Constrictive Pericarditis: Septal Bounce, Annulus Reversus, and Respiratory Variation in Echocardiographic Diagnosis
Pathophysiological Basis of Signs
In constrictive pericarditis, pronounced interventricular dependence and rapidly changing pressure gradients between RV and LV, especially in early diastole, lead to the characteristic septal bounce (Nicoara, Skubas et al., 2020). The rigid pericardium restricts filling and creates respiratory-dependent redistribution of flows between the ventricles.
Tissue Doppler Imaging: Annulus Reversus and Annulus Paradoxus
Characteristic findings in tissue Doppler imaging (Nicoara, Skubas et al., 2020):
Annulus reversus — tethering of the lateral wall leads to a decrease in lateral mitral e' below the medial mitral e'.
Annulus paradoxus — preservation/enhancement of medial mitral e' creates an inverse correlation between E/e' and LV filling pressure. According to Ha JW et al. (Circulation, 2001), the ratio of transmitral velocity to mitral annular velocity is inversely proportional to the pulmonary capillary wedge pressure in patients with constriction.
Diagnostic Criteria (ASE, 2025)
In patients with pericardial constriction, the following are typically observed:
| Sign | Value |
|---|---|
| Respiratory shift of IVS | Respiratory phase, septal bounce |
| Respiratory variation of transmitral flow | >25% |
| Respiratory variation of tricuspid flow | >40% |
| Medial early diastolic velocity (e') | Normal/increased (>7 cm/s) |
| Expiratory reversal of end-diastolic flow in hepatic veins | Reversal/forward flow ratio = 0.8 |
| Annulus reversus and strain reversus | Present |
A comprehensive assessment of these parameters allows differentiation of constrictive pericarditis from restrictive conditions.
Frequently asked questions
How does annulus reversus differ from annulus paradoxus?
Annulus reversus is the decrease of lateral mitral e' below medial due to tethering of the lateral wall. Annulus paradoxus is the preservation/enhancement of medial e', creating an inverse correlation between E/e' and LV filling pressure (Nicoara, Skubas et al., 2020).
What are the thresholds of respiratory variation of flows indicating constriction?
Respiratory variation of transmitral flow >25% and tricuspid >40% (ASE, 2025).
What should the medial e' be in constriction?
Normal or increased — >7 cm/s (ASE, 2025).
What should be assessed in the hepatic veins?
Enhanced expiratory reversal of end-diastolic flow with a reversal to forward flow ratio = 0.8 (ASE, 2025).
Why does septal bounce occur?
Due to pronounced interventricular dependence and rapidly changing early diastolic pressure gradients between RV and LV (Nicoara, Skubas et al., 2020).