Doppler Tissue Imaging Improves Assessment

of Abnormal Interventricular Septal and

Posterior Wall Motion in Constrictive
Pericarditis
Partho P. Sengupta, MD, DM, Jadgish C. Mohan, MD, DM, Vimal Mehta, MD, DM,
Ramesh Arora, MD, DM, Bijoy K. Khandheria, MD, and Natesa G. Pandian, MD,
New Delhi, India; Rochester, Minnesota; and Boston, Massachusetts

We hypothesized that Doppler tissue imaging in the

short axis would provide enhanced quantitative information for differentiating the pattern and extent
of abnormal septal and posterior wall motion in
constrictive pericarditis (CP). Using quantitative
pulsed wave and color M-mode Doppler tissue imaging, we quantified the pattern of abnormal septal
and posterior wall motion and studied its incremental advantage over conventional M-mode and 2-dimensional echocardiography in 40 patients with
surgically proven CP. The pattern and extent of
abnormalities were compared with 35 age- and sexmatched control subjects and 20 patients with abnormal septal motion of other causes. In 33 patients
(82.5%) with CP, the interventricular septum
showed high-velocity (>7 cm/s) early diastolic biphasic motion with or without multiple recoil waves
(polyphasic diastolic septal fluttering). In the poste-

Abnormal motion of the interventricular septum

and posterior wall in constrictive pericarditis (CP)

has long been recognized.1-4 These abnormalities
result from variations in interventricular relaxation
dynamics; however, neither M-mode nor 2-dimensional (2D) echocardiography provides specific diagnostic information.3 Doppler tissue imaging (DTI),
a relatively newer echocardiographic technique,
provides quantitative information about myocardial
motion with high temporal and spatial resolution.5
Longitudinal tissue contraction and relaxation velocities are normal in CP and are useful in its clinical
diagnosis.6-8 However, few data are available on the
usefulness of tissue velocity imaging in the short axis
From the GB Pant Hospital (P.P.S., J.C.M., V.M., R.A.), New Delhi;
Division of Cardiovascular Diseases, Mayo Clinic, Rochester
(B.K.K.); and Tufts New England Medical Center, Boston
(N.G.P.).
Reprint requests: Bijoy K. Khandheria, MD, Division of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN
55905.
0894-7317/$30.00
Copyright 2005 by the American Society of Echocardiography.
doi:10.1016/j.echo.2004.11.017

226

rior wall, the early diastolic wave was normal but

the late diastolic wave was reduced in 24 patients
(60%) and absent in 7 (17.5%). In comparison,
M-mode and 2-dimensional echocardiography identified abnormal septal or posterior wall motion in 24
patients (60%) (P .003). The pattern of abnormal
septal motion in CP could be differentiated from
abnormal septal motion of other causes in 16 patients (80%). The overall sensitivity and specificity
of high-velocity polyphasic septal flutter for differentiating CP from control cases and other diseases
was 82.5% and 92.7%, respectively. In CP, Doppler
tissue imaging in the short axis provides unique
diagnostic information and reliably differentiates
CP from control cases and most other causes of
abnormal septal motion. (J Am Soc Echocardiogr
2005;18:226-30.)

for diagnosing CP. We hypothesized that patients

with CP may have a characteristic pattern of interventricular septal and posterior wall motion that
could be quantified with DTI and provide unique
diagnostic information.

METHODS
Study Group
The study included a selected group of 40 patients with
surgically proven CP (Tables 1 and 2). CP was defined
preoperatively as a scarred or fused pericardium causing
decreased ventricular and atrial distensibility and rightsided heart failure. The cause of CP was tubercular in 26
patients (65%), pyogenic in 2 (5%), radiation exposure in
2 (5%), and unknown in 10 (25%). The diagnostic evaluation of this group of patients included transthoracic
echocardiography (40 patients), transesophageal echocardiography (3), cardiac catheterization (30), computed
tomography (4), and magnetic resonance imaging (5). All
patients had clinical and echocardiographic evidence of
increased right-sided filling pressures. A dilated inferior
vena cava with spontaneous echocontrast and hepatic

