- Brian D Hoit, MD
Brian D Hoit, MD
- Professor of Medicine and Physiology and Biophysics
- Case Western Reserve University and University Hospitals of Cleveland
- Section Editors
- Martin M LeWinter, MD
Martin M LeWinter, MD
- Section Editor — Myopericardial Disease
- Professor of Medicine and Molecular Physiology and Biophysics
- University of Vermont
- Gabriel S Aldea, MD
Gabriel S Aldea, MD
- Section Editor — Cardiac Surgery
- Professor of Surgery
- University of Washington
- Edward Verrier, MD
Edward Verrier, MD
- Section Editor — Cardiac Surgery
- Professor of Surgery
- University of Washington School of Medicine
The normal pericardium is a fibroelastic sac surrounding the heart that contains a thin layer of fluid. When larger amounts of fluid accumulate (pericardial effusion) or when the pericardium becomes scarred and inelastic, one of three pericardial compressive syndromes may occur:
●Cardiac tamponade – Cardiac tamponade, which may be acute or subacute, is characterized by the accumulation of pericardial fluid under pressure. Variants include low pressure (occult) and regional tamponade.
●Constrictive pericarditis – Constrictive pericarditis is the result of scarring and consequent loss of the normal elasticity of the pericardial sac. Pericardial constriction is typically chronic, but variants include subacute, transient, and occult constriction.
●Effusive-constrictive pericarditis – Effusive-constrictive pericarditis is characterized by underlying constrictive physiology with a coexisting pericardial effusion, often with cardiac tamponade . This usually results in a mixed hemodynamic picture with features of both constriction and tamponade. Such patients may be mistakenly thought to have only cardiac tamponade; however, elevation of the right atrial and pulmonary wedge pressures after drainage of the pericardial fluid points to the underlying constrictive process.
In both typical constrictive pericarditis and effusive-constrictive pericarditis, cardiac filling is impeded by an external force. The normal pericardium can stretch to accommodate physiologic changes in cardiac volume. However, after its reserve volume is exceeded the pericardium markedly stiffens. In severe pericardial compressive syndromes, the pericardium becomes virtually inelastic, resulting in minimal ability to adapt to volume changes.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Hancock EW. Subacute effusive-constrictive pericarditis. Circulation 1971; 43:183.
- Troughton RW, Asher CR, Klein AL. Pericarditis. Lancet 2004; 363:717.
- Adler Y, Charron P, Imazio M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2015; 36:2921.
- Cameron J, Oesterle SN, Baldwin JC, Hancock EW. The etiologic spectrum of constrictive pericarditis. Am Heart J 1987; 113:354.
- Ling LH, Oh JK, Schaff HV, et al. Constrictive pericarditis in the modern era: evolving clinical spectrum and impact on outcome after pericardiectomy. Circulation 1999; 100:1380.
- Bertog SC, Thambidorai SK, Parakh K, et al. Constrictive pericarditis: etiology and cause-specific survival after pericardiectomy. J Am Coll Cardiol 2004; 43:1445.
- Szabó G, Schmack B, Bulut C, et al. Constrictive pericarditis: risks, aetiologies and outcomes after total pericardiectomy: 24 years of experience. Eur J Cardiothorac Surg 2013; 44:1023.
- George TJ, Arnaoutakis GJ, Beaty CA, et al. Contemporary etiologies, risk factors, and outcomes after pericardiectomy. Ann Thorac Surg 2012; 94:445.
- Vistarini N, Chen C, Mazine A, et al. Pericardiectomy for Constrictive Pericarditis: 20 Years of Experience at the Montreal Heart Institute. Ann Thorac Surg 2015; 100:107.
- Imazio M, Brucato A, Maestroni S, et al. Risk of constrictive pericarditis after acute pericarditis. Circulation 2011; 124:1270.
- Bansal R, Perez L, Razzouk A, et al. Pericardial constriction after cardiac transplantation. J Heart Lung Transplant 2010; 29:371.
- ROBERTSON R, ARNOLD CR. Constrictive pericarditis with particular reference to etiology. Circulation 1962; 26:525.
- Sekiguchi H, Horie R, Suri RM, et al. Constrictive pericarditis caused by immunoglobulin G4-related disease. Circ Heart Fail 2012; 5:e30.
- Stojan G, Melia MT, Khandhar SJ, et al. Constrictive pleuropericarditis: a dominant clinical manifestation in Whipple's disease. BMC Infect Dis 2013; 13:579.
- Bush CA, Stang JM, Wooley CF, Kilman JW. Occult constrictive pericardial disease. Diagnosis by rapid volume expansion and correction by pericardiectomy. Circulation 1977; 56:924.
- Spodick DH. The normal and diseased pericardium: current concepts of pericardial physiology, diagnosis and treatment. J Am Coll Cardiol 1983; 1:240.
