Synopsis
Distinguish potentially curable pericardial constriction from restrictive myocardium, identify transient inflammation and refer fixed disease for timely pericardiectomy.
- Constrictive pericarditis is impaired diastolic filling from a non-compliant pericardium and is a potentially curable cause of predominantly right-sided HF.
- Clues are raised JVP, prominent y descent, Kussmaul sign, pericardial knock, ascites and oedema with relatively clear lungs.
- Echo looks for ventricular interdependence: septal bounce, respiratory mitral/tricuspid inflow variation and expiratory hepatic-vein diastolic reversal.
- Medial mitral e-prime is often preserved or increased and may exceed lateral e-prime ('annulus reversus'), unlike myocardial restriction.
- CT defines calcification and thickness; CMR identifies inflammation—but normal thickness does not exclude physiological constriction.
- Inflammatory transient constriction may resolve with cause-specific/anti-inflammatory therapy and serial imaging.
- Complete pericardiectomy is definitive for persistent symptomatic fixed constriction; refer before cachexia, cirrhosis or severe end-organ dysfunction.
- Diuretics relieve congestion but excessive preload reduction can lower output and should not postpone surgical assessment.
Key red flags
Hypotension, hyponatraemia, renal dysfunction, jaundice/cardiac cirrhosis, severe hypoalbuminaemia or cachexia signals high operative risk and urgent referral.
Persistently elevated right-sided pressure after pericardial drainage suggests visceral-pericardial constriction and needs expert haemodynamic review.
Investigation priorities
Demonstrate interdependence and distinguish constriction from restriction.