The “2+1” Simplified Echocardiographic Diagnostic Framework for Constrictive Pericarditis

Figures

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  Figure 1. Case 1. Two-dimensional TTE, apical 4-chamber (A, C, D) and parasternal short-axis (B) views with tissue Doppler (A), M-mode with respirometer (B), and pulsed-wave Doppler of the tricuspid valve (C) and mitral valve (D), demonstrates a supranormal septal e’ (arrow, 16 cm/s), respirophasic movement of the interventricular septum due to exaggerated interventricular dependence (fulfilling the 2 criteria in the “2 + 1” framework), and a lack of significant respiratory variation across the mitral valve (18%) and tricuspid valve (33%).

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  Figure 2. Case 1. Two-dimensional TTE, subcostal view of hepatic vein with respirometer (A) and bull's-eye global longitudinal pattern (B), demonstrates exaggerated early expiratory diastolic flow reversal (red arrows) and reduction in lateral strain (green star) with increased in septal strain (blue star).

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  Figure 3. Case 1. Cardiovascular magnetic resonance, T1 turbo spin echo axial image, 4-chamber view, demonstrates pericardial thickening (arrows).

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  Figure 4. Case 2. Two-dimensional TTE, apical 4-chamber view with tissue Doppler (A) and subcostal view of the hepatic vein with respirometer (B), demonstrates annulus paradoxus with supranormal septal e’ at 17.2 cm/s (single arrow) and exaggerated early expiratory diastolic flow reversal in the hepatic vein (3 arrows).

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  Figure 5. Case 2. Bull's-eyes global longitudinal strain pattern demonstrates typical CP pattern with elevated septal strain (blue star) and diminished lateral strain (green star).

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  Figure 6. Case 2. Gross pathologic specimen demonstrates that the pericardium is thickened with hyalinized fibrous tissue consistent with CP.

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  Figure 7. Case 3. Two-dimensional TTE, apical 4-chamber view (A, B) showing very high (supranormal) septal e’ (red arrow); annulus paradoxus and lower lateral e’ (blue arrow) vs higher septal e’; and annulus reversus.

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  Figure 8. Case 3. Bull's-eye global longitudinal strain demonstrates a similar pattern with the previous 2 patients where septal strain (blue star) is higher than lateral strain (green star).

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  Figure 9. Case 3. Two-dimensional TTE, apical 4-chamber view (A, B) demonstrates mitral and tricuspid inflow variations (both 24%) that did not meet the traditional CP criteria.

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  Figure 10. Case 3. Chest computed tomography demonstrates significant pericardial calcification, especially at the lateral wall of the pericardium up to 10.6 mm (green line).

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  Figure 11. Case 3. Gross examination of pericardial specimens A, B, and C (representing different portions excised by the surgeon) demonstrates diffuse pericardial thickening with hyaline degenerative change, focal calcification, and viable thickened fibro collagenous tissue.