Journal of the American Society of Echocardiography

Volume 18 Number 3

Sengupta et al 227

Table 1 Comparison of clinical and echocardiographic

characteristics of patients with constrictive pericarditis and
control subjects

Characteristic

Age, y, mean SD
Male, No.
IN sinus rhythm, No.
New York Heart Association functional
class, mean SD
Aorta, cm, mean SD
Left atrium, cm, mean SD
Left ventricle (end-diastole), cm, mean
SD
Left ventricle (systole), cm, mean
SD
Interventricular septum (diastole), cm,
mean SD
Posterior wall (diastole), cm, mean
SD
Ejection fraction, %, mean SD

Constrictive
pericarditis
(n 40)

Control
(n 35)

24 12
24
36
2.9 0.7

20 12
23
35
1

2.4 0.69 2.2 0.4

3.2 0.7 3.3 0.6
4.0 0.9 3.8 0.7
2.7 0.8

2.4 0.5

0.6 0.1

0.7 0.1

0.7 0.1

0.7 0.2

57 9

60 7

referred for operation without cardiac catheterization

because they had persistent clinical and echocardiographic signs of constriction for more than 6 months after
pericardial effusions, and a confirmed tubercular cause of
CP. In the other 30 patients (75%), the decision to perform
pericardiectomy was individualized on the basis of the
clinical presentation, presence of hemodynamic signs
suggestive of CP on cardiac catheterization, or demonstration of calcified or thickened pericardium. During cardiac
catheterization, all 30 patients had an increase and equalization of end-diastolic pressures in the 4 cardiac chambers, a dip-and-plateau pattern in the ventricular pressure
curves, and rapid x and y descents in the atrial pressure
curves. Three patients were in atrial fibrillation. We also
evaluated 35 age- and sex-matched control subjects and 20
patients with other patterns of abnormal septal motion,
including 5 patients with atrial septal defect, 5 with VVI
pacing, 4 with cor pulmonale from chronic obstructive
airway disease, 2 with left bundle branch block, 2 with
primary pulmonary hypertension, and 1 each with pulmonary embolism and postoperative tetrology of Fallot.
Echocardiographic Examination

Table 2 Comparison of mitral annular and short-axis

Doppler tissue velocities in patients with constrictive
pericarditis and control subjects

Characteristic

Long-axis mitral annular velocity,

cm/s, mean SD
Sa
Ea
Ea/E
Aa
Short-axis tissue velocity, cm/s,
mean SD
Septum
Sm
Em
Am
Posterior wall
Sm
Em
Am

Constrictive
pericarditis
(n 40)

10.8
17.0
1.7
9.9

3.0
3.4
0.5
3.8

Control
(n 35)

11.9
15.7
1.7
9.9

1.8
4.6
0.6
1.8

4.6 3.1
8.9 2.6
8.1 3.3

4.6 1.1
5.0 1.0*
3.4 1.4*

7.6 3.0
12.7 4.8
3.2 2.4

7.9 2.3
11.9 4.7
6.9 2.8

Aa, Peak annular late diastolic velocity; Am, peak myocardial late diastolic
velocity; E, peak early diastolic transmitral flow velocity; Ea, annular early
diastolic velocity; Em, peak myocardial early diastolic velocity; Sa, peak
annular systolic velocity in ejection; Sm, peak myocardial systolic velocity in
ejection.
*P .001.
P .01.

diastolic flow reversal (retrograde or reversal flow velocity

25% of diastolic antegrade flow) that increased in expiration (Table 3) was found in all cases. Respiratory variation of mitral inflow peak early diastolic velocity (inspiratory-expiratory peak E variation 15%) was seen in 27
patients (67.5%). Of the 40 patients, 10 (25%) were

The echocardiographic examination included a detailed

2D, M-mode, and Doppler examination (GE Vingmed
System V, Horten, Norway), with a 2.5- to 3.5-MHz
probe. For DTI, the Nyquist limit was set between 15
and 20 cm/s and frame rates were optimized (110
25/s). Cineloop of the parasternal long-axis 2D view of
the septum with tissue color was recorded, and sampling points were placed from the base to the apex for
segregating the pattern of motion in different regions of
the septum (Figure 1, C). The hinge portion of the
septum was identified as the area below which the
septum showed systolic motion toward the left ventricular (LV) cavity, whereas the area above this and closer
to the aortic valve moved in a reverse direction. The
transducer was moved in the short axis, and patients
were asked to hold their breath in end-expiration for
recording peak septal velocities by pulsed wave Doppler. This corresponded to an area of the septum beyond
the hinge point (Figure 1, D). However, in the presence
of a markedly displaced hinge point and paradoxical
septal motion, peak septal velocities were measured
from an area of septum wherever the velocities were
greatest. For the posterior wall, the sample was obtained in the short axis from the endocardial border at
the level of the papillary muscle.
Statistical Methods
Data are presented as the mean SD. Continuous echocardiographic and DTI variables were compared using the
paired t test. The efficacy of M-mode or 2D echocardiography and DTI for identifying abnormal septal motion in
CP was compared using the McNemar test for paired data.
P .05 was considered significant. Sensitivity and specificity were calculated with standard formulas.

