Transcript Restriction and Constriction

Restriction and Constriction
Nick Tehrani, MD
Restrictive Cardiomyopathy
EVOLVED
As a bedside clinical diagnosis of constriction
confirmed by right heart catheterization findings of
constrictive physiology in patients who:
POROVED NOT TO HAVE ANY
PERICARDIAL DISEASE
Traditional Hemodynamic Criteria
Traditional Hemodynamic Criteria
Utilitity
Traditionalof:
Hemodynamic Criteria:
of LIMITED Utility
Traditionalare
Hemodynamic
Criteria
Hurrell DG, Nishimura RA, Higano ST, Appelton
CP, Danielson GK, Holmes DR, Tajik AJ. Value of
dynamic respiratory changes in left and right
ventricular pressures for the diagnosis of
constrictive pericarditis. Circ. 1996; 93:2007-2013
Restrictive Cardiomyopathy
Represents an extreme form of
Diastolic Dysfunction:
Abnormal increase in Diastolic
ventricular pressure impeding
filling of the LV To NL EDV
Diastole: A historical view
Diastole as the passive interval between
systolic events
Discovery of Frank-Starling mechanism:

LV-EDV, helps regulate the SV
Katz:

After MV opening, LV pressure
continue to decline, despite LV volume
LV as an active suction
incresase
pump in early diastole.
Diastolic Properties of the LV
End of IVRT
Active suction.
ATP req’d
To Re-uptake
Ca++
Quantitative assessent of the 4
phases of Diastole:
Late
diastolic filling
IVRT
Early diastolic
filling
Diastasis
IVRT>100 ms
 Earliest diastolic abnormality.
 Impaired LV relax.
 Filling pressures=NL
 Dz. progression:
Decreased LV
compliance, and
Increased filling
pressure
Quantitative assessment of the 4
phases of Diastole:
IVRT
Early filling:
 DT < 130-180 ms
Interplay of Early and
Late filling:
 E:A ratios…….
 If E at A> 20 cm/s
=> E/A unreliable
Utilized in relation
to PV “a” wave
duration.
Tachycardia
PR prologgation
“A” wave duration…….
E:A ratios, as a Function of Age
Impaired LV relaxation (IVRT )
Decreased LV Compliance
Pseudonormal
Restrictive
The three abnormal LV filling
patterns
Pathophysiologic Similarity of:
Restriction and Constriction
Abnormal increase in ventricular
pressure
impeding filling of the LV To NL EDV
Restriction
Myocardial
Disorder
Constriction
Pericardial
Disorder
Anatomy
Lt. Atrium is not
completely
intrapericardial
All other cardiac
chambers are
completely
intrapericardial
Pulmonary Veins are
completely
intrathoracic
Effect of Inspiration
Normal Pericardium:

Inspiratory decrease in intrathoracic
pressure is uniformly transmitted to
the lungs, PVs, LA, LV, RA, and RV
Effect of Inspiration
Constrictive Pericarditis:


Thickened pericardium isolates the heart form
transmission of intrathoracic pressure changes
Increased inspiratory capacitance of the Lungs
PVs, and LA => PCWP decrease

BUT
The decrease in intrathoracic pressure is not
transmitted to the LV, RV, RA
Dissociation of Intrathoracic and
Intracardiac Pressures
First demonstrated to be present in
constrictive pericarditis using Doppler
techniques in 1989, by Hatle in her
landmark study.
Hatle LK, Appleton CP, Popp RL.
Differentiation of constrictive pericarditis
And restrictive cardiomyopathy by Doppler
Echocardiography. Circ. 1989;79357-370
Dissociation of Intrathoracic and
Intracardiac Pressures
The inciting
Physiologic
Event.
Hatle LK, et. al.
Circ. 1989;79357-370
Ventricular Interdependence
Hatle LK, et. al.
Circ. 1989;79357-370
Insp
Expir
Ventricular Pressures
Are DISCORDANT
Traditional v.s. Dynamic
Catheterization Hemodynamics
Why bother
with Echo
These
measurments
aregiven
only
The
greatusing
utilityHigh-fidelity
of Dynamic
Possible
Respiratory
cath measurments?
Micromanometer
systems
(not a common practice).
Dissociation of Intrathoracic
and Intracardiac Pressures
Effect of Inspiration: Constriction
Inspir.
Insp.
PCWP
Expir.
PCWP
PCWP
Expir.
Expir.
Inspir.
No proportionate decrease in LV diastolic pressure
Decreased transmitral gradient => Transmitral flow
LV SV
RV SV
Pathophysiologic Differences
Constriction
Restriction
Myocardial compliance is NL
No impedence to
Ab-Nl Myocardial compliance
Diastolic EARLY FILLING
Total cardiac volume is fixed by
the pericardium
Atria are able to empty into the
Ventricles, though at higher Press.
Marked Respiratory effect of
LV on the RV
Impedence to filling increases
throughout the diastole
Pericardium is compliant
Septum is non-compliant
Reduction of the proportion of
LV filling with atrial contraction:
=> Atrial enlargement
Minimal Respiratory effect of
RV on the LV
Specific Echocardiographic Criteria for
Constriction/Restriction
Mitral E wave pattern
Pulmonary Vein pattern
Hepatic Vein pattern
Mitral E wave
Criteria for Constriction
Decrease in of 25%
in Mitral “E” velocity
on inspiration.
In RESTRICTION:
no respiratory
variation of Mitral inflow
There is
Specific Echocardiographic Criteria for
Constriction/Restriction
Mitral E wave pattern
Pulmonary Vein pattern
Normal PV Flow-TTE
PSV1- LA relaxation and
pressure decrease.
PSV2- Interaction of RVSV, w/ LA pressure and
compliance.
Utilized in relation
to Mitral “A” wave
duration.
PVa duration- Interplay
of multiple factors
Three abnormal PV filling patterns
in Restriction
E:A ratios, as a function of Age
Impaired LV relaxation (IVRT )
Decreased LV Compliance
Pseudonormal
Restrictive
Relation of Mitral “A” wave to
Pulmonary Venous “a” wave duration
Normal Physiology

