2Anatomy Lt. Atrium is not completely intrapericardial All other cardiac chambers are intrapericardialPulmonary Veins are completely intrathoracic
3The pericardium Two-layered sac: A thin film of fluid (~ 50 ml). Inner serosal layer (visceral pericardium) adhering to outer wall of heartReflected at the level of the great vesselsJoins the tough fibrous outer layer (parietal pericardium ).A thin film of fluid (~ 50 ml).PulmonaryTrunkPLVL
4Function of pericardium Fixes heart within mediastinum and limits its motion;Prevents extreme dilatation of heart during sudden rises of intracardiac volumeA barrier to limit spread of infection from the adjacent lungs.But patients with complete absence of the pericardium (congenitally or surgically) generally do fine without it? actual physiologic importance.*********************
5Pathology of Constrictive Pericarditis Fibrotic, thickened, and adherent pericardium restriction of diastolic filling of the heart.An initial episode of acute pericarditis (may be subclinical):Organisation & resorption of effusionFibrous scarring and thickening of pericardiumObliteration of the pericardial spaceUniform restriction of filling of all heart chambers.Calcium deposition stiffening of pericardium.
6Pathology of Constrictive Pericarditis Scarring and loss of normal elasticity of pericardial sac §restriction of ventricular filling in mid and late diastole majority of ventricular filling occurs rapidly in early diastole andventricular volume does not increase after the end of early filling period.Restrictive cardiomyopathy:Non-dilated rigid ventricle Severe diastolic dysfunction and restrictive filling Hemodynamics similar to CP.
7CP and Restrictive Cardiomyopathy Both Share:diastolic dysfunctionElevated diastolic pressuresabnormal ventricular fillingDecreased end diastolic volume (EDV).Differentiation important Different management.Diagnosis:Mostly: Clinical and conventional tests.Others: May needBiopsySurgical exploration
8Pathophysiologic Similarity of: Restriction and Constriction Abnormal increase in ventricular pressure impeding filling of RV & LV To NL EDVConstrictionRestrictionMyocardialDisorderPericardialDisorder
9Differences Constriction Restriction Myocardial compliance is NL Ab-Nl Myocardial complianceNo impedance toDiastolic EARLY FILLINGImpedance to filling increasesthroughout the diastoleTotal cardiac volume is fixed byNon-compliant pericardiumPericardium is compliantSeptum is non-compliantAtria are able to empty into theventricles, though at higher Press.proportional LV filling withatrial contraction Atrial enlargementMarked Respiratory effect ofRV on LVMinimal Respiratory effect ofRV on LV***********
10Etiology of Constrictive Pericarditis Idiopathic: ~ 50%Others:Tuberculous: ~ 15%Post-viral pericarditisPost-surgical; TraumaMediastinal IrradiationESRD treated with HDNeoplastic pericardial infiltrationFungal and Parasitic P.Incomplete treatment of purulent pericarditisPost MI pericarditis (Dressler syndrome)Epicardial ICD patches implantationPulmonary AsbestosisMethysergideSarcoidosisChanging Etiology
16History Prior history of pericarditis,trauma,cardiac surgery, ora systemic disease (TB, connective tissue disease, malignancy) CPA history of infiltrative disease that may involve the heart muscle (e.g., amyloidosis, sarcoidosis) RCMPPrior thoracic radiation treatment can result in eitherconstrictive pericarditis,restrictive cardiomyopathy, orCombination of both constrictive pericarditis and restrictive cardiomyopathy.
17Clinical Features - Symptoms and signs Reduced cardiac output:fatigue, hypotension, reflex tachycardiaElevated systemic venous pressure (Rt. Heart Failure)JVP distension, hepatomegaly with marked ascites and peripheral edema.Pulmonary venous congestionexertional dyspnea, cough and orthopneaChest pain typical of anginaUnder-perfusion of the coronary arteries orcompression of an epicardial coronary artery by the thickened pericardium.
18Physical examination JVP: deep, steep Y descent. Elevated jugular venous pressure (JVP). ◊JVP: deep, steep Y descent.constrictive pericarditis,restrictive cardiomyopathy,TR with enlarged compliant RA, orRt. heart failure (e.g., RV infarction or PH).Kussmaul's sign (lack of inspiratory decline in JVP)Pulsus paradoxus (rare in classic CP)Peripheral edemaAscites and hepatomegalyPleural effusions.Pericardial knock (50%) in CP.Not in restrictive cardiomyopathy.Audible S3: in RCMP; abrupt cessation of rapid ventricular filling.Not usually present in CP.