Journal of the American Society of Echocardiography

March 2005

228 Sengupta et al

Table 3 Respiratory variations in transmitral, pulmonary,

and hepatic venous flow doppler in 35 patients with
surgically proven constrictive pericarditis

Mitral inflow
E, cm/s
A, cm/s
E/A
Pulmonary vein
S, cm/s
D, cm/s
Hepatic vein
SR, cm/s
SR/S
DR, cm/s
DR/D

Percentage
variation

Inspiration

Expiration

65.8 19.7
38.0 12.5
1.8 0.5

77.4 19.3
45.5 17.5
1.8 0.6

15.1 8.9
17.8 9.3
1.3 1.0

37.8 12.9
44.7 13.0

44.5 9.5
54.7 15.4

9.6 8.1
16.8 13.9

20.2
0.6
24.2
0.8

8.9
0.4
10.6
0.2

26.5
0.8
38.2
1.6

10.9
0.3
14.8
0.5

24.3
29.0
33.8
51.2

30.1
16.6
24.8
33.0

Values are mean SD.

A, Late diastolic transmitral flow velocity; D, diastolic pulmonary vein flow
velocity; DR, diastolic hepatic vein flow reversal velocity; DR/D, ratio of
reversal to forward flow velocities in diastole; E, early diastolic transmitral
flow velocity; S, systolic pulmonary vein flow velocity; SR, systolic hepatic
vein flow reversal velocity; SR/S, ratio of reversal to forward flow velocities in
systole.

RESULTS
In control subjects, septal motion was low velocity;
the highest early diastolic velocity was 6.8 cm/s.
After the isovolumic relaxation wave, a biphasic
early diastolic filling wave occurred (Figure 2). This
was followed by a late diastolic wave. In diastole, the
posterior wall showed a small isovolumic relaxation
wave, followed by an early diastolic and late diastolic wave.
In CP, DTI identified abnormal septal motion in 33
patients (82.5%). A high-velocity polyphasic fluttering of the septum with peak velocity greater than
7 cm/s was seen in 29 patients (72.5%). This included a high-velocity (7 cm/s) early diastolic
biphasic motion that coincided with the early diastolic notching of the septum on M-mode tracing,
followed by multiple recoil waves (reverberations).
High-velocity early diastolic biphasic motion (7
cm/s) without recoil was seen in 4 other patients. In
the posterior wall, the early diastolic wave was
unaltered, whereas the late diastolic wave was reduced in 24 patients (60%) and absent in 7 (17.5%).
Tissue velocity imaging identified abnormalities in
septal or posterior wall motion in CP more frequently than M-mode or 2D echocardiography (33
vs 24 patients, P .003).
DTI also differentiated the pattern of abnormal
septal motion in CP from that in 16 of 20 patients
who had abnormal septal motion (M-mode/2D) of
different causes. Patients with a permanent pacemaker (VVI) had low-velocity septal fluttering (Figure 2, C). Patients with atrial septal defect had

Figure 1 Doppler tissue imaging for quantifying abnormal

septal and posterior wall motion in constrictive pericarditis.
A, Characteristic findings on M-mode echocardiography
are septal notching (arrow 1) and abrupt flattening of
posterior wall (arrow 2). B, Color M-mode echocardiography shows high-velocity motion (arrow) in early diastole.
C, To obtain optimal measurements, septal hinge area is
identified by analyzing colorized loop from parasternal
long-axis view. Note varying polarity of spectral waves.
Spectral tracing from hinge area has least outward motion
(blue). Septal area distal to hinge area has maximal motion
away from left ventricular cavity (red). D, Peak velocity
from area is obtained by pulsed Doppler imaging in short
axis for estimating peak velocity (arrow) in early diastole
and measures 16 cm/s. Offline analysis of color loops helps
identify various components of spectral tracing (E) and
corresponding waves in septum and posterior wall (F). F,
Spectral tracing from posterior wall (blue) shows absence of
late diastolic waves in constrictive pericarditis. Am, Late
diastolic velocity; Em, early diastolic velocity; Sm, systolic
velocity.