With LA contraction
Forward flow Volume and Duration
Exceeds
Backward flow into the PV
Relation of Mitral “A” wave to
PV “a” wave duration
Restrictive Physiology:

PV-a Velocity > 35 cm/s
OR

PV-a duration, 30 ms
longer than Mitral “A”
wave duration.
200 ms
121 ms
PV interrogation using TTE is often
techniaclly limited.
PVs are best assessed using
TEE
Normal PV Flow-TEE
Rt. Upper PV
NO Variation from
Inspiation to Expiration
LV inflow
PV Dopplar Patterns in Restriction-TEE
Lt. Upper PV
LV Inflow
PV flow is not respirophasic
Systolic/Diastolic velocity is
markedly down in both inspiration
and expiration
LV inflow Peak-E velocity is
not respirophasic
PV Dopplar Patterns in Costriction-TEE
Lt. Upper PV
PV flow

LV Inflow
IS Respirophasic:
25% variation of both the
Systolic and Diastolic components
Systolic/Diastolic
Ratio higher than for restriction
(0.7 v.s. 0.4)
LV inflow Peak-E:
17% respiratory variation
(v.s. none for restriction)
Specific Echocardiographic Criteria for
Constriction/Restriction
Mitral E wave pattern
Pulmonary Vein pattern
Hepatic Vein pattern
Respiratory Cycle :Hepatic Vein Flow
IVC
Inspiration
Expiration
Hepatic Vein Dopplar: Normal
Normal
Systolic and diastolic forward flow
S-vel. > D-vel.
Diastolic flow reversal:
Expir.>>Insp.
Hepatic Vein Dopplar: Constriction
Constriction
Diastolic flow reversal is
augmented in expiration.
DFRexp.>25% forward
diastolic velocity
Hepatic Vein Dopplar: Restriction
Restriction
Forward flow primarily in
Diastole.
Inspiration increases both
>systolic, and
>Diastolic
Flow reversals.
Nasser S Tehrani:
These pts not respond as well to surgery
Hepatic Vein Dopplar: Compilation
Mixed physiology
(restriction/constriction)
Diastolic flow reversal
during both Ispiration
and expiration
Constriction Doppler
Inspiration
Expiration
Animation
Animation
Pitfalls and Caveats
Subgroup of patients with constriction
who do not exhibit respiratory changes
COPD
Constriction: Non-respirophasic
Oh et. al. Circ. 1997;95:796-799
12 Pts. W/ confirmed constriction, but
without the classic findings

Deduced post
Stripping, as Sx
Not improve
Etiology of Non-respirophasic pattern
Mixed Restriction and Constriction
Marked increase in Preload
Preload reduction to
unmask the respiratory
variation
Nasser S Tehrani:Wide STD.Deviation,
But may be diagnostic for a ginven pt.
Constriction: Non-respirophasic
Supine
Supine
Insp.
Sitting
Expir.
Sitting
Insp.
Expir.
Effect of changing loading conditions
w/ VALSALVA in RESTRICTION
E 20%
A to a lesser degree
Pitfalls and Caveats
Subgroup of patients with constriction
who do not exhibit respiratory changes
COPD
COPD v.s. Constriction
100% change in E Velocity
flow
velocity profiles are
not restrictive as LV filling
Individual Mitral
pressure is not increased.
COPD v.s. Constriction
COPD
COPD: Greater than NL
decrease in intrathroracic
pressure is generated with
inspiration =>
Increased SVC Flow
Const.
Constriction: Minimal
change in SVC velocities
with inspiration.
Tissue Dopplar PW Analysis of
Mitral Annular Motion
Physiologic Premise:
Assessment of
VELOCITY of LV
-Contraction, and
-Relaxation
How to:
Apical 4 chamber
minimizes the
translational and
rotational components of
LV Contraction.
TDI function of the
machine is activated
Gain is lowered to
approx. Zero
Wall filters are
minimized to display
lower velocities (annular
velocity < 20 cm/s)
Sweep at 100 or 200
mm/sec
Tissue Dopplar:
Restriction and Constriction
Mitral inflow E wave is elevated in both
Annular E wave
 Restriction, peak E-wave < 8 cm/sec
 Constriction, Peak E-wave > 8 cm/sec
The above is Premised on the assumption that:
Annular E wave is preload independent.
Both Pro- and Con- studies regarding this premise exist.
Constriction v.s. Restriction
Dx has important therapeutic implications
Clinical Presentaion similar: RHF
Historical etiologies helpful, but not
diagnostic
A thick pericardium is not necessarily
constrictive
A restrictive process may constrict
Echo and Hemodynamic features may
overlap
Restrictive Cardiomyopathy
Broad categories of diseases involved:
Etiologies of Constriction
Infectious: Post-viral, TB, Purulent
Traumatic:Post CABG, Pacer, Sternal
trauma
Post XRT
Chronic inflammatory Dz: RA, SLE
Uremia
Neoplasia
The End