2 The Pericardium Fibroelastic sac surrounding heart Composed of 2 layers: serous parietal and fibrous visceral pericardiumForms a sac-like potential space: contains thin layer of fluid (5-10 cc)
3 The Pericardium:Pericardial reflections: surround pulmonary and systemic inflow and great vesselsTransverse sinus: great arteries posteriorlyOblique sinus: posterior to LA between pulmonary veins
4 Constrictive Pericarditis: Pericardium becomes thickened and fibroticLoss of elasticity and complianceCan follow (usually late) any pericardial inflammatory process
5 Etiologies: Idiopathic or Viral: 42-49% Post cardiac surgery: 11-37% Post Radiation: 9-31%CT disease: 3-7%Postinfectious: 3-6%TBBacterial/purulentOthers: 1-10%MalignancyTraumaAsbestosisSarcoidosisDrugsUremia
6 Physiology of Constriction: Rapid early diastolic fillingImpaired late diastolic filling due toinelastic pericardiumPericardium acts as a calcified shell:Decreased compliance: fills to a point and abruptly stopsPressure/Volume changes within the heart affect other chambers: InterdependenceNothing gets in: Intrathoracic pressures not transmitted to cardiac chambers and encased great vessels
7 Hemodynamics:CVP tracing: Rapid descent of RAP with ventricular filling (y descent)
8 Hemodynamics:Ventricular tracing: rapid early diastolic filling with abrupt halt and plateau:Square-root signDip-and-plateauEqualization of diastolic pressures
9 Respiratory Hemodynamics: Intrathoracic pressure not transmitted to cardiac chambersRight-sided venous return does not increase as significantly with inspiration:Increase in RV inflow across TVPulmonary venous pressure still decreases with inspiration:Decrease in LV inflow across MV
11 Respiratory Hemodynamics: Increased Interdependence of RV and LV:Inspiration: Right-sided filling > Left-sided fillingLV output is minimized by decreased inflowRV septum bows into LV further decrease in COResult:Decrease in LV systolic pressureRelative increase in RV systolic pressure
13 Discordance vs Concordance: Grossman, th edition.
14 Echocardiographic Evaluation: Preferred modality for assessing the pericardium and pericardial diseaseLess reliable that MR or CT for pericardial thickening, calcification, or constrictionStill employed as initial diagnostic testRecommended by the ACC/AHA
15 Normal Pericardium: M-Mode: Two-Dimensional: Systolic separation of the visceral and parietal pericardium2 layers move in parallelTwo-Dimensional:Brightest structureHeart/Visceral pericardium slide/twist within the parietal pericardium
17 M-Mode: Constriction Dense-echos posterior to LV: Move in parallelAbrupt, posterior motion of the ventricular septum in early diastole (dip):Flat in mid-diastole (plateau with equal RV and LV)Abrupt anterior motion in atrial contraction (RV filling)IVC and hepatic vein dilatation
19 2D: ConstrictionIncreased echogenicity of the pericardium from thickeningLoss of movement of heart within pericardium:Fixed and adherentMay see effusion (effusive-constrictive)Septal shudder or bounceAbrupt posterior movement of septumIn inspiration with underfilling of LV
26 Other 2D Findings: Dilation of IVC Decreased collapse of IVC w/ inspirationHepatic vein plethoraBiatrial enlargementAbrupt stop in diastolic filling of ventricles
27 Doppler Echocardiography: Crucial component in the evaluation of constrictionCorresponds with the physiology and reflects the hemodynamics previously discussed
28 Doppler Findings:RV and LV inflow show prominent E wave due to rapid early diastolic fillingShort deceleration time of E wave as filling abruptly stopsSmall A wave as little filling occurs in late diastole following atrial contractionOtto. Textbook of Clinical Echocardiography, 3rd Edition, 2004.
