Multimodality Imaging Approach in the Diagnosis of Constrictive Pericarditis

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

I carefully read the article titled “Multimodality Imaging approach in the Diagnosis of Constrictive Pericarditis" sent to me for review. My comments, criticisms, and suggestions are listed below:

1. I congratulate the authors for this well-written review.

2. To help the reader better understand the subject, it would be appropriate to provide information about normal pericardial anatomy and function.
3. I recommend including the following subheadings in the article: pathophysiology; etiology; clinical findings.
4. Despite advances in cardiac imaging, diagnosis can sometimes be challenging. In such cases, invasive hemodynamic evaluation via cardiac catheterization may be necessary. Discussing this topic in light of the literature would be beneficial.
5. Providing information about imaging options during post-medical treatment or post-surgical evaluation would also be beneficial.
6. Comparative analysis of the impact of preoperative imaging findings on post-pericardiectomy outcomes in patients with chronic constrictive pericarditis will enhance this review's contribution to the literature.
7. Diagnostic approaches to evaluating additional coronary or valvular pathologies in patients and their roles in treatment planning should be discussed.
8. The roles of pericardial fluid analysis, pericardial and epicardial biopsy in differential diagnosis should be given in a separate paragraph.
9. Providing information on the use of multimodal imaging approaches in the differential diagnosis of post-cardiac injury syndrome would be beneficial.
10. It would be helpful if an algorithmic schema could be created that combines the imaging approach with symptoms, physical findings, laboratory data, and ECG findings.

Best Regards

Comments on the Quality of English Language

The English could be improved to more clearly express the research.

Author Response

Please see the attachment

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for inviting me to review this paper.

This is a narrative review describing how echocardiography, CMR, cardiac CT, and nuclear imaging complement each other in diagnosing constrictive pericarditis, distinguishing CP from restrictive cardiomyopathy, identifying active pericardial inflammation, and guiding management decisions. The manuscript is generally well aligned with modern conceptual frameworks emphasizing integrated anatomy, physiology, and inflammatory activity. I have the following comments.

 

1. The paper reads as an expert narrative review but lacks any description of how evidence was selected. This is important because diagnostic accuracy statements and imaging roles vary by cohort, etiology, and study era. Please add a short section describing search sources, years, key terms, inclusion of guidelines/position papers, and how you handled heterogeneous evidence. This will improve transparency and reduce risk of selective citation.
2. You mention cardiac-echo findings “closely parallel discordant pressure patterns observed during catheterization” but there is no catheterization or hemodynamic section. In real-world diagnostic pathways—especially when noninvasive imaging is equivocal—simultaneous cath data remains a cornerstone (e.g., discordant LV/RV systolic pressures with respiration; equalization of diastolic pressures; differentiating CP vs RCM in difficult cases). Please add a concise section describing when to proceed to cath exam, key hemodynamic criteria, pitfalls, how cath integrates with CMR/PET markers of inflammation when considering medical therapy vs early pericardiectomy.
3. Diagnostic thresholds should be standardized and placed in a practical criteria table for the readers. Table 1 is high-level and doesn’t contain numeric thresholds. Please consider to add table showing key diagnostic criteria by modality including: echo: septal bounce, respiratory inflow variation cutoffs, hepatic vein reversal thresholds, septal e′ cutoffs, annulus reversus/paradoxus, strain reversus ratio (<0.96); CMR: real-time ventricular interdependence/septal shift; pericardial edema (T2/STIR) and LGE patterns; CT: pericardial thickness, distribution of calcification, adjunct inflammatory tools; PET: FDG uptake patterns, preparation pitfalls, interpretive caveats, etc.
4. The authors appropriately emphasized that distinguishing CP from RCM is critical and that tissue Doppler is highly discriminative. However, the review would benefit from a single integrated comparison across modalities (echo + CMR + CT + PET), rather than echo-dominant discussion with scattered RCM references.
5. A key message is that CMR edema and LGE can identify inflammatory phenotypes likely to respond to medical therapy, while absent LGE suggests fibrotic burnt-out CP more suitable for early pericardiectomy. This is clinically valuable, but the manuscript should better define what constitutes high likelihood of reversibility (how much edema/LGE? what trend on follow-up imaging?), suggested follow-up interval and modality for monitoring response, how inflammatory biomarkers should be integrated.
6. The CT section is strong on pericardial calcification and surgical planning. It also discussed delayed enhancement, dual-energy iodine mapping, and photon-counting CT. However, to be clinically balanced, please specify when CT is preferred over CMR (device contraindication, severe claustrophobia, need for calcification mapping).
7. The AI section is interesting, but it reads like a general AI in cardiac imaging overview and is not clearly CP-specific, except for a few cited examples.
8. Figure 4 diagnostic flow chart is a helpful summary but it currently gave limited guidance on what defines typical CP on TTE, did not explicitly incorporate invasive hemodynamics, may oversimplify the branch from CMR inflammation to therapy (medical vs pericardiectomy).

Comments on the Quality of English Language

Typos and language polish needed (e.g., “Ecocardiography” in Figure caption; “infiammatory” in keywords).

Author Response

Please see the attachment

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

I would like to express my gratitude to the authors for their meticulous revisions based on comments, criticisms, and suggestions. I believe this version of the article will make a significant contribution to the literature.

Sincerely

Reviewer 2 Report

Comments and Suggestions for Authors

The authors had addressed my concerns. Congratulations on publishing!