Constrictive Pericarditis


Constrictive pericarditis


  • Certain causes of pericarditis such as tuberculosis, haemopericardium, bacterial infection and rheumatic heart disease result in the pericardium becoming thick, fibrous and calcified.
  • This may also develop late after open heart surgery, and fibrosis also occurs with the use of dopamine agonists, e.g. cabergoline, perigolide.
  • Constrictive pericarditisvsrestrictive cardiomyopathy
    • Constrictive pericarditis should be distinguished from restrictive cardiomyopathy .The two conditions are very similar in their presentation, but the former is fully treatable, whereas most cases of the latter are not.

Clinical features

  • The symptoms and signs of constrictive pericarditis occur due to:
    • reduced ventricular filling (similar to cardiac tamponade, i.e. Kussmaul’s sign, Friedreich’s sign, pulsusparadoxus)
    • systemic venous congestion (ascites, dependent oedema, hepatomegaly and raised JVP)
    • pulmonary venous congestion (dyspnoea, cough, orthopnoea, PND) less commonly
    • reduced cardiac output (fatigue, hypotension, reflex tachycardia)
    • rapid ventricular filling (‘pericardial knock’ heard in early diastole at the lower left sternal border)
    • atrial dilatation (30% of cases have atrial fibrillation).



  • Chest X-ray shows a relatively small heart in view of the symptoms of heart failure.
    • Pericardialcalcification is present in up to 50%.
    • A lateral chest film may be useful in detecting calcification that is missed on an AP film. However, a calcified pericardium is not necessarily a constricted one
  • ECG reveals low-voltage QRS complexes with generalized T wave flattening or inversion.
  • Echocardiography shows thickened calcified pericardium, and small ventricular cavities with normal wall thickness.
  • CT and CMR are used to assess pericardial anatomy and thickness (3 mm or greater)
  • Endomyocardial biopsy may be helpful in distinguishing constrictive pericarditis from restrictive cardiomyopathy in difficult cases.
  • Cardiac catheterization.
  • End-diastolic pressures in the left and right ventricles measured during this procedure are usually equal, owing to pericardial constriction.


The treatment for chronic constrictive pericarditis is complete resection of the pericardium. This is a risky procedure with a high complication rate due to the presence of myo- cardial atrophy in many cases at the time of surgery. Thus early pericardiectomy is suggested in non-tuberculous cases, before severe constriction and myocardial atrophy have developed.

In cases of tuberculous constriction, the presence of pericardial calcification implies chronic disease.

    • Current evidence tends to favourearly pericardiectomy with antituberculous drug cover in these cases.
    • If there is no calcification, a course of antituberculous therapy should be attempted first.
    •  If the patient’s haemodynamic state remains static or deteriorates after 4–6 weeks of therapy, pericardi- ectomy is recommended.

    Calcific Constrictive Pericarditis
    constrictive pericarditis presentation
    Constrictive Pericarditis
    Patient case studies focusing on Constrictive Pericarditis.
    Constrictive pericarditis four-chamber, ECG-gated cine SSFP MR
    In mid-diastole, the thickened pericardium begins to restrict right ventricular filling, causing a rapid increase in ventricular pressure. Early changes of septal flattening and bowing of the interventricular septum toward the left ventricle (normally concave in shape toward the left ventricle during diastolic filling) are seen. This pressure change results in diastolic septal dysfunction, the septal bounce described in echocardiography.
    4.8. Constrictive Pericarditis – Chest X-Rays – Dr. Vaidya
    Causes of pericarditis