19Diagnostic Testing 2-D and Doppler Echo: rule out other causes of right heart failuredifferentiation between CP and RMD may be difficult.CT and MRI can help in detecting an abnormal pericardium,provide anatomical informationBut not pathophysiological abnormality.Patients with surgically proven CP may have a normal-appearing pericardium on imaging studies(Talreja D.R., Edwards W.D., Danielson G.K.; et al. Circulation ).OrPericardial thickness without constriction:after radiation therapy orprior cardiac operation.********************
21Cardiac Catheterization Not necessary for patients with typical CP: Classic clinical presentationTypical features on noninvasive testing:restrictive mitral inflow velocity,typical respiratory changes in transmitral and hepatic vein Doppler velocitiesnormal to increased (e’) mitral annular tissue velocity.Indicated:If still a question of diagnosis after a comprehensiveClinicalNoninvasive evaluation.
22Cardiac Cath. Hemodynamics High-Fidelity Micromanometers: §Useful for studies of Cardiac MechanicsCombined with quantitative volume measurements to examine chamber function.Volumetric data acquired by:ventricular angiography,simultaneous echocardiography.Standard fluid-filled catheter systems:Pressure data is sufficient for most clinical hemodynamic studiesMany artifacts and suboptimal frequency-response to accurately assess ventricular properties in research studies.
23Measurements Obtain Rt. and Lt. cardiac pressure waveforms. These measurments are onlyPossible using High-fidelityMicromanometer systems .MeasurementsObtain Rt. and Lt. cardiac pressure waveforms.All right-sided pressure recorded simultaneously with LV pressure.Pressures recorded during:normal quiet respiration (for measurement of end-expiratory pressures) andexaggerated respirationVolume loading of 1 liter NS ifon diuretics andRAP (<15 mm Hg).Overdrive pacing if in A. FibRAP, PASP, RVEDP, PCWP, LVEDP, & height of rapid filling wave (RFW).********************
24Traditional Criteria for CP Diastolic equalization of Pressures:LVED – RVEDP ≤ 5 mm HgNarrow RV Pulse Pressure:RVEDP/RVSP > 1/3 (33%)Lack of significant pulmonary HTN:SPAP < 55 mm HgDip and Plateau Pressure (Square Root Sign):Height of LV rapid filling wave (RFW) > 7 mm HgKussmaul’s Sign:Inspiratory fall in mean RA pressure < 3 mmSometime elevation of mean RA pressure with inspiration
251- RV and LV Tracings In Systole: 1) RV & LV diastolic pressures In diastole:1) RV & LV diastolic pressures- Elevated - Equalized4) Square root signRapid filling wave (RFW)due to tithering effect of pericardium, pulling the ventricular muscle back to its diastolic configurationMuscle is compliant steep drop in early diastoleBecause of restraint RFW, then plateau2) Pulse Pressure of RV > 1/3 «In Systole:3) SRVp < 55 mmHgRV SP=60RV DP=30RVDP/RVSP=30/60=1/2 (50%)(>1/3; >33%)
26RV, LV pressure tracings - rapid pressure deceleration (dip) §rapid filling wave (RFW)pressure equalization of RV and LV (plateau)Square Root SignStawowy P et al. Circ Cardiovasc Imaging 2008;1:
282- RA pressure tracings Elevated RA pressure Sharp, deep Y descent a v Stawowy P et al. Circ Cardiovasc Imaging 2008;1:avcElevated RA pressureSharp, deep Y descent
29RA and LV pressures RA and LV represent inflow and outflow of heart In CP:< 5 mm Hg difference in diastoleSometimes: Steep X and Y descents “W” shape of RA tracingavaxy
30Kussmaul Sign ? (5) Deep inspiration: - ve pressure in intrathoracic IVC+ ve pressure in intraabdominal IVC PG in IVC pulling blood to chest.Normal pericardium allows transmission of this PG to cardiac chambers flow to RA.In CP: less transmission of – ve pressure less drop in RA pressure in inspiration < 3 mmHg(5)
34Dissociation of Intrathoracic and Intracardiac Pressures 3- LV and PCWP TracingDissociation of Intrathoracic and Intracardiac PressuresHatle LK, et. al.Circ. 1989;vvvv
353- LV and PCWP Tracing Catheter in PA: Outside heart Pressure changes with respiratory variation preserved (PA & PCWP).Intracardiac (LV) p less changes Drop in PCWP-LV diastolic PG during inspiration flow into LV.Insp.Exp.
