7Anatomy Lt. Atrium is not Completely intrapericardial All other cardiac chambers are completely intrapericardialPulmonary Veins are completely intrathoracic
8Effect of Inspiration Normal Pericardium Constrictive Pericarditis Intra thoracic pressureVenous returnTransient size of RVNormal LV fillingIntra thoracic pressureVenous returnRV not expandedAbnormal LV fillingUptodate 2011
10Physiology CP vs RCM Constrictive Pericarditis Restrictive Myocardial compliance is NLPericardium not compliantSeptum compliantRapid early diastolic fillingcardiac volume is fixed by the pericardiumRespiratory effect of LV on the RVAb-Nl Myocardial compliancePericardium compliantSeptum not compliantImpedence to filling increases throughout the diastoleNo Respiratory effect of RV and the LV
12Why is it important to make the distinction RCM vs CP? Associated with significant morbidity and mortalityRestriction rarely treatable/curableConstriction may be curable with surgery.
13RCM Findings CP Inexplained CHF CXray: No Cardiomegaly ( Clinically, Cxray, BNP..)Echo: Normal LV systolic functionFindingsTrans mitral Doppler:Restrictive Pattern: E/A>2TDI:(E’>8cm/s, E/E’<15 Normal S wave)TDI:E’<8cm/s,E/E’>15RCMCPCPCho YH and Schaff.Heart Fail Rev 2012
14CXray: No Cardiomegaly ( Clinically, Cxray, BNP..) Inexplained CHFCXray: No Cardiomegaly ( Clinically, Cxray, BNP..)Echo: M-Mode, 2-DNormal LV Systolic FunctionFindings
15M-mode and 2-D CP Pericardial thickening and calcification Septal bounceDilated not collapsing Inferior Vena CavaFlattening of LV post wallEarly pathological outward and inward movement of the IVSColor M-mode Propagation
17CPDifferential Dx:Constrictive PericarditisPericardial TamponadePulmonary HypertensionLBBBRight Ventricular Pacing.Paradoxal motion of the IVS occurring in early diastoleSensibility 62%,Specificity 93%Journal of Thoracic Imaging. 27(1):w1, January 2012.
19Mastouri et al. Expert Rev Cardiovasc 2010 M-Mode CPSigns reflecting increased ventricular interdependenceAbrupt early diastolic anterior motion of the IVS followed by a rebound toward the LV post wall.Mastouri et al. Expert Rev Cardiovasc 2010.
20M-Mode CP Signs reflecting rapid early ventricular diastolic filling: Flattening at the LV post wallSensitivity 92%, Specificity 100%Voelkel et al ,Circulation Nov;58(5):871-5.
21Mastouri et al. Expert Rev Cardiovasc 2010 M-Mode CPSigns reflecting increased Right Ventr diastolic pressure above Pulmonary Art pressurePremature opening of the pulmonary valveSensibility 14%,Specificity 100%Mastouri et al. Expert Rev Cardiovasc 2010
22Sensibility 74%,Specificity 91% Am J 2001,87,86-94
23RCM 2-D Small LV cavity with large atria Increased wall thickness ( especially in interatrial septum in Amyloidosis)Thickened valves and granular sparkling texture (amyloidosis)
27Constriction: Non-respirophasic Mixed Restriction and ConstrictionMarked increase in PreloadProvocation test with head-up tilting or sitting position with decrease of the preload may unmask the CP.Maisch, Seferovic, Ristic et al.ESC guidelines on pericardial disease, E J 2004
53Conclusions Dx has important therapeutic implications Clinical Presentaion similarEchocardiography (Doppler,TDI, Strain/Strain rate) have increased yield.Cardiac catheterisation still considered mandatory.