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.
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Terminology
While classification schemes differ throughout the literature, effusive-constrictive pericarditis is often defined as one of the three primary constrictive pericardial syndromes 1.
Epidemiology
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
Clinical presentation
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
Radiographic features
Echocardiography
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