91 has a sensitivity (S) of 75% and specificity (E) of 85% 9 (Figures 1A, 1B, 1C and 1D);…”

“…5 In Europe and the United States, the most frequent etiology is idiopathic, followed by post-cardiac surgery, while in other parts of the world, such as Brazil, tuberculosis is more common. [5][6][7] The pathophysiology of CP is related to the elevation and equalization of cardiac pressures, since the heart is located in a fixed space determined by the rigid pericardium, to exaggerated ventricular interdependence and to the dissociation of intrathoracic and intracardiac pressures. 6,7 During inspiration, the rigid pericardium promotes the dissociation of intrathoracic and intracardiac pressures by preventing the decrease in intrathoracic pressure from being fully transmitted to the cardiac chambers.…”

“…[5][6][7] The pathophysiology of CP is related to the elevation and equalization of cardiac pressures, since the heart is located in a fixed space determined by the rigid pericardium, to exaggerated ventricular interdependence and to the dissociation of intrathoracic and intracardiac pressures. 6,7 During inspiration, the rigid pericardium promotes the dissociation of intrathoracic and intracardiac pressures by preventing the decrease in intrathoracic pressure from being fully transmitted to the cardiac chambers. Thus, as the pressure in the extrapericardial pulmonary veins decreases during inhalation, there is attenuation of the pulmonary venous gradient toward the left atrium, contributing to the reduction of left ventricle (LV) filling.…”

“…Thus, as the pressure in the extrapericardial pulmonary veins decreases during inhalation, there is attenuation of the pulmonary venous gradient toward the left atrium, contributing to the reduction of left ventricle (LV) filling. 5,6 During inspiration, the decrease in LV filling allows for an increase in right ventricle (RV) filling with a deviation of the interventricular septum to the left, configuring ventricular interdependence. Consequently, fillings related to the left heart (mitral, aortic, and pulmonary venous flows) decrease, while fillings related to the right heart (tricuspid, hepatic, pulmonary artery, and inferior vena cava) increase.…”

“…Suspicion of CP is based on clinical history and physical examination, and requires evaluation and confirmation by imaging and hemodynamic data. 6 Echocardiography is the most commonly used imaging modality for the initial assessment of pericardial disease, as it is widely available, safe, fast, and inexpensive compared to other methods, aiding in the diagnosis of CP and excluding other causes of diastolic heart failure. 10 Doppler echocardiographic findings in constriction:…”