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Constriction with Normal Pericardial Thickness — EECC MCQ

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HardPericardial DiseaseConstriction with Normal Pericardial ThicknessEECC

A 60-year-old man has echocardiographic features suggesting cardiac constriction: septal bounce, plethoric IVC, and hepatic vein expiratory diastolic flow reversal. However, the pericardium appears normal in thickness. Can constrictive pericarditis occur with normal pericardial thickness?

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Correct answer: D — Yes — up to 20% of surgically confirmed constrictive pericarditis has normal pericardial thickness on imaging; constriction can result from visceral pericardial fibrosis or microscopic fibrotic change not detectable on standard imaging

The 2025 ESC Myocarditis/Pericarditis Guidelines emphasise that normal pericardial thickness does NOT exclude constrictive pericarditis. Approximately 18-20% of surgically confirmed cases have pericardial thickness ≤2 mm on CT/CMR. This occurs because: (1) constriction can result from visceral pericardial fibrosis (the visceral layer is too thin to measure on standard imaging); (2) microscopic collagen deposition can cause functional constriction without macroscopic thickening; (3) pericardial calcification (even without thickening) can cause rigid constriction. Diagnosis relies on the constellation of: clinical features (elevated JVP with prominent y descent, Kussmaul sign, pericardial knock), echocardiographic features (septal bounce, respirophasic variation), CMR (pericardial LGE, real-time cine), and haemodynamic assessment (simultaneous RV/LV pressures showing equalisation and discordance).

Reference: ESC (2025): Myocarditis/Pericarditis Guidelines