From the Guidelines
No, hyperdynamic left ventricular (LV) function is not consistent with constrictive pericarditis on an echocardiogram. Constrictive pericarditis typically presents with normal or reduced LV systolic function rather than hyperdynamic function, as indicated by the European Society of Cardiology guidelines 1. The hallmark echocardiographic findings in constrictive pericarditis include:
- Pericardial thickening and calcifications
- Indirect signs of constriction, such as RA and LA enlargement with normal appearance of the ventricles and normal systolic function
- Early pathological outward and inward movement of the interventricular septum (“dip-plateau phenomenon”)
- Flattening waves at the LV posterior wall
- LV diameter is not increasing after the early rapid filling phase
- Restricted filling of both ventricles with respiratory variation >25% over the AV-valves, as noted in the guidelines 1 and further emphasized by the American Society of Echocardiography and the European Association of Cardiovascular Imaging 1.
The pathophysiology involves a thickened, fibrotic, and often calcified pericardium that restricts cardiac filling during diastole, limiting stroke volume and cardiac output. This restriction leads to equalization of diastolic pressures in all cardiac chambers. Hyperdynamic LV function, characterized by increased contractility and ejection fraction, would suggest other conditions such as anemia, hyperthyroidism, anxiety, sepsis, or compensatory responses to other cardiovascular conditions rather than constrictive pericarditis. The most recent guidelines from the American Society of Echocardiography and the European Association of Cardiovascular Imaging 1 support the notion that constrictive pericarditis is associated with specific echocardiographic features that are distinct from hyperdynamic LV function.
From the Research
Echocardiogram Findings in Constrictive Pericarditis
- Constrictive pericarditis is characterized by impaired diastolic filling due to a rigid pericardium encasing the heart, which can lead to right-sided heart failure 2.
- Echocardiogram findings in constrictive pericarditis may include a septal bounce or shudder, which can prompt further investigation 2.
- The Mayo Clinic criteria for echocardiographic diagnosis of constrictive pericarditis include respiration-related ventricular septal shift, variation in mitral inflow E velocity, medial mitral annular e' velocity, ratio of medial mitral annular e' to lateral e', and hepatic vein expiratory diastolic reversal ratio 3.
Hyperdynamic Left Ventricular Function
- Hyperdynamic left ventricular (LV) function is not typically associated with constrictive pericarditis, as the condition is characterized by impaired diastolic filling and restrictive physiology 4, 5.
- However, it is possible for patients with constrictive pericarditis to have preserved or even increased LV systolic function, as seen in a case report where a patient had preserved left ventricular systolic function with abnormal pericardial thickening and restrictive left ventricular filling consistent with pericardial constriction 4.
- The presence of hyperdynamic LV function on an echocardiogram would not be consistent with the typical findings of constrictive pericarditis, but it is not a definitive exclusion criterion, and further investigation would be necessary to confirm the diagnosis 2, 3.
Diagnostic Considerations
- Constrictive pericarditis can be difficult to diagnose due to non-specific presentation and may mimic other conditions such as heart failure with preserved ejection fraction (HFpEF) 2.
- Echocardiography, cardiac magnetic resonance imaging, and invasive biventricular pressure measurements can be used to diagnose constrictive pericarditis and differentiate it from other conditions 2, 3.
- A comprehensive echocardiogram review, including the Mayo Clinic criteria, can help establish the diagnosis of constrictive pericarditis 3.