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Constrictive Cardiomyopathy Versus Restrictive Cardiomyopathy Echocardiography Dr Djilali Hanzal Cardiologist National Guard Hospital.

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Presentation on theme: "Constrictive Cardiomyopathy Versus Restrictive Cardiomyopathy Echocardiography Dr Djilali Hanzal Cardiologist National Guard Hospital."— Presentation transcript:

1 Constrictive Cardiomyopathy Versus Restrictive Cardiomyopathy Echocardiography Dr Djilali Hanzal Cardiologist National Guard Hospital

2 Outline  Background  Physiology  Clinical Features  Echocardiography :  M mode  2D  Doppler  Tissue Doppler  Strain Imaging  Conclusion

3 Etiology CP Bertog SC, J Am Coll Cardiol. 2004;43(8):1445.

4 Tajik AJ Circulation. 1999;100(13):1380. Symptoms

5 Varieties of constrictive pericarditis Rien muller et al.J Thorac Imaging 1993

6 J Am Coll Cardiol 2004;43;

7 Anatomy Lt. Atrium is not Completely intrapericardial All other cardiac chambers are completely intrapericardial Pulmonary Veins are completely intrathoracic

8 Effect of Inspiration Normal Pericardium Intra thoracic pressure Venous return Venous return Transient size of RV Normal LV filling Constrictive Pericarditis  Intra thoracic pressure  Venous return  RV not expanded  Abnormal LV filling Uptodate 2011

9 Mechanism FILLING IMPAIREMENT FILLING IMPAIREMENT LV-RV INTERDEPENDANCE LV-RV INTERDEPENDANCE

10 Physiology CP vs RCM Constrictive Pericarditis Myocardial compliance is NL Pericardium not compliant Septum compliant Rapid early diastolic filling cardiac volume is fixed by the pericardium Respiratory effect of LV on the RV Restrictive Ab-Nl Myocardial compliance Pericardium compliant Septum not compliant Impedence to filling increases throughout the diastole No Respiratory effect of RV and the LV

11 Restrictive Cardiomyopathy (Myocardial Disorders) Myocardial disease Endomyocardial disease Storage disease Infiltrative Noninfiltrative Endomyocardial fibrosis Hemochromatosis Amyloidosis Sarcoidosis Idiopathic CMP Diabetic CMP E William Hancok, Heart 2001,

12 Why is it important to make the distinction RCM vs CP?  Associated with significant morbidity and mortality  Restriction rarely treatable/curable  Constriction may be curable with surgery.

13 Inexplained CHF CXray: No Cardiomegaly ( Clinically, Cxray, BNP..) Echo: Normal LV systolic function Trans mitral Doppler: Restrictive Pattern: E/A>2 Trans mitral Doppler: Restrictive Pattern: E/A>2 TDI: (E’>8cm/s, E/E’<15 Normal S wave) TDI: (E’>8cm/s, E/E’<15 Normal S wave) CP TDI: E’ 15 TDI: E’ 15 RCM CP Cho YH and Schaff.Heart Fail Rev 2012

14 Inexplained CHF CXray: No Cardiomegaly ( Clinically, Cxray, BNP..) Echo: M-Mode, 2-D Normal LV Systolic Function

15 M-mode and 2-D CP  Pericardial thickening and calcification  Septal bounce  Dilated not collapsing Inferior Vena Cava  Flattening of LV post wall  Early pathological outward and inward movement of the IVS  Color M-mode Propagation

16 18% of PC had normal thickness

17 CP  Differential Dx:  Constrictive Pericarditis  Pericardial Tamponade  Pulmonary Hypertension  LBBB  Right Ventricular Pacing.  Paradoxal motion of the IVS occurring in early diastole  Sensibility 62%,Specificity 93% Journal of Thoracic Imaging. 27(1):w1, January 2012.

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19 M-Mode CP Signs reflecting increased ventricular interdependence Abrupt early diastolic anterior motion of the IVS followed by a rebound toward the LV post wall. Abrupt early diastolic anterior motion of the IVS followed by a rebound toward the LV post wall.. Mastouri et al. Expert Rev Cardiovasc 2010

20 M-Mode CP  Signs reflecting rapid early ventricular diastolic filling: Flattening at the LV post wall Flattening at the LV post wall   Sensitivity 92%, Specificity 100% Voelkel et al,Circulation Nov;58(5):871-5.

