Transcript Echocardiographic Evaluation of Constrictive Pericarditis

Echocardiographic
Evaluation of
Constrictive Pericarditis
Angela Morello, M.D.
December 18, 2007
The Pericardium
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Fibroelastic sac
surrounding heart
Composed of 2 layers:
serous parietal and
fibrous visceral
pericardium
Forms a sac-like
potential space: contains
thin layer of fluid (5-10
cc)
The Pericardium:
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Pericardial reflections:
surround pulmonary and
systemic inflow and great
vessels
Transverse sinus: great
arteries posteriorly
Oblique sinus: posterior
to LA between
pulmonary veins
Constrictive Pericarditis:
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Pericardium becomes thickened and fibrotic
Loss of elasticity and compliance
Can follow (usually late) any pericardial
inflammatory process
Etiologies:
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Idiopathic or Viral: 4249%
Post cardiac surgery: 1137%
Post Radiation: 9-31%
CT disease: 3-7%
Postinfectious: 3-6%
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TB
Bacterial/purulent
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Others: 1-10%
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Malignancy
Trauma
Asbestosis
Sarcoidosis
Drugs
Uremia
Physiology of Constriction:
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Rapid early diastolic filling
Impaired late diastolic filling due to
inelastic pericardium
Pericardium acts as a calcified shell:
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Decreased compliance: fills to a point and abruptly stops
Pressure/Volume changes within the heart affect other
chambers: Interdependence
Nothing gets in: Intrathoracic pressures not transmitted to
cardiac chambers and encased great vessels
Hemodynamics:
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CVP tracing: Rapid descent of RAP with
ventricular filling (y descent)
Hemodynamics:
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Ventricular tracing: rapid
early diastolic filling with
abrupt halt and plateau:
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Square-root sign
Dip-and-plateau
Equalization of diastolic
pressures
Respiratory Hemodynamics:
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Intrathoracic pressure not transmitted to cardiac
chambers
Right-sided venous return does not increase as
significantly with inspiration:
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Increase in RV inflow across TV
Pulmonary venous pressure still decreases with
inspiration:
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Decrease in LV inflow across MV
Goldstein J. Curr Probl Cardiol 2004.
Respiratory Hemodynamics:
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Increased Interdependence of RV and LV:
Inspiration: Right-sided filling > Left-sided filling
 LV output is minimized by decreased inflow
 RV septum bows into LV further decrease in CO
 Result:
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Decrease in LV systolic pressure
 Relative increase in RV systolic pressure
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Inspiratory Discordance:
Discordance vs Concordance:
Grossman, 2000 6th edition.
Echocardiographic Evaluation:
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Preferred modality for assessing the pericardium
and pericardial disease
Less reliable that MR or CT for pericardial
thickening, calcification, or constriction
Still employed as initial diagnostic test
 Recommended by the ACC/AHA
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Normal Pericardium:
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M-Mode:
Systolic separation of the visceral and parietal
pericardium
 2 layers move in parallel
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Two-Dimensional:
Brightest structure
 Heart/Visceral pericardium slide/twist within the
parietal pericardium
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M-Mode
M-Mode: Constriction
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Dense-echos posterior to LV:
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Abrupt, posterior motion of the ventricular septum in
early diastole (dip):
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Move in parallel
Flat in mid-diastole (plateau with equal RV and LV)
Abrupt anterior motion in atrial contraction (RV filling)
IVC and hepatic vein dilatation
Normal Pericardium:
2D: Constriction
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Increased echogenicity of the pericardium from
thickening
Loss of movement of heart within pericardium:
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Fixed and adherent
May see effusion (effusive-constrictive)
Septal shudder or bounce
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Abrupt posterior movement of septum
In inspiration with underfilling of LV
Fixed& echogenic pericardium:
Pericardial thickening:
Subcostal:
Septal Bounce:
Septal Bounce:
Septal Bounce:
Other 2D Findings:
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Dilation of IVC
Decreased collapse of IVC w/ inspiration
Hepatic vein plethora
Biatrial enlargement
Abrupt stop in diastolic filling of ventricles
Doppler Echocardiography:
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Crucial component in the evaluation of
constriction
Corresponds with the physiology and reflects
the hemodynamics previously discussed
Doppler Findings:
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RV and LV inflow show
prominent E wave due to
rapid early diastolic
filling
Short deceleration time
of E wave as filling
abruptly stops
Small A wave as little
filling occurs in late
diastole following atrial
contraction
Otto. Textbook of Clinical Echocardiography, 3rd Edition, 2004.
Doppler Findings:
Redfield MM, et al. JAMA 2003.
