Echocardiographic Diagnosis of Constrictive Pericarditis: Mayo Clinic Criteria

Study Questions:

Are there definitive echocardiography/Doppler criteria that can distinguish constrictive pericarditis from restrictive myocardial disease and from severe tricuspid regurgitation?


Patients with surgically confirmed constrictive pericarditis (n = 130) at a large academic medical center (2008–2010) were compared to patients (n = 36) with diagnosed restrictive myocardial disease or severe tricuspid regurgitation after constrictive pericarditis was considered, but excluded. Comprehensive echocardiograms were reviewed in blinded fashion. 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 mitral annular medial e’ to lateral e’, and 5) hepatic vein expiratory diastolic reversal ratio.


All five principal variables differed significantly between the groups. In patients with atrial fibrillation or flutter (n = 29), all but mitral inflow velocity remained significantly different. Three variables were independently associated with constrictive pericarditis: 1) ventricular septal shift, 2) medial mitral e’, and 3) hepatic vein expiratory diastolic reversal ratio. The presence of ventricular septal shift in combination with either medial e’ ≥9 cm/s or hepatic vein expiratory diastolic reversal ratio ≥0.79 was associated with a desirable combination of sensitivity (87%) and specificity (91%). When all three factors were present, specificity increased to 97%, but sensitivity decreased to 64%.


Echocardiography may allow differentiation of constrictive pericarditis from heart failure due to restrictive myocardial disease or severe tricuspid regurgitation. Respiration-related ventricular septal shift, preserved or increased mitral annular medial e' velocity, and prominent hepatic vein expiratory diastolic flow reversal are independently associated with the diagnosis of constrictive pericarditis.


The hallmark study that defined echo/Doppler parameters for the differentiation of construction from restriction (Hatle LK, et al. Circulation 1989;89:357-70) was based on study of only 12 patients with restrictive cardiomyopathy, 7 with constriction, and 20 controls; in practice, reliable noninvasive differentiation between these entities has been problematic using only the described respiratory variation in transvalvular flow velocities. The present study is important for the size of the population studied, the evidence supporting the respective classifications, and the relative accuracy of the described combination of echo/Doppler. Ventricular septal shift in combination with mitral annular medial e’ ≥9 cm/s and/or hepatic vein expiratory diastolic reversal ratio (early expiration retrograde flow peak velocity/early expiration antegrade flow peak velocity) ≥0.79 appears to be a reliable means to differentiate constrictive pericarditis from restrictive disease and from severe tricuspid regurgitation.

Clinical Topics: Heart Failure and Cardiomyopathies, Noninvasive Imaging, Pericardial Disease, Acute Heart Failure, Echocardiography/Ultrasound

Keywords: Pericarditis, Constrictive, Heart Failure, Echocardiography

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