21  Signs reflecting increased Right Ventr diastolic pressure above Pulmonary Art pressure Premature opening of the pulmonary valve Premature opening of the pulmonary valve   Sensibility 14%,Specificity 100% Mastouri et al. Expert Rev Cardiovasc 2010 M-Mode CP

22 Sensibility 74%,Specificity 91% Am J 2001,87,86-94

23 RCM 2-D  Small LV cavity with large atria  Increased wall thickness ( especially in interatrial septum in Amyloidosis)  Thickened valves and granular sparkling texture (amyloidosis)

24 Inexplained CHF CXray: No Cardiomegaly ( Clinically, Cxray, BNP..) Echo: M-Mode, 2-D Normal LV Systolic Function Echo-Doppler: Restrictive Pattern: E/A>2,DT<150ms,IVRT<60ms AV Inflow

25 Echo-Doppler  Mitral and Tricuspid Inflow  IVRT  TR  Hepatic Veins  Pulmonary Regurgitation  Pulmonary Veins  Superior Vena Cava

26 Specificity 67%, Sensibility 86% J Am Coll Cardio 1994 jan.23,154- JACC,1994 Jan;23(1): CP

27 Constriction: Non-respirophasic Mixed Restriction and Constriction Marked increase in Preload Provocation test with head-up tilting or sitting position with decrease of the preload may unmask the CP. Provocation 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

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29 AF and CP

30 J Am Coll Cardio 2001;37:

31 CP JACC 1994 Jan;23(1):154-62

32 Diagrammatic representation of the transmitral early (E-wave) and late (A-wave) velocities during diastole throughout the respiratory cycle. Nihoyannopoulos P, Dawson D Eur J Echocardiogr 2009;10:iii23-iii33 Published on behalf of the European Society of Cardiology. All rights reserved. © The Author For permissions please

33 CP

34

35 Circulation 2002, Rajagopalan et al. AJC 2001 Specificity79%, Sensitivity 86% Normal

36 CP

37 RCMCP PV is Respirophasic PV is not Respirophasic Normal

38 CP

39 CP vs COPD CP

40 Inexplained CHF CXray: No Cardiomegaly ( Clinically, Cxray, BNP..) Echo: Normal LV systolic function Echo-Doppler: Restrictive Pattern: E/A>2,DT<150ms,IVRT<60ms AV Inflow Tissue Doppler: Annular TDI

41 Specificity 89%,Sensibility100% Rajagopalan et al.Am.J.Cardio 2001

42 E/e’=6 Am J Cardiol 2004;93:

43 MITRAL “ANNULUS REVERSUS” E’ Lateral > E’ Septal E’ Lateral< E’Septal E’ Lateral =E’ Septal Normal CP RCM Reuss et al.Eur J Echocardiography 2009

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45 Inexplained CHF CXray: No Cardiomegaly ( Clinically, Cxray, BNP..) Echo: Normal LV systolic function Echo-Doppler: Restrictive Pattern: E/A>2,DT<150ms,IVRT<60ms AV inflow Tissue Doppler: Annular TDI Strain Imaging

46 Myocardial Mechanics in RCM and CP Deformation Parameter CPRCM Longitudinal Strain Normal Circumferential Strain Decreased Normal JACC Cardiovasc Imaging Jan;1(1):29-38

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48 2-D Speckle-tracking CP RCM J Am Soc Echocardiogr 2009:22:24-33

49 CP RCM Em: Longitudinal early diastolic lengthening velocity J Am Soc Echocardiogr 2009:22:24-33

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51

52 Too much for Diastology

53 Conclusions  Dx has important therapeutic implications  Clinical Presentaion similar  Echocardiography (Doppler,TDI, Strain/Strain rate) have increased yield.  Cardiac catheterisation still considered mandatory.

54 End

55 Inexplained CHF CXray: No Cardiomegaly ( Clinically, Cxray, BNP..) Echo: Normal LV systolic function Echo-Doppler: Restrictive Pattern: E/A>2,DT<150ms,IVRT<60ms AV inflow Tissue Doppler Annular TDI Strain Hemodynamic

56 Normal CP QTDI International J of Cardio 137(2009)22-39

57 RCM International J of Cardio 137(2009)22-39

58 Major historical events in CP Korean Circ J 2012;42:


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