From the Guidelines
Yes, a patient with constrictive pericarditis can have a normal ejection fraction. Ejection fraction, which measures the percentage of blood pumped out of the left ventricle with each contraction, typically remains preserved in constrictive pericarditis. This is because constrictive pericarditis primarily affects ventricular filling during diastole rather than systolic contraction. The thickened, fibrotic, and often calcified pericardium creates a rigid shell around the heart that restricts diastolic filling, leading to equalization of diastolic pressures in all cardiac chambers. However, once blood enters the ventricles, the myocardial contractile function (systolic function) often remains intact, allowing for normal ejection of the blood that was able to enter the ventricle. This preservation of ejection fraction despite significant hemodynamic compromise is a characteristic feature that helps distinguish constrictive pericarditis from restrictive cardiomyopathy and other cardiac conditions. Patients typically present with symptoms of right-sided heart failure such as peripheral edema, ascites, and elevated jugular venous pressure, despite having normal systolic function as measured by ejection fraction.
According to the 2015 ESC guidelines for the diagnosis and management of pericardial diseases 1, constrictive pericarditis is characterized by impaired diastolic filling of the ventricles due to pericardial disease, with preserved right and left ventricular function in the absence of previous or concomitant myocardial disease or advanced forms. The guidelines also note that patients with constrictive pericarditis may have a normal pericardial thickness in up to 20% of cases.
Key features of constrictive pericarditis include:
- Impaired diastolic filling of the ventricles
- Preserved right and left ventricular function
- Normal ejection fraction
- Symptoms of right-sided heart failure, such as peripheral edema, ascites, and elevated jugular venous pressure
- Equalization of diastolic pressures in all cardiac chambers
The diagnosis of constrictive pericarditis can be challenging, and cardiac catheterization may be useful in certain circumstances, such as differentiating constrictive pericarditis from restrictive cardiomyopathy 1. However, non-invasive imaging techniques, such as echocardiography and cardiac magnetic resonance imaging (CMR), can also provide useful information for diagnosis and management.
In terms of management, pericardiectomy is the accepted standard of treatment in patients with chronic constrictive pericarditis who have persistent and prominent symptoms 1. However, surgery should be considered cautiously in patients with either mild or very advanced disease, and in those with radiation-induced constriction, myocardial dysfunction, or significant renal dysfunction.
From the Research
Constrictive Pericarditis and Ejection Fraction
- Constrictive pericarditis is a disorder of cardiac filling caused by an inelastic pericardium, which can lead to heart failure symptoms despite a preserved left ventricular ejection fraction 2, 3.
- The diagnosis of constrictive pericarditis is challenging and requires meticulous echocardiographic assessment, often supplemented by cross-sectional cardiac imaging and haemodynamic catheterisation 3.
- Patients with constrictive pericarditis can present with preserved left ventricular ejection fraction, as the condition primarily affects diastolic filling rather than systolic function 4, 2, 3, 5.
- A normal ejection fraction does not rule out constrictive pericarditis, as the condition is characterized by impaired diastolic filling rather than systolic dysfunction 4, 2, 3, 5.
- The presence of a normal ejection fraction in a patient with suspected constrictive pericarditis should prompt further investigation, including echocardiography, cardiac MRI, and haemodynamic assessment, to confirm the diagnosis 4, 2, 3, 5.