Contemporary Assessment and Management of Effusive-Constrictive Pericarditis

Effusive-constrictive pericarditis (ECP) is a complex clinical condition that combines features of pericardial effusion/tamponade and constrictive pericarditis. The classic hemodynamic definition is persistent elevation of right atrial pressure despite drainage of a pericardial effusion. This review summarizes recent data on its epidemiology, pathophysiology, diagnosis, and management. Prevalence varies from 2.4% to 14.8% depending on diagnostic criteria and etiology, reaching up to 50% in tuberculous pericarditis in endemic regions. Common causes include idiopathic, infectious (particularly tuberculous and bacterial), malignant, and post-surgical etiologies. While invasive hemodynamic assessment remains the reference standard, echocardiography is now the primary diagnostic tool, enabling recognition of constrictive physiology before and after pericardiocentesis. Cardiac magnetic resonance adds complementary information on pericardial thickness, inflammation, and potential for reversibility, aiding therapeutic decisions. Inflammatory ECP frequently resolves with medical therapy (NSAIDs, colchicine, corticosteroids, or IL-1 inhibitors) while tuberculous cases require antimicrobial therapy with corticosteroids in selected patients. ECP is a heterogeneous condition with variable clinical trajectories. Early identification through multimodality imaging is essential to guide therapy, target reversible inflammation, and prevent chronic constriction. Most inflammatory cases respond to anti-inflammatory treatment, whereas pericardiectomy is reserved for persistent, irreversible constrictive physiology despite optimal medical therapy.