Figure 1
Etiology-based risk stratification and outcomes after pericardiectomy for constrictive pericarditis. (Created in BioRender with permission; Harake L, 2026; https://BioRender.com/ll02ak0). CP: constrictive pericarditis; CT: computed tomography, TB: tuberculosis
Figure 2
Representative imaging and pathologic substrates guiding surgical management of constrictive pericarditis. (A) Cardiac magnetic resonance imaging using phase-sensitive inversion recovery demonstrating pericardial late gadolinium enhancement with increased pericardial thickness, consistent with an inflammatory constrictive phenotype that may be potentially reversible with medical therapy. (B) Cardiac computed tomography showing severe circumferential “eggshell” pericardial calcification characteristic of chronic fibrotic constriction. (C) Gross surgical specimen following pericardiectomy demonstrating markedly thickened and fibrotic pericardium.
Table 1
Preoperative evaluation of constrictive pericarditis using clinical assessment, multimodality imaging, and invasive hemodynamics to confirm constrictive physiology, guide surgical timing, and distinguish alternative causes of systemic congestion. RCM: restrictive cardiomyopathy; TR: tricuspid regurgitation; CP: constrictive pericarditis; LGE: late gadolinium enhancement
| MODALITY | KEY FINDINGS IN CONSTRICTIVE PERICARDITIS | DIAGNOSTIC VALUE | ROLE IN SURGICAL DECISION-MAKING |
|---|---|---|---|
| Clinical Assessment | Right-sided heart failure, systemic congestion, preserved systolic function | Establishes pretest probability and excludes noncardiac causes of congestion | Identifies disease severity, comorbidities, and operative risk |
| Transthoracic Echocardiography | Respirophasic septal shift, exaggerated respiratory variation in mitral inflow, expiratory hepatic vein diastolic flow reversal, preserved or increased medial mitral annular e′ velocity | Cornerstone for confirming constrictive physiology using Mayo Clinic criteria | Differentiates CP from RCM and severe TR and guides need for further testing |
| Speckle-Tracking Strain Imaging | Preserved global longitudinal strain with reduced lateral wall strain and relative medial preservation | Improves diagnostic sensitivity and phenotyping | Serial improvement supports reversibility in inflammatory or transient CP |
| Cardiac Computed Tomography | Pericardial thickening or calcification, distribution of calcium, relationship to coronary arteries and bypass grafts | Defines anatomic extent of disease | Essential for surgical planning and risk stratification |
| Cardiac Magnetic Resonance Imaging | Pericardial edema on T2 imaging, late gadolinium enhancement indicating inflammation, quantitative LGE burden | Differentiates inflammatory from fibrotic constriction | Guides timing of surgery versus continued medical therapy |
| Invasive Hemodynamic Assessment | Equalized diastolic pressures, dip-and-plateau pattern, respiratory dissociation of intracardiac pressures, ventricular discordance, systolic area index ≥ 1.1 | Reserved for equivocal or discordant noninvasive findings | Confirms constriction when diagnosis remains uncertain |
| Differentiation from Alternative Diagnoses (RCM and Severe TR) | RCM: low mitral annular e′ velocities, biatrial enlargement, pulmonary hypertension, ventricular concordance. Severe TR: right ventricular and annular dilation, systolic hepatic vein flow reversal, prominent c–v waves | Distinguishes myocardial or valvular causes of systemic congestion from pericardial constriction | Identifies patients unlikely to benefit from pericardiectomy and avoids inappropriate surgery |
Figure 3
Diagnostic and surgical decision algorithm for constrictive pericarditis. (Created in BioRender with permission; Harake L, 2026; https://BioRender.com/bl0r8ba). CMR: cardiac magnetic resonance imaging; CT: computed tomography; CRP: C reactive protein; NSAIDS: nonsteroidal anti-inflammatory drugs; RA: right atrial