Effusive-constrictive pericarditis

Last revised by Rengarajan R on 29 Jul 2021

Effusive-constrictive pericarditis is a rare constrictive pericardial syndrome of a constellation of findings in which a fibrotic visceral pericardium and a pericardial effusion contribute to cardiac tamponade pathophysiology. It is most often encountered after the performance of a pericardiocentesis; removal of pericardial fluid for tamponade due to a pericardial effusion results in a rapid decrease in right atrial pressure, whereas those with effusive-constrictive pericarditis will have an absent or blunted (<50%) drop 1.

While classification schemes differ throughout the literature, effusive-constrictive pericarditis is often defined as one of the three primary constrictive pericardial syndromes 1

Effusive-constrictive pericarditis is rare, reported occurring in <1% of patients with pericardial disease. The most common etiology in developing nations is tuberculosis (secondary to tuberculous pericarditis) and is most commonly idiopathic in the developed world. Other etiological associations include 3:

  • radiation
  • post-surgical
  • neoplastic

The patient presentation typically significant for features of both constrictive pericarditis and a hemodynamically significant pericardial effusion (or overt tamponade) including:

  • dyspnea
  • tachycardia
  • chest pain
  • peripheral edema
  • ascites

Prior to pericardiocentesis, suggestive features on transthoracic echocardiography in the presence of pericardial effusion include;

  • exaggerated mitral septal annular e' velocity
    • velocities of the septal and lateral annuli of the mitral valve are often measured as surrogates of diastolic function
    • septal e' velocity, as measured by tissue Doppler imaging, should be lower than the e' velocity of the lateral annulus
    • relationship reversed in constrictive physiology, a phenomenon known as annulus reversus
  • complex effusions
  • respirophasic shifts of the interventricular septum
    • inspiratory shift to the left, expiratory shift to the right 5

Echocardiographic features suggestive of effusive-constrictive pericarditis after the removal of the pericardial effusion include 6;

  • variation in mitral inflow velocity E wave >25% with respiration
    • measurement achieved by placing a pulsed wave Doppler gate at the tips of the mitral valve leaflets
  • hepatic venous Doppler D wave velocity blunted
    • diastolic flow may also be reversed on expiration
  • respirophasic septal shift
    • alternating direction with inspiration/expiration
  • annulus reversus
    • exaggeration of the septal annular e' velocity
  • dilation of the inferior vena cava
    • hepatic veins also often dilated
    • loss of inspiratory collapse

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Cases and figures

  • Case 1: complex pericardial effusion
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