The Noninvasive Diagnosis of Constrictive Pericarditis

Abstract

Until the mid-20th century, the noninvasive diagnosis of constrictive pericarditis (CP) was based on a typical constellation of physical signs and detection of pericardial calcification on the chest X-ray. The introduction of phonocardiography, apexcardiography and jugular venous pulse tracings made it possible to record in graphic form certain important physical signs such as the pericardial ‘knock’ and prominent jugular venous Y descent. During the 1970s, the availability of M-mode echocardiograms recorded on strip charts was an important advance, because it permitted imaging of the presence and extent of pericardial thickening or calcification. It also enabled the cardiologist to visualize and time certain abnormalities of motion of the ventricular septum, ventricular wall or pulmonic valve, each of which was hailed, when first introduced, as a ‘new echo sign of CP’. However, most such signs are nonspecific, not consistently present, or subtle to perceive. On the two-dimensional echogram, typical appearances include normal to small ventricles within a rigid thick pericardial shell, with abrupt halting of ventricular expansion early in diastole, and biatrial dilatation. The Doppler pattern of transmitral flow shows diagnostic promise, in particular an abnormally short deceleration phase of rapid early left ventricular filling indicates ‘restrictive’ or ‘constrictive’ ventricular pathophysiology. Recent imaging techniques such as computed tomography and magnetic resonance imaging also have a diagnostic role in CP inasmuch as they may provide better visualization of the extent and degree of thickening of the whole pericardial perimeter than can be achieved by cardiac ultrasound. In conclusion, the diagnosis of CP depends on assessment of physical signs and noninvasive investigations taken together. CP may be suspected if several échocardiographie ‘signs’ are evident in the same patient, especially if pericardial thickening and normal left ventricle size, contraction and wall thickness are noted in a patient with frank apparent right-sided congestive failure but no significant valve disease.