36Dissociation of Intrathoracic and Intracardiac Pressures
37Dynamic, Respiratory Variations in CP In Inspiration:dissociation of intrathoracic and intracardiac pressures increase in ventricular interaction Increasing RV fillingDecreasing LV filling.Alternative hypothesis for discordance:increase in inspiratory flow to RV decreased transseptal gradient decrease in early diastolic suction of LV.Doppler Echo:transmitral and hepatic vein flows. §
38PCWP and LV- Restriction ?PCWP and LV- RestrictionSimultaneous drop in LVDP and PCWP with respirationNegative intrathoracic pressure is transmitted to Intracardiac chambers
45Constrictive Pericarditis in the Modern Era: Novel Criteria for Diagnosis in the Cardiac Catheterization LaboratoryJ Am Coll Cardiol. 2008;51(3). Deepak R. Talreja,; Rick A. Nishimura,; Jae K. Oh,; David R. HolmesCriterionSensitivity (%)Specificity (%)Positive Predictive Accuracy (%)Negative Predictive Accuracy (%)LVEDP − RVEDP ≤5 mm Hg46545840PASP <55 mm Hg90297366RVEDP/RVSP >1/3937179LV RFW >7 mm Hg45446242Inspiratory decrease in RAP <5 mm Hg3739Systolic area index >1.19710095
46“Classical” Criteria of CP vs. RCMP J Am Coll Cardiol. 2008;51(3): doi: /j.jacc≤ 5≤ 55> 33%> 7
47Pressure Waveforms During Exaggerated Respiration The area under ventricular pressure curve was used to determine change in relative volumes of LV and RVa better determinant of beat-to-beat stroke volume than the peak pressure aloneThe systolic area index: RV area (mm Hg × s) to LV area (mm Hg × s) in inspiration versus expiration.
48(A) constrictive pericarditis. LV and RV Pressure From 2 Patients During Expiration and Inspiration(A) constrictive pericarditis.During inspiration:increase in area of RV pressure curve (orange) compared with expiration.Enhancement of LV-RV coupling.area of LV pressure curve (yellow) decreases in height and width as compared with expiration.B) restrictive myocardial diseasedecrease in area of RV pressure curve (orange) as compared with expiration.area of the LV pressure curve (yellow) is unchanged as compared with expiration.CP31LV-RVcoupling2RP221
4997 100 95 1.1 Systolic area index >1.1 J Am Coll Cardiol. 2008;51(3): doi: /j.jacc1.1This ratio is a measurement of the degree of ventricular interaction.
55LV AngiogramNeedle broke off during IV injection, embolized to right heart cardiac perforation entering pericardium chronic constrictive pericarditis, presented as congestive heart failure Pericardectomy and removal of the foreign body was successful.********************
56Management CCP is a progressive irreversible disease Minority survive for years with modest elevated JVP and peripheral edema controlled by diet and diuretics.Drugs that slow HR, eg beta blockers and Ca2+ channel blockers should be avoided as mild sinus tachycardia is a compensatory mechanism.The majority of patients become progressively more disabled and subsequently suffer the complications of severe cardiac cachexia.
57Surgical & Pathology Findings in CP obliteration of pericardial spacebulging of heart upon incision of pericardium,abnormal pericardial thickening and/or calcificationpost-operatively- decrease in RA - increase in cardiac index.
58EFFUSIVE CONSTRICTIVE PERICARDITIS (ECP) Rare clinical syndromePericardial effusion and pericardial constriction,Constrictive hemodynamics persistent after p. effusion is removed.Mechanism:visceral pericardial constriction Visceral pericardiectomyPericardial effusions vary in size and age.Type: Transudative, exudative, sanguineous, or chylous.An effusion for months to years may evolve into ECPAny point of time; from occurrence of P. Effusion to development of constriction.Symptoms due to limitation of end-diastolic volume.pericardial effusion/ tampnade, And pericardial constriction.
59EFFUSIVE CONSTRICTIVE PERICARDITIS Etiology Idiopathic factorsIrradiationCardiac surgeryNeoplasm - Most commonly lung, breast, or hematologicInfectious disease - Particularly in immunocompromised statesmost commonly tuberculosis and fungal disease,Streptococcus species reportedMyocardial infiltrationConnective tissue diseaseUremia
60EFFUSIVE CONSTRICTIVE PERICARDITIS (ECP) Hancock in 1960: helped in current understanding of ECP.Hancock, EW. Subacute effusive-constrictive pericarditis. Circulation 1971.Hancock, EW. On the elastic and rigid forms of constrictive pericarditis. Am Heart J 1980.24 patients undergoing pericardiectomy for CP,9 had concurrent effusion.6 of 9 had hemodynamic studies before surgery.Sagrista-Sauldea et al in 2004; prospective study of 1184 patients with pericarditis,6.9% of 218 patients with tamponade had confirmed EFP.Sagrista-Sauleda J, Angel J, Sanchez A, et al. Effusive-constrictive pericarditis. N Engl J Med. 2004
61Clinical clues to ECP: Pulsus paradoxus rare in classical CP (absence of transmission of the inspiratory decline in pressure to right heart chambers) Absence of pericardial knock (effusion)The Y descent less dominant than expectedKussmaul's sign frequently absent
62PA and Ao. Tracing ? SPAP> 55 mm Hg Pulsus Paradoxus (Ao.) Insp. Exp.Pulsus Paradoxus
63EFFUSIVE CONSTRICTIVE PERICARDITIS (ECP) Diagnosis:during pericardiocentesis in patients considered to have uncomplicated cardiac tamponade.Despite lowering pericardial pressure to normal,persistence of elevated RA pressuredevelopment of y decent dominanceimpaired respiratory variation. §because of visceral constrictive component of the syndrome persistent elevation and equalization of intracardiac diastolic pressures.
