Effusive-constrictive pericarditis

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.

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