How is constrictive pericarditis different than restrictive cardiomyopathy and cardiac tamponade?

Constrictive Pericarditis

Pathology of constriction:

  • Thick scarred pericardium equalizes 4 chamber pressure, limits ventricular filling, reduces cardiac volume.
  • JV pressure wave form in constriction: rapid ventricular (RV) filling causes rapid Y-descent
  • Then, diastolic filling stops abruptly, causing a dip and plateau diastolic RV waveform

Causes of constriction:

  • Mediastinal radiation
  • Chronic idiopathic pericarditis
  • Cardiac surgery
  • Tuberculous pericarditis

Signs & Symptoms of Constriction:

  • R-sided heart failure: JVD, hepatic congestion, ascites, peripheral edema
  • Clear lungs
  • Exercise intolerance, muscle wasting, cardiac cachexia
  • Jugular veins with prominent X and Y descent 
  • Y descent may look like JV pulse is “falling away” from you
  • Respiratory increase in jugular venous pressure (Kussmaul’s sign)
  • Pericardial knock (high-pitched early diastolic sound)

Imaging of Pericardial Constriction:

  • CT with thickening +/- calcification of the pericardium
  • CT/MRI preferred modalities to evaluate pericardial thickening
  • Echo may show systolic discordance of LV/RV pressures, ventricular interdependence
  • In constriction, cath of LV and RV will show discordance of LV and RV pressures

Differential Diagnosis of Pericardial Constriction:

  • Restrictive cardiomyopathy
    • RCM and Constriction both have Kussmaul’s sign, RV cath “dip and plateau” sign in early diastole
    • Whereas RCM has no significant respiratory mitral variation, Constriction has marked variation of mitral inflow (>25%) and hepatic flow
    • Whereas RCM has early reduced diastolic mitral annular velocity (Ea)Constriction has normal Ea velocities
    • Whereas RCM is associated with pulmonary congestion, Constriction usually has clear lungs
    • Whereas RCM has a reduced mitral annular diastolic velocity < 8 cm/sConstriction has mitral annular diastolic velocity > 8 cm/s
    • Whereas RCM shows ventricular concordance on simultaneous LV/RV cath,  Constriction has ventricular discordance on simultaneous LV/RV cath
  • Cardiac Tamponade
    • Constriction and Tamponade both have elevated JVP, Kussmaul’s sign, pulsus paradoxus
    • Whereas tamponade has blunting of/abscence Y-descent, Constriction has prominent X and Y descent
    • Echocardiogram should easily be able to differentiate tamponade from constriction.

Definitive treatment for pericardial constriction:  pericardial resection




1. Little WC and Freeman GL.  Pericardial Disease.  Circulation. 2006 Mar 28;113(12):1622-32.

2. European Society of Cardiology Pericardial Disease Guidelines 2015.






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