29 Doppler Findings:Redfield MM, et al. JAMA 2003.
30 Review of Doppler: Pulmonary vein flow (on apical 4 chamber): Correspond to LA fillingProminent a waveProminent y descentProminent diastolic filling phaseBlunted systolic filling following atrial contraction
31 Doppler: Mitral and Tricuspid Inflow Marked respiratory variation in biventricular inflowInspiration:Negative intrapleural pressureIncreased RV inflow velocity and diastolic fillingDecreased LV inflow velocityGreater than 25% respiratory variation
32 Mitral Inflow: CXR: Transmitral Doppler: Turkish Society of Cardiology, 2007.
36 Tissue Doppler:Important in differentiating restriction and constrictionProminent E’, Loss of A’Gorcsan, J. Japanese Circ Society, 2000
37 Tissue Doppler: Annular Paradox: E/E’ increasedMean LAP decreasedHigh pressure and low ratioPeak E’ ≥ 8 cm/s: (Rajagopalan, N. at al. AJC 2001.)89% senstive for constriction100% specific
38 Improving Sensitivity: Choi et al. J Am Soc Echo, 2007 Jun.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
39 Normal Tissue Doppler: Nurcan,et al. Turkish Society of Cardiology, 2006.
40 The Study:44 patients:28 male, 16 femaleMean age 47 years (10-76 years)17 patients with constrictive pericarditis12 patients with restrictive cardiomyopathy15 control subjectsStandard mitral inflow doppler and tissue doppler performed
41 Study Results: ●E’ and S’ significantly higher in constrictive group: Constriction:E’ 9.5 +/- 1.7 cm/sS’ 7.7 +/-1.3 cm/sT(E-E’) /- 32 msRestriction:E’ 4.7 +/- 1.6 cm/sS’ 4.6 +/- 1.9 cm/sT(E-E’) / ms●E’ and S’ significantly higher in constrictive group:(P< 0.001)●T(E-E’) significantly shorter in constrictive group:(P= 0.02)
42 Study Results:Diagnostic accuracy of E’ > S’ >T(E-E’) for differentiation of constriction vs restriction:AUC: 0.99 vs 0.87 vs 0.74, resp.E’ of 8 cm/s: 100% specific, 70% sensitive at differentiation
43 Study Results: Combining E’ with S’ and T(E-E’): Sensitivity increased compared to E’ alone:70% sensitive with E’ alone88% sensitive with E’ + S’94% sensitive with E’ + S’ + T(E-E’)P = 0.001
44 Study Conclusion:Additional Measurement of S’ and T(E-E’) can be incrementally helpful in differentiation of constrictive pericarditis from restrictive cardiomyopathy when added to E’
45 Other Echo techniques: Rajagopalan, et al. Am J Cardiol 2001:Evaluate Tissue Doppler and Color M-Mode flow propagation to distinguish CP and RCM30 patients:19 Constrictive pericarditis11 Restrictive cardiomayopathyConfirmed by other modalitiesCompared with mitral inflow respiratory variation
46 Propagation Velocity: Color M-Mode of diastolic flow from LA to apex in 4 chamber view20 by TTE, 10 by TEEFlow propagation slope of first aliasing contour (white line):Steep at 110 cm/s in CPLess steep at 35 cm/s in RCMRajagopalan N. Am J Cardiol 2001;87:86
47 Results:Slope of first aliasing contour of > 100 cm/s differentiated CP from RCM:91% specificity74% sensitivity
48 Other Results:Respiratory variation of the mitral inflow peak early velocity of ≥10%: 84% sensitivity and 91% specificityVariation in the pulmonary venous peak diastolic velocity of ≥18%: 79% sensitivity and 91% specificityTissue Doppler peak E’ of ≥8.0 cm/s: 89% sensitivity and 100% specificity.
49 Echo is still not perfect…. Other modalities to aid in diagnosis of constrictive pericarditis:CXRCTCMRCardiac catheterizationSurgical biopsy
50 Multislice Cardiac CT: Langher, et al. Heart 2006.