- Talreja DR, Edwards WD, Danielson GK, et al. Constrictive pericarditis in 26 patients with histologically normal pericardial thickness. Circulation 2003; 108:1852.
- Ling LH, Oh JK, Breen JF, et al. Calcific constrictive pericarditis: is it still with us? Ann Intern Med 2000; 132:444.
- Cheitlin MD, Armstrong WF, Aurigemma GP, et al. ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography). Circulation 2003; 108:1146.
- Schnittger I, Bowden RE, Abrams J, Popp RL. Echocardiography: pericardial thickening and constrictive pericarditis. Am J Cardiol 1978; 42:388.
- Agatston AS, Rao A, Price RJ, Kinney EL. Diagnosis of constrictive pericarditis by pulsed Doppler echocardiography. Am J Cardiol 1984; 54:929.
- Ling LH, Oh JK, Tei C, et al. Pericardial thickness measured with transesophageal echocardiography: feasibility and potential clinical usefulness. J Am Coll Cardiol 1997; 29:1317.
- Engel PJ, Fowler NO, Tei CW, et al. M-mode echocardiography in constrictive pericarditis. J Am Coll Cardiol 1985; 6:471.
- Boonyaratavej S, Oh JK, Tajik AJ, et al. Comparison of mitral inflow and superior vena cava Doppler velocities in chronic obstructive pulmonary disease and constrictive pericarditis. J Am Coll Cardiol 1998; 32:2043.
- Tei C, Child JS, Tanaka H, Shah PM. Atrial systolic notch on the interventricular septal echogram: an echocardiographic sign of constrictive pericarditis. J Am Coll Cardiol 1983; 1:907.
- Hoit BD. Imaging the pericardium. Cardiol Clin 1990; 8:587.
- D'Cruz IA, Dick A, Gross CM, et al. Abnormal left ventricular-left atrial posterior wall contour: a new two-dimensional echocardiographic sign in constrictive pericarditis. Am Heart J 1989; 118:128.
- Ha JW, Oh JK, Ling LH, et al. Annulus paradoxus: transmitral flow velocity to mitral annular velocity ratio is inversely proportional to pulmonary capillary wedge pressure in patients with constrictive pericarditis. Circulation 2001; 104:976.
- Veress G, Ling LH, Kim KH, et al. Mitral and tricuspid annular velocities before and after pericardiectomy in patients with constrictive pericarditis. Circ Cardiovasc Imaging 2011; 4:399.
- Sun JP, Abdalla IA, Yang XS, et al. Respiratory variation of mitral and pulmonary venous Doppler flow velocities in constrictive pericarditis before and after pericardiectomy. J Am Soc Echocardiogr 2001; 14:1119.
- Oh JK, Hatle LK, Seward JB, et al. Diagnostic role of Doppler echocardiography in constrictive pericarditis. J Am Coll Cardiol 1994; 23:154.
- Oh JK, Tajik AJ, Appleton CP, et al. Preload reduction to unmask the characteristic Doppler features of constrictive pericarditis. A new observation. Circulation 1997; 95:796.
- Klein AL, Abbara S, Agler DA, et al. American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease: endorsed by the Society for Cardiovascular Magnetic Resonance and Society of Cardiovascular Computed Tomography. J Am Soc Echocardiogr 2013; 26:965.
- Welch TD, Ling LH, Espinosa RE, et al. Echocardiographic diagnosis of constrictive pericarditis: Mayo Clinic criteria. Circ Cardiovasc Imaging 2014; 7:526.
- Rienmüller R, Doppman JL, Lissner J, et al. Constrictive pericardial disease: prognostic significance of a nonvisualized left ventricular wall. Radiology 1985; 156:753.
- Verhaert D, Gabriel RS, Johnston D, et al. The role of multimodality imaging in the management of pericardial disease. Circ Cardiovasc Imaging 2010; 3:333.
- Sechtem U, Tscholakoff D, Higgins CB. MRI of the normal pericardium. AJR Am J Roentgenol 1986; 147:239.
- Breen JF. Imaging of the pericardium. J Thorac Imaging 2001; 16:47.
- Kojima S, Yamada N, Goto Y. Diagnosis of constrictive pericarditis by tagged cine magnetic resonance imaging. N Engl J Med 1999; 341:373.
- Masui T, Finck S, Higgins CB. Constrictive pericarditis and restrictive cardiomyopathy: evaluation with MR imaging. Radiology 1992; 182:369.
- Feng D, Glockner J, Kim K, et al. Cardiac magnetic resonance imaging pericardial late gadolinium enhancement and elevated inflammatory markers can predict the reversibility of constrictive pericarditis after antiinflammatory medical therapy: a pilot study. Circulation 2011; 124:1830.
