Constrictive Pericarditis Mimicking Heart Failure: A Radiologic–Hemodynamic Diagnostic Approach Using Multimodality Imaging

Executive Clinical Summary

A man in his late 60s presented with progressive heart failure symptoms over two years, including severe lower extremity edema, dyspnea, and repeated decompensation. Physical examination revealed jugular venous distention and Kussmaul sign. Imaging demonstrated extensive pericardial calcification with pericardial thickening (~6 mm) and bilateral pleural effusion.

This case illustrates a classic yet frequently delayed diagnosis: constrictive pericarditis, where the pathology lies not in myocardial failure but in a rigid, noncompliant pericardium that restricts diastolic filling.

Key Clinical Questions

Why can constrictive pericarditis mimic advanced heart failure?
What imaging findings are most diagnostic?
How can CT, echocardiography, and MRI be integrated?
When should pericardiectomy be considered?

Clinical Hook

A patient repeatedly treated for heart failure continues to deteriorate. Diuretics provide only temporary relief. The edema returns. Dyspnea worsens.

The myocardium appears relatively preserved.

The real problem is not the heart itself—but the rigid shell surrounding it.

Learning Objectives

By the end of this article, readers should be able to:

Recognize key imaging features of constrictive pericarditis
Understand the pathophysiology of ventricular interdependence
Differentiate constrictive pericarditis from restrictive cardiomyopathy
Apply multimodality imaging in diagnosis
Identify when surgical treatment is required
Avoid common diagnostic pitfalls in heart failure evaluation

Anatomy Review

The pericardium is a thin fibroelastic sac surrounding the heart, normally allowing physiologic expansion during diastole.

In constrictive pericarditis, this structure becomes:

Thickened
Fibrotic
Calcified
Noncompliant

This transforms the pericardium into a rigid constraint, limiting ventricular filling and altering intracardiac hemodynamics.

Case Presentation

Patient Profile

Male, late 60s

History

Progressive heart failure over ~2 years
Remote history of pulmonary tuberculosis (~60 years prior)

Symptoms

Dyspnea
Lower extremity edema
Reduced exercise tolerance
Fatigue

Physical Examination

Jugular venous distention
Kussmaul sign
Bilateral leg edema

Clinical Severity

NYHA Functional Class IV

Pathophysiology

The disease process follows a continuum:

Inflammation → Fibrosis → Thickening → Adhesion → Calcification → Diastolic restriction

The key mechanism is impaired diastolic filling, combined with:

Ventricular Interdependence

Increased venous return during inspiration
Right ventricular expansion constrained
Septal shift toward left ventricle
Reduced left ventricular filling

This produces characteristic respiratory hemodynamic variation.

Clinical Presentation

Patients often present with features indistinguishable from right-sided heart failure:

Peripheral edema
Ascites
Hepatic congestion
Dyspnea
Fatigue

A critical diagnostic clue is persistent venous congestion despite heart failure therapy.

Imaging Features

Chest X-ray — The First Diagnostic Clue

Figure 1. Lateral chest radiograph showing extensive pericardial calcification

Interpretation:
Extensive, continuous calcification along the pericardial contour is observed, consistent with chronic pericardial inflammation and fibrosis.

Clinical Significance:
Pericardial calcification strongly suggests chronic constrictive pericarditis but is not diagnostic alone.

CT — Structural Assessment

Figure 2. Axial chest CT demonstrating bilateral pleural effusion

Interpretation:
Bilateral pleural effusions are present in the context of severe pericardial calcification and venous congestion.

Clinical Significance:
While nonspecific, this finding supports systemic venous congestion when integrated with clinical and imaging features.

Echocardiography — Hemodynamic Diagnosis

Key findings:

Septal bounce
Respiratory variation in inflow velocities
Annulus reversus
Hepatic vein diastolic flow reversal

Echocardiography is essential because it evaluates physiology, not just anatomy.

MRI — Tissue Characterization

CMR is particularly useful to assess:

Active inflammation
Pericardial edema (T2-weighted imaging)
Late gadolinium enhancement

This helps determine whether the condition is reversible inflammatory constriction or chronic fibrotic disease.

Radiologist Interpretation

Findings

Diffuse pericardial calcification
Pericardial thickening (~6 mm)
Bilateral pleural effusion
Clinical signs of venous congestion

Impression

Findings are most consistent with severe chronic constrictive pericarditis.

Differential Diagnosis

Diagnosis	Key Imaging Finding	Clinical Clue	Differentiation
Constrictive pericarditis	Pericardial calcification	Kussmaul sign	Pericardial constraint
Restrictive cardiomyopathy	Normal pericardium	Myocardial disease	Tissue abnormality
Cardiac amyloidosis	Myocardial thickening	Systemic disease	No calcified pericardium
Tricuspid regurgitation	Dilated right heart	Murmur	No constriction
Mitral stenosis	LA enlargement	Valve disease	Pulmonary dominance

Multimodality Imaging Comparison

Modality	Strength	Limitation	Best Use
X-ray	Detect calcification	Limited specificity	Screening
CT	Anatomy & calcification	Radiation	Structural evaluation
Echo	Hemodynamics	Operator-dependent	Functional diagnosis
MRI	Tissue characterization	Availability	Inflammation assessment

Treatment

Medical Therapy

Diuretics for symptom control

Anti-inflammatory Therapy

Considered when active inflammation is present

Surgical Treatment

Pericardiectomy is the definitive treatment in chronic cases

Prognosis

Outcome depends on:

Chronicity of disease
Degree of myocardial involvement
Organ dysfunction (liver, kidney)

Artificial Intelligence Perspective

AI can support diagnosis through:

Detection of pericardial calcification (CT-based CNN models)
Echocardiographic motion analysis (septal bounce detection)
Multimodal fusion models integrating imaging + clinical data

However, AI must not replace hemodynamic interpretation, which remains clinician-driven.

Clinical Pearls

Pericardial calcification ≠ diagnosis, but a critical clue
Kussmaul sign is highly suggestive
Echo evaluates physiology; CT evaluates structure
Always differentiate from restrictive cardiomyopathy
Multimodality imaging is essential

Common Diagnostic Pitfalls

Treating as simple heart failure
Ignoring pericardial calcification on X-ray
Over-reliance on a single modality
Failure to assess hemodynamics
Missing reversible inflammatory phase

Conclusion

Constrictive pericarditis is a deceptively complex disease that often masquerades as refractory heart failure.

The key to diagnosis lies not in identifying a single imaging finding, but in integrating clinical signs, structural imaging, and hemodynamic data.

Multimodality imaging is not optional—it is essential.

Key Takeaways

Think beyond myocardial dysfunction in refractory heart failure
Pericardial calcification is a crucial imaging clue
Echocardiography provides functional confirmation
CT and MRI offer complementary insights
Early diagnosis improves outcomes

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