Diagnosis of Constrictive Pericarditis
To The Editor:
The interesting case featured in “Images in Cardiovascular Medicine” in the March 3, 1998, issue of Circulation1 illustrates how elusive the diagnosis of constrictive pericarditis can be and demonstrates how important it is to perform a comprehensive 2-dimensional/Doppler echocardiographic examination on all patients referred to the echocardiography laboratory. In patients with symptoms and signs of congestive heart failure, it does not suffice to simply report on the systolic function of the left and right ventricles. Comprehensive evaluation should include assessment of diastolic function. Likewise, a comprehensive invasive evaluation, if needed, should not be limited to the nonspecific findings of a dip-and-plateau waveform and equalization of elevated ventricular diastolic pressures but should include an assessment of ventricular interdependence.2
Two-dimensional echocardiographic features suggestive of constrictive pericarditis, namely, abnormal motion of the interventricular septum and a dilated inferior vena cava, should prompt serious consideration of this diagnosis. Using pulsed-wave Doppler to assess diastolic filling, the echocardiographer can provide confirmatory evidence of constrictive pericarditis by demonstrating respiration-related changes in the mitral and tricuspid inflow velocities and in pulmonary vein and hepatic vein flow.2 3
The traditional criteria used for the invasive diagnosis of constrictive pericarditis have been shown to be nonspecific.4 Simultaneous right and left heart catheterization should include an assessment of the dynamic changes in intracardiac pressures that occur with respiration. Right and left ventricular systolic pressure changes are discordant in constrictive pericarditis because there is increased ventricular interdependence; these discordant changes are highly predictive of constrictive pericarditis.4
The decrease in the right ventricular diastolic pressure seen after pericardiectomy (Figure 1 of the March 3 case) reminds us that constrictive pericarditis is eminently treatable and should always be considered in the differential diagnosis of patients presenting with congestive heart failure, especially if ventricular systolic function is normal.
- Copyright © 1999 by American Heart Association
Correa SD, Amsterdam EA. Constrictive pericarditis. Circulation. 1998;97:806.
Hatle LK, Appleton CP, Popp RL. Differentiation of constrictive pericarditis and restrictive cardiomyopathy by Doppler echocardiography. Circulation. 1989;79:357–370.
Hurrell DG, Nishimura RA, Higano ST, Appleton CP, Danielson GK, Holmes DR Jr, Tajik AJ. Value of dynamic respiratory changes in left and right ventricular pressures for the diagnosis of constrictive pericarditis. Circulation. 1996;93:2007–2013.
We appreciate the thoughtful comments of Drs McCully, Higano, and Oh regarding our image, “Constrictive Pericarditis” (Circulation. 1998;97:806). We, of course, agree that in patients with congestive heart failure, echocardiographic evaluation (and invasive study, when indicated) should be thorough, as they describe. As they note, multiple abnormalities suggestive of constrictive pericarditis can be seen on both M-mode and 2-dimensional echocardiography. The specific abnormalities they describe are very valuable for detecting constrictive pericarditis, and the simultaneous presence of several of these abnormalities strongly supports the diagnosis. We chose to illustrate certain clinical findings pointing to this diagnosis and the confirmatory evidence of CT, which is more useful than echocardiography for quantifying pericardial thickness.