paradoxical septal motion without polyphasic septal

fluttering (Figure 2, D). Of the other 10 patients, 4
(20%) had high-velocity early diastolic fluttering
resembling that of CP. This included two patients
with pulmonary hypertension and one each with
pulmonary embolism and left bundle branch block.
A high-velocity biphasic early diastolic motion (peak
velocity 7 cm/s) with or without recoil waves had
82.5% sensitivity and 92.7% specificity for diagnosing CP.

DISCUSSION
CP is characterized by a morphologic abnormality
(thickened, nonpliable pericardium) and a physiologic abnormality (impaired diastolic filling). The
pattern of diastolic dysfunction specific for CP is
best identified by 2D echocardiography and Doppler
echocardiography, and in some cases, invasive hemodynamic recordings are needed.9 The LV chamber shows rapid early diastolic filling and rapid
expansion during early diastole, with a plateau
during the rest of diastole. The interventricular
septum shows two characteristic features: an abrupt
bouncing motion toward the LV during inspiration,

Journal of the American Society of Echocardiography

Volume 18 Number 3

Sengupta et al 229

motion corresponded to the area beyond the hinge

point and was sampled in our study.
Diagnostic Significance

Figure 2 Comparison of pattern of septal motion in control case (A), VVI pacing (B), atrial septal defect (ASD)
(C), and constrictive pericarditis (CP) (D). Note lowvelocity motion in control cases (A) and VVI pacing (B).
ASD (C) shows paradoxical motion that lacks flutter pattern characteristically seen in CP. Patients with CP may
have paradoxical motion of septum over significant length.
Note, however, that pattern of paradoxical motion in CP
(D) differs from that in ASD by presence of multiple recoil
waves (arrows).

followed by a shift in the opposite direction during

expiration, reflecting an exaggerated interventricular interdependence and abnormal early and late
diastolic notching. These M-mode and 2D echocardiographic features, however, have not been found
to be specific for CP.1-4 Clinical interpretation of
abnormal septal and posterior wall motion on Mmode echocardiography is, however, subjective and
needs expertise because a low-amplitude motion
may not be properly interpreted. In comparison,
DTI depends on Doppler shifts, has better resolution, and is a superior quantitative technique for
analyzing transient high-velocity motion.5 In our
study, use of DTI improved the interpretation of
abnormal septal motion in CP. A characteristic
polyphasic fluttering pattern of motion was seen in
the majority of patients, which reliably differentiated it from patterns of abnormal motion seen in
other conditions.
Oki et al10 studied the short-axis tissue velocities
from the interventricular septum and observed a
sharp, marked backward motion immediately before
the early diastolic expansion wave in the septum.
These were not observed in healthy subjects. However, in most of our patients, we observed a biphasic
motion with a higher velocity motion away from the
LV cavity. This difference can be explained by
variations in sampling sites from the septum. The
pattern recorded in our study became more biphasic
or predominantly negative as the sampling area was
moved closer to the basal portion of the septum.
The area of septum with the maximal amplitude of

Respiratory variations and specific flow patterns

across the mitral valve, the pulmonary or hepatic
vein, and the inferior vena cava have been used to
diagnose CP noninvasively and to differentiate it
from restrictive cardiomyopathy.11,12 However,
these variations can be relatively inaccurate, and an
increase in preload normalizes the classic respiratory variations seen in CP.6 Similarly, a pronounced
respiratory variation in transmitral flow resembling
CP can occur in adolescents and children.13,14 Thus,
flow Doppler variables pose problems for diagnosing CP in younger patients. Our results suggest that
the pattern of high-velocity diastolic fluttering of the
septum seen on short-axis DTI can be used in these
situations to reliably distinguish between constrictive physiology and normal LV filling. This is relevant
in situations in which the presence or absence of
constriction needs to be validated, for example, for
serially assessing constriction in a patient with previous pericarditis or effusion or diagnosing constrictive physiology when a thickened pericardium is
detected incidentally.
Limitations
We evaluated a relatively young cohort of patients,
the majority of whom had chronic CP caused by
tuberculosis. Because the classic picture of CP has
been that of a chronic disorder caused most often by
tuberculosis, our study represents findings of isolated constriction and may not be applicable to
populations with other causes, for example, radiation and postsurgical groups that often have features
of mixed myocardial and pericardial disease. Furthermore, we recorded the peak septal motion in
apnea; thus, the abnormal waveforms reflect differences in biventricular relaxation and filling patterns.
However, this was not established in our study by
simultaneous comparison of DTI with right ventricular and LV pressure waveforms obtained during
cardiac catheterization, because these were done in
different clinical settings on two different days. The
use of tissue velocity imaging for differentiating CP
from restrictive cardiomyopathy was also not addressed in this study.
Conclusion
In CP, tissue velocity imaging shows a characteristic
high-velocity fluttering of the interventricular septum and a marked attenuation or absence of the late
diastolic wave in the posterior wall. This information reliably differentiates patients with CP from
healthy subjects and most of those with abnormal
septal motion of other cause.