Review of Doppler:
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Pulmonary vein flow (on
apical 4 chamber):
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Correspond to LA filling
Prominent a wave
Prominent y descent
Prominent diastolic filling
phase
Blunted systolic filling
following atrial
contraction
Doppler: Mitral and Tricuspid Inflow
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Marked respiratory variation in biventricular
inflow
Inspiration:
Negative intrapleural pressure
 Increased RV inflow velocity and diastolic filling
 Decreased LV inflow velocity
 Greater than 25% respiratory variation
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Mitral Inflow:
CXR:
Transmitral Doppler:
Turkish Society of Cardiology, 2007.
Respiratory Mitral Inflow:
Respiratory Tricuspid Inflow:
Tissue Doppler:
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Important in
differentiating restriction
and constriction
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Prominent E’, Loss of A’
Gorcsan, J. Japanese Circ Society, 2000
Tissue Doppler:
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Annular Paradox:
E/E’ increased
 Mean LAP decreased
 High pressure and low ratio
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Peak E’ ≥ 8 cm/s: (Rajagopalan, N. at al. AJC 2001.)
89% senstive for constriction
 100% specific
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Improving Sensitivity:
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Choi et al. J Am Soc Echo, 2007 Jun.
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To evaluate additional value of systolic mitral
annular velocity (S’) and time difference between
onset of mitral inflow (T(E’-E)) and onset of E’ to
differentiate constriction and restriction
Normal Tissue Doppler:
Nurcan,et al. Turkish Society of Cardiology, 2006.
The Study:
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44 patients:
28 male, 16 female
 Mean age 47 years (10-76 years)
 17 patients with constrictive pericarditis
 12 patients with restrictive cardiomyopathy
 15 control subjects
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Standard mitral inflow doppler and tissue
doppler performed
Study Results:
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Constriction:
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Restriction:
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E’ 9.5 +/- 1.7 cm/s
S’ 7.7 +/-1.3 cm/s
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E’ 4.7 +/- 1.6 cm/s
S’ 4.6 +/- 1.9 cm/s
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T(E-E’) 21.0 +/- 32 ms
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T(E-E’) 53.1 +/- 30.4 ms
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●E’ and S’ significantly higher in constrictive group:
(P< 0.001)
●T(E-E’) significantly shorter in constrictive group:
(P= 0.02)
Study Results:
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Diagnostic accuracy of E’ > S’ >T(E-E’) for
differentiation of constriction vs restriction:
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AUC: 0.99 vs 0.87 vs 0.74, resp.
E’ of 8 cm/s: 100% specific, 70% sensitive at
differentiation
Study Results:
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Combining E’ with S’ and T(E-E’):
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Sensitivity increased compared to E’ alone:
70% sensitive with E’ alone
 88% sensitive with E’ + S’
 94% sensitive with E’ + S’ + T(E-E’)
 P = 0.001
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Study Conclusion:
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Additional Measurement of S’ and T(E-E’) can
be incrementally helpful in differentiation of
constrictive pericarditis from restrictive
cardiomyopathy when added to E’
Other Echo techniques:
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Rajagopalan, et al. Am J Cardiol 2001:
Evaluate Tissue Doppler and Color M-Mode flow
propagation to distinguish CP and RCM
 30 patients:
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19 Constrictive pericarditis
 11 Restrictive cardiomayopathy
 Confirmed by other modalities
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Compared with mitral inflow respiratory variation
Propagation Velocity:
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Color M-Mode of
diastolic flow from LA
to apex in 4 chamber
view
20 by TTE, 10 by TEE
Flow propagation slope
of first aliasing contour
(white line):
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Steep at 110 cm/s in CP
Less steep at 35 cm/s in
RCM
Rajagopalan N. Am J Cardiol 2001;87:86
Results:
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Slope of first aliasing
contour of > 100 cm/s
differentiated CP from
RCM:
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91% specificity
74% sensitivity
Other Results:
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Respiratory variation of the mitral inflow peak
early velocity of ≥10%: 84% sensitivity and
91% specificity
Variation in the pulmonary venous peak diastolic
velocity of ≥18%: 79% sensitivity and 91%
specificity
Tissue Doppler peak E’ of ≥8.0 cm/s: 89%
sensitivity and 100% specificity.
Echo is still not perfect….
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Other modalities to aid in diagnosis of
constrictive pericarditis:
CXR
 CT
 CMR
 Cardiac catheterization
 Surgical biopsy
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Multislice Cardiac CT:
Langher, et al. Heart 2006.
Cardiac MR: Normal Pericardium
Cardiac MR: Constrictive Pericarditis
Thanks!