MioAtlas
G6: Pericardium

Constrictive pericarditis

Chronic fibrocalcific disorder of the pericardial sac in which parietal and visceral pericardial layers fuse into a rigid, thickened, non-compliant shell encircling and constricting the heart.

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Definition

Chronic fibrocalcific disorder of the pericardial sac in which parietal and visceral pericardial layers fuse into a rigid, thickened, non-compliant shell encircling and constricting the heart. It permits initial rapid early diastolic ventricular filling, but abruptly halts it in mid and late diastole when the inelastic pericardial limit is reached, generating dissociation between intrathoracic and intracardiac pressures and exaggerated ventricular interdependence [C2] [G6-05] [M5].

Severity criteria

  • Single grade: Established constrictive pericarditis defined by:
    • Mayo Clinic echocardiographic criteria:
    • In the study by Welch et al. [G6-05], «Five principal echocardiographic variables were selected based on prior studies and potential for clinical use: (1) respiration-related ventricular septal shift, (2) variation in mitral inflow E velocity, (3) medial mitral annular e' velocity, (4) ratio of medial mitral annular e' to lateral e', and (5) hepatic vein expiratory diastolic reversal ratio.» [G6-05].
    • Of these variables, «The presence of ventricular septal shift in combination with either medial e'≥9 cm/s or hepatic vein expiratory diastolic reversal ratio ≥0.79 corresponded to a desirable combination of sensitivity (87%) and specificity (91%).» [G6-05].
    • The authors conclude that «Respiration-related ventricular septal shift, preserved or increased medial mitral annular e' velocity, and prominent hepatic vein expiratory diastolic flow reversals are independently associated with the diagnosis of constrictive pericarditis.» [G6-05].
    • Hemodynamic and phonocardiographic criteria:
    • Elevation and equalization of end-diastolic pressures in all 4 chambers (difference ≤ 5 mmHg between mean right atrial pressure, RV end-diastolic pressure, and mean pulmonary capillary wedge pressure, typically all elevated to 14–22 mmHg) [C2] [M5].
    • Ventricular dip-and-plateau curve (square root sign) on intracavitary pressure tracings [C2] [G6-13] [M5].
    • Characteristics of the pericardial knock: «Pericardial knock was recognized as an early high frequency sound recorded between 90 to 120 ms after the aortic closing sound and occurring at the trough of the Y descent of the jugular venous pressure tracing.» [G6-13]. In this study it was noted that «The timing of the pericardial knock in five patients with constrictive pericarditis corresponded to a sudden and premature plateau of the diastolic left ventricular volume curve» [G6-13].

Findings by layer

Hemodynamics

  • Systemic venous congestion and elevated, equalized filling pressures [C2] [M5]:
    • Mean right atrial pressure: Elevated (14–20 mmHg) [C2] [M5].
    • Mean pulmonary capillary wedge pressure: Elevated (15–22 mmHg) [M5].
    • Cardiac output: Moderately depressed (3.2–4.8 L/min) [C2].
    • LV ejection fraction (left ventricular ejection fraction): Preserved (50–65%) in early stages [C2].
    • Systemic arterial blood pressure: Normotension or borderline systolic pressure (systolic blood pressure 100–120 mmHg, diastolic blood pressure 65–80 mmHg) [C2].

Rhythm

  • Normal sinus rhythm or atrial fibrillation [C2] [G6-06]. Ling et al. evaluated this clinical spectrum: «The contemporary spectrum of CP in 135 patients (76% male) evaluated at the Mayo Clinic from 1985 to 1995 was compared with that of a historic cohort.» [G6-06].

ECG

  • Low voltage QRS complex (low voltage): QRS voltage < 0.5 mV in peripheral limb leads [E1] [G6-06].
  • Diffuse T-wave flattening or inversion in precordial leads [C2] [G6-06].
  • Atrial enlargement (P mitrale wave) in sinus rhythm [E1].

Heart sounds and murmurs

  • Pericardial knock: High-frequency early diastolic sound recorded 90–120 ms after aortic component of S2, at the lowest nadir of the JVP y descent [G6-13].
  • S1 and S2 sounds of usual intensity; murmurs generally absent [C2].

Arterial pulse

  • Small-amplitude arterial pulse (parvus) due to stroke volume reduction [B4].
  • Pulsus paradoxus usually absent (< 10 mmHg in the vast majority of cases) [B5] [G6-06].

Jugular venous pulse

  • Marked jugular venous distention (mean venous pressure in cmH₂O 14–22 cmH₂O) [B3] [G6-06].
  • Deep and rapid 'y' descent (Friedreich sign, deep y descent): Accelerated early diastolic atrial emptying without initial resistance [B3] [G6-13] [M5].
  • Positive Kussmaul sign (kussmaul): Failure of JVP to collapse or paradoxical rise during inspiration [B3] [C2].

Maneuvers

  • Inspiration: Elicits Kussmaul sign (visible increase in jugular distention) and intensifies pericardial knock [B3] [G6-13].

Simulator severity grades

Simulator severity grades: Single grade
Baseline rhythm: Normal Sinus Rhythm

Also known as: Constrictive pericarditis · Chronic constrictive pericarditis · Pericardial constriction · Pick disease · Constrictive heart disease

Other pathologies in this group

Related clinical comparisons

Sources

  1. [B3] The jugular venous pressure revisited . Cleve Clin J Med (2013) . DOI: 10.3949/ccjm.80a.13039 PubMed: 24085809
  2. [B4] The Carotid Pulse . Clinical Methods: The History, Physical, and Laboratory Examinations (1990) . PubMed: 21250154
  3. [B5] Pulsus paradoxus . Eur Respir J (2013) . DOI: 10.1183/09031936.00138912 PubMed: 23222878
  4. [C2] 2025 ESC Guidelines for the management of myocarditis and pericarditis . Eur Heart J (2025) . DOI: 10.1093/eurheartj/ehaf192 PubMed: 40878297
  5. [E1] AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part V: electrocardiogram changes associated with cardiac chamber hypertrophy: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology . Circulation (2009) . DOI: 10.1161/CIRCULATIONAHA.108.191097 PubMed: 19228820
  6. [G6-01] American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease: endorsed by the Society for Cardiovascular Magnetic Resonance and Society of Cardiovascular Computed Tomography . J Am Soc Echocardiogr (2013) . DOI: 10.1016/j.echo.2013.06.023 PubMed: 23998693
  7. [G6-05] Echocardiographic diagnosis of constrictive pericarditis: Mayo Clinic criteria . Circ Cardiovasc Imaging (2014) . DOI: 10.1161/CIRCIMAGING.113.001613 PubMed: 24633783
  8. [G6-06] Constrictive pericarditis in the modern era: evolving clinical spectrum and impact on outcome after pericardiectomy . Circulation (1999) . DOI: 10.1161/01.cir.100.13.1380 PubMed: 10500037
  9. [G6-13] Genesis of pericardial knock in constrictive pericarditis . Am J Cardiol (1980) . DOI: 10.1016/0002-9149(80)90510-7 PubMed: 7416016
  10. [M5] Pericardial disease . Circulation (2006) . DOI: 10.1161/CIRCULATIONAHA.105.561514 PubMed: 16567581