Journal of the American Society of Echocardiography

March 2005

230 Sengupta et al

REFERENCES
1. Morgan JM, Raposo L, Clague JC, Chow WH, Oldershaw PJ.
Restrictive cardiomyopathy and constrictive pericarditis: noninvasive distinction by digitized M-mode echocardiography.
Br Heart J 1989;61:29-37.
2. Trappe HJ, Herrmann G, Daniel WG, Frank G, Lichtlen PR.
Reduced diastolic left ventricular posterior wall motion in
patients with constrictive pericarditis: incidence, hemodynamic and clinical correlations. Int J Cardiol 1988;20:53-63.
3. Engel PJ, Fowler NO, Tei CW, Shah PM, Driedger HJ,
Shabetai R, et al. M-mode echocardiography in constrictive
pericarditis. J Am Coll Cardiol 1985;6:471-4.
4. Candell-Riera J, Garcia del Castillo H, Permanyer-Miralda G,
Soler-Soler J. Echocardiographic features of the interventricular septum in chronic constrictive pericarditis. Circulation
1978;57:1154-8.
5. Sengupta PP, Mohan JC, Pandian NG. Tissue Doppler echocardiography: principles and applications. Indian Heart J
2002;54:368-78.
6. Ha JW, Oh JK, Ommen SR, Ling LH, Tajik AJ. Diagnostic
value of mitral annular velocity for constrictive pericarditis in
the absence of respiratory variation in mitral inflow velocity.
J Am Soc Echocardiogr 2002;15:1468-71.
7. Garcia MJ, Rodriguez L, Ares M, Griffin BP, Thomas JD,
Klein AL. Differentiation of constrictive pericarditis from restrictive cardiomyopathy: assessment of left ventricular dia-

8.

9.

10.

11.

12.

13.

14.

stolic velocities in longitudinal axis by Doppler tissue imaging.

J Am Coll Cardiol 1996;27:108-14.
Rajagopalan N, Garcia MJ, Rodriguez L, Murray RD, AppersonHansen C, Stugaard M, et al. Comparison of new Doppler
echocardiographic methods to differentiate constrictive pericardial heart disease and restrictive cardiomyopathy. Am J Cardiol
2001;87:86-94.
Karia DH, Xing YQ, Kuvin JT, Nesser HJ, Pandian NG.
Recent role of imaging in the diagnosis of pericardial disease.
Curr Cardiol Rep 2002;4:33-40.
Oki T, Tabata T, Yamada H, Abe M, Onose Y, Wakatsuki T,
et al. Right and left ventricular wall motion velocities as
diagnostic indicators of constrictive pericarditis. Am J Cardiol
1998;81:465-70.
Hatle LK, Appleton CP, Popp RL. Differentiation of constrictive pericarditis and restrictive cardiomyopathy by Doppler
echocardiography. Circulation 1989;79:357-70.
Oh JK, Hatle LK, Seward JB, Danielson GK, Schaff HV,
Reeder GS, et al. Diagnostic role of Doppler echocardiography in constrictive pericarditis. J Am Coll Cardiol 1994;23:
154-62.
Alehan FK, Ozkutlu S, Alehan D. Effects of respiration on left
ventricular diastolic function in healthy children. Eur Heart J
1996;17:453-6.
Zhendong Y. Effects of age and respiration on right ventricular diastolic filling patterns in normal children. Pediatr Cardiol
1998;19:218-20.