64ECP post pericardiocentesis: Pericardial pressure normalized YECP post pericardiocentesis:Pericardial pressure normalizedRA pressure remains elevated with features of CP (deep Y descent).
65Persistently elevated RA pressure after pericardiocentesis Cardiac tamponade complicatingright heart failure ortricuspid regurgitation.
66ConclusionCP still challenging diagnosis for clinicians, especially when both myocardial and pericardial disease present.Although noninvasive testing help in the diagnosis of CP, some cases remain unclear.Dynamic respiratory changes reflecting the enhancement of ventricular interaction at cardiac catheterization is most useful.The ratio of RV to LV systolic pressure X area during inspiration vs. expiration (systolic area index) is a novel measurement of enhanced ventricular interaction.
68Cardiac Catheterization Typical hemodynamic response in CP:early rapid filling and equalization of end-diastolic pressures in all 4 cardiac chambersbut also in RMD.More severe pulmonary hypertensiongreater difference between LVEDP and RVEDP in patients with RMD.Though statistically significant differences in overall values of these criteria, butthe – ve and + ve predictive value were of limited.
71Pressure Waveforms During Exaggerated Respiration Peak inspiratory beat was selected as the systolic impulse preceded by the lowest early diastolic nadir of the LV pressures.Selection of the peak inspiratory beat required that the early diastolic nadir was at a minimum for the diastolic filling period before and after the systolic pressure contours.Peak expiratory beat was selected as the systolic impulse that was preceded by the highest early diastolic nadir of the LV pressure.In CP:inspiratory decrease in the LV volume andenhancement of ventricular coupling (obligatory increase in RV volume)The LV pressure curves become smaller in terms of both the height and width of curve,The RV pressure curve becomes larger during peak inspiration.Previously, RV index based on RV peak systolic pressure variation between inspiration and expiration was used as a measure of ventricular coupling.We subsequently found that changes in the peak pressure alone were not sensitive enough to detect all patients with CP.Therefore, the area under the ventricular pressure curve was used to determine the change in the relative volumes of the LV and RVa better determinant of beat-to-beat stroke volume than the peak pressure aloneThe systolic area index: the ratio of RV area (mm Hg × s) to LV area (mm Hg × s) in inspiration versus expiration.
72Constrictive Pericarditis in the Modern EraNovel Criteria for Diagnosis in the Cardiac Catheterization Laboratory Deepak R. Talreja, MD, FACC; Rick A. Nishimura, MD, FACC; Jae K. Oh, MD, FACC; David R. Holmes, MD, FACC J Am Coll Cardiol. 2008;51(3): doi: /j.jaccAbstractObjectives This study sought to determine the clinical utility of a new catheterization criterion for the diagnosis of constrictive pericarditis (CP).Background The finding of early rapid filling and equalization of end-diastolic pressures obtained by cardiac catheterization are necessary for the diagnosis of CP, but these findings are also present in patients with restrictive myocardial disease (RMD). Enhanced ventricular interaction is unique to CP.Methods High-fidelity intracardiac pressure waveforms from 100 consecutive patients undergoing hemodynamic catheterization for diagnosis of CP versus RMD were examined. Fifty-nine patients had surgically documented CP and comprised group 1; the remaining 41 patients with RMD comprised group 2. The ratio of the right ventricular to left ventricular systolic pressure-time area during inspiration versus expiration (systolic area index) was used as a measurement of enhanced ventricular interaction.Results There were statistically significant differences in the conventional catheterization criteria between CP and RMD, but the predictive accuracy of any of the criteria was <75%. The systolic area index had a sensitivity of 97% and a predictive accuracy of 100% for the identification of patients with surgically proven CP.Conclusions The ratio of right ventricular to left ventricular systolic area during inspiration and expiration is a reliable catheterization criterion for differentiating CP from RMD, which incorporates the concept of enhanced ventricular interdependence.