- Zurick AO, Bolen MA, Kwon DH, et al. Pericardial delayed hyperenhancement with CMR imaging in patients with constrictive pericarditis undergoing surgical pericardiectomy: a case series with histopathological correlation. JACC Cardiovasc Imaging 2011; 4:1180.
- Thavendiranathan P, Verhaert D, Walls MC, et al. Simultaneous right and left heart real-time, free-breathing CMR flow quantification identifies constrictive physiology. JACC Cardiovasc Imaging 2012; 5:15.
- Hurrell DG, Nishimura RA, Higano ST, et al. Value of dynamic respiratory changes in left and right ventricular pressures for the diagnosis of constrictive pericarditis. Circulation 1996; 93:2007.
- Rajagopalan N, Garcia MJ, Rodriguez L, et al. Comparison of new Doppler echocardiographic methods to differentiate constrictive pericardial heart disease and restrictive cardiomyopathy. Am J Cardiol 2001; 87:86.
- Schoenfeld MH, Supple EW, Dec GW Jr, et al. Restrictive cardiomyopathy versus constrictive pericarditis: role of endomyocardial biopsy in avoiding unnecessary thoracotomy. Circulation 1987; 75:1012.
- Maisch B, Bethge C, Drude L, et al. Pericardioscopy and epicardial biopsy--new diagnostic tools in pericardial and perimyocardial disease. Eur Heart J 1994; 15 Suppl C:68.
- Guazzi M, Polese A, Magrini F, et al. Negative influences of ascites on the cardiac function of cirrhotic patients. Am J Med 1975; 59:165.
- Sagristà-Sauleda J, Permanyer-Miralda G, Candell-Riera J, et al. Transient cardiac constriction: an unrecognized pattern of evolution in effusive acute idiopathic pericarditis. Am J Cardiol 1987; 59:961.
- Haley JH, Tajik AJ, Danielson GK, et al. Transient constrictive pericarditis: causes and natural history. J Am Coll Cardiol 2004; 43:271.
- Chowdhury UK, Subramaniam GK, Kumar AS, et al. Pericardiectomy for constrictive pericarditis: a clinical, echocardiographic, and hemodynamic evaluation of two surgical techniques. Ann Thorac Surg 2006; 81:522.
- DeValeria PA, Baumgartner WA, Casale AS, et al. Current indications, risks, and outcome after pericardiectomy. Ann Thorac Surg 1991; 52:219.
- Ghavidel AA, Gholampour M, Kyavar M, et al. Constrictive pericarditis treated by surgery. Tex Heart Inst J 2012; 39:199.
- Busch C, Penov K, Amorim PA, et al. Risk factors for mortality after pericardiectomy for chronic constrictive pericarditis in a large single-centre cohort. Eur J Cardiothorac Surg 2015; 48:e110.
- Ha JW, Oh JK, Schaff HV, et al. Impact of left ventricular function on immediate and long-term outcomes after pericardiectomy in constrictive pericarditis. J Thorac Cardiovasc Surg 2008; 136:1136.
- Choudhry MW, Homsi M, Mastouri R, et al. Prevalence and Prognostic Value of Right Ventricular Systolic Dysfunction in Patients With Constrictive Pericarditis Who Underwent Pericardiectomy. Am J Cardiol 2015; 116:469.
- Hancock EW. On the elastic and rigid forms of constrictive pericarditis. Am Heart J 1980; 100:917.
- Sagristà-Sauleda J, Angel J, Sánchez A, et al. Effusive-constrictive pericarditis. N Engl J Med 2004; 350:469.
- Hancock EW. A clearer view of effusive-constrictive pericarditis. N Engl J Med 2004; 350:435.
- Hugo-Hamman CT, Scher H, De Moor MM. Tuberculous pericarditis in children: a review of 44 cases. Pediatr Infect Dis J 1994; 13:13.
- Ntsekhe M, Matthews K, Syed FF, et al. Prevalence, hemodynamics, and cytokine profile of effusive-constrictive pericarditis in patients with tuberculous pericardial effusion. PLoS One 2013; 8:e77532.
- Shabetai R. The Pericardium, Kluwer Academic Publishers, Norwell, MA 2003. p.227.
- CLINICAL PRESENTATION
- Physical examination
- Chest radiograph
- Two-dimensional and M-mode
- Doppler echocardiography
- CT scan
- Magnetic resonance imaging
- Hemodynamic evaluation
- Plasma BNP
- DIFFERENTIAL DIAGNOSIS
- Comparison with restrictive cardiomyopathy
- Comparison with cardiac tamponade
- Comparison with chronic liver disease
- TREATMENT AND OUTCOME
- Transient constrictive pericarditis
- Chronic constrictive pericarditis
- OCCULT CONSTRICTIVE PERICARDITIS
- EFFUSIVE CONSTRICTIVE PERICARDITIS
- Incidence and etiology
- Clinical features
- Treatment and course
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS