So with constriction the thorax pressure and the pulmonary venous pressure will drop, but there are phasic filling differences within the heart, because the gradient to fill the left side of the heart is decreased. The heart is no longer able to push outward against the pericardium, so the pressure is forced inward into the cardiac chambers. So during expiration, the pressure in the right atrium causes flow reversal in the hepatic veins. Whereas, with chronic late stages of restriction, there is an inspiratory reversal during diastole, because there is no shifting of septum and the right heart cannot accommodate increased flow which results from chronic diastolic dysfunction and this causes hepatic vein reversal.
So while diagnosing Constrictive Pericarditis on echocardiography can certainly be a challenge, it can be done with confidence. Paying close attention to the details and recognizing when your patient with heart failure symptoms might actually be more than meets the eye, can help to make the correct diagnosis and ensure adequate treatment for your patient.
Lara Miller, RDMS, RVT, RDCS, RCCS, ACS, FASE
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(13): 1380-6.
Myers RB, Spodick DH. Constrictive pericarditis: clinical and pathophysiologic characteristics. Am Heart J. 1999;138(2 Pt 1):219-32.
Mehta A, Mehta M, Jain AC. Constrictive pericarditis. Clin Cardiol. 1999;22(5):334-44.
Hancock EW. Differential diagnosis of restrictive cardiomyopathy and constrictive pericarditis. Heart. 2001;86(3): 343-9.
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(6):1317-23.
Talreja DR, Edwards WD, Danielson GK, et al. Constrictive pericarditis in 26 patients with histologically normal pericardial thickness. Circulation. 2003;108(15):1852-7.
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(1):86-94.
Oh JK, Hatle LK, Seward JB, et al. Diagnostic role of Doppler echocardiography in constrictive pericarditis. J Am Coll Cardiol. 1994;23(1):154-62.
Hatle LK, Appleton CP, Popp RL. Differentiation of constrictive pericarditis and restrictive cardiomyopathy by Doppler echocardiography. Circulation. 1989;79(2):357-70.
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(4):796-9.
Sengupta PP, Mohan JC, Mehta V et al. Accuracy and pitfalls of early diastolic motion of the mitral annulus for diagnosing constrictive pericarditis by tissue Doppler imaging. Am J Cardiol. 2004;93(7):886-90.
Ha JW, Ommen SR, Tajik AJ, et al. Differentiation of constrictive pericarditis from restrictive cardiomyopathy using mitral annular velocity by tissue Doppler echocardiography. Am J Cardiol. 2004;94(3):316-9.
Garcia MJ, Rodriguez L, Ares M, et al. Differentiation of constrictive pericarditis from restrictive cardiomyopathy: assessment of left ventricular diastolic velocities in longitudinal axis by Doppler tissue imaging. J Am Coll Cardiol. 1996;27(1):108-14.
von Bibra H, Schober K, Jenni R, et al. Diagnosis of constrictive pericarditis by pulsed Doppler echocardiography of the hepatic vein. Am J Cardiol. 1989;63(7):483-8.
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(9):976-8.
Reuss CS, Wilansky SM, Lester SJ, et al. Using mitral 'annulus reversus' to diagnose constrictive pericarditis. Eur J Echocardiogr. 2009;10(3):372-5.
Sengupta PP, Mohan JC, Mehta V et al. Doppler tissue imaging improves assessment of abnormal interventricular septal and posterior wall motion in constrictive pericarditis. J Am Soc Echocardiogr. 2005;18(3):226-30.
Sengupta PP, Krishnamoorthy VK, Abhayaratna WP, et al. Disparate patterns of left ventricular mechanics differentiate constrictive pericarditis from restrictive cardiomyopathy. JACC Cardiovasc Imaging. 2008;1(1):29-38.
Circ Cardiovasc Imaging. 2014 May;7(3):526-34. doi: 10.1161/CIRCIMAGING.113.001613. Epub 2014 Mar 14.
American Society of Echocardiography Clinical Recommendations for Multimodality Cardiovascular Imaging of Patients with Pericardial Disease (J Am Soc Echocardiogr 2013;26:965-1012.)