Echocardiographic Evaluation of Constrictive Pericarditis

1. Echocardiographic Evaluation of Constrictive Pericarditis Angela Morello, M.D. December 18, 2007

2. The Pericardium • Fibroelastic sac surrounding heart • Composed of 2 layers: serous parietal and fibrous visceral pericardium • Forms 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 vessels • Transverse sinus: great arteries posteriorly • Oblique sinus: posterior to LA between pulmonary veins

4. Constrictive Pericarditis: • Pericardium becomes thickened and fibrotic • Loss of elasticity and compliance • Can follow (usually late) any pericardial inflammatory process

5. Idiopathic or Viral: 42-49% Post cardiac surgery: 11-37% Post Radiation: 9-31% CT disease: 3-7% Postinfectious: 3-6% TB Bacterial/purulent Others: 1-10% Malignancy Trauma Asbestosis Sarcoidosis Drugs Uremia Etiologies:

6. Physiology of Constriction: • Rapid early diastolic filling • Impaired late diastolic filling due to inelastic pericardium • Pericardium acts as a calcified shell: • Decreased compliance: fills to a point and abruptly stops • Pressure/Volume changes within the heart affect other chambers: Interdependence • Nothing 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 sign • Dip-and-plateau • Equalization of diastolic pressures

9. Respiratory Hemodynamics: • Intrathoracic pressure not transmitted to cardiac chambers • Right-sided venous return does not increase as significantly with inspiration: • Increase in RV inflow across TV • Pulmonary venous pressure still decreases with inspiration: • Decrease in LV inflow across MV

10. Goldstein J. Curr Probl Cardiol 2004.

11. Respiratory Hemodynamics: • Increased Interdependence of RV and LV: • Inspiration: Right-sided filling > Left-sided filling • LV output is minimized by decreased inflow • RV septum bows into LV further decrease in CO • Result: • Decrease in LV systolic pressure • Relative increase in RV systolic pressure

12. Inspiratory Discordance:

13. Discordance vs Concordance: Grossman, 2000 6th edition.

14. Echocardiographic Evaluation: • Preferred modality for assessing the pericardium and pericardial disease • Less reliable that MR or CT for pericardial thickening, calcification, or constriction • Still employed as initial diagnostic test • Recommended by the ACC/AHA

15. Normal Pericardium: • M-Mode: • Systolic separation of the visceral and parietal pericardium • 2 layers move in parallel • Two-Dimensional: • Brightest structure • Heart/Visceral pericardium slide/twist within the parietal pericardium

16. M-Mode

17. M-Mode: Constriction • Dense-echos posterior to LV: • Move in parallel • Abrupt, 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

18. Normal Pericardium:

19. 2D: Constriction • Increased echogenicity of the pericardium from thickening • Loss of movement of heart within pericardium: • Fixed and adherent • May see effusion (effusive-constrictive) • Septal shudder or bounce • Abrupt posterior movement of septum • In inspiration with underfilling of LV

20. Fixed& echogenic pericardium:

21. Pericardial thickening:

22. Subcostal:

23. Septal Bounce:

24. Septal Bounce:

25. Septal Bounce:

26. Other 2D Findings: • Dilation of IVC • Decreased collapse of IVC w/ inspiration • Hepatic vein plethora • Biatrial enlargement • Abrupt stop in diastolic filling of ventricles

27. Doppler Echocardiography: • Crucial component in the evaluation of constriction • Corresponds 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 filling • Short deceleration time of E wave as filling abruptly stops • Small A wave as little filling occurs in late diastole following atrial contraction Otto. 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 filling • Prominent a wave • Prominent y descent • Prominent diastolic filling phase • Blunted systolic filling following atrial contraction

31. Doppler: Mitral and Tricuspid Inflow • Marked respiratory variation in biventricular inflow • Inspiration: • Negative intrapleural pressure • Increased RV inflow velocity and diastolic filling • Decreased LV inflow velocity • Greater than 25% respiratory variation

32. Mitral Inflow: CXR: Transmitral Doppler: Turkish Society of Cardiology, 2007.

33. Respiratory Mitral Inflow:

35. Respiratory Tricuspid Inflow:

36. Tissue Doppler: • Important in differentiating restriction and constriction • Prominent E’, Loss of A’ Gorcsan, J. Japanese Circ Society, 2000

37. Tissue Doppler: • Annular Paradox: • E/E’ increased • Mean LAP decreased • High pressure and low ratio • Peak E’ ≥ 8 cm/s: (Rajagopalan, N. at al. AJC 2001.) • 89% senstive for constriction • 100% 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 female • Mean age 47 years (10-76 years) • 17 patients with constrictive pericarditis • 12 patients with restrictive cardiomyopathy • 15 control subjects • Standard mitral inflow doppler and tissue doppler performed

41. Constriction: E’ 9.5 +/- 1.7 cm/s S’ 7.7 +/-1.3 cm/s T(E-E’) 21.0 +/- 32 ms Restriction: E’ 4.7 +/- 1.6 cm/s S’ 4.6 +/- 1.9 cm/s T(E-E’) 53.1 +/- 30.4 ms Study Results: ●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’ alone • 88% 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 RCM • 30 patients: • 19 Constrictive pericarditis • 11 Restrictive cardiomayopathy • Confirmed by other modalities • Compared with mitral inflow respiratory variation

46. Propagation Velocity: • Color M-Mode of diastolic flow from LA to apex in 4 chamber view • 20 by TTE, 10 by TEE • Flow propagation slope of first aliasing contour (white line): • Steep at 110 cm/s in CP • Less steep at 35 cm/s in RCM Rajagopalan N. Am J Cardiol 2001;87:86

47. Results: • Slope of first aliasing contour of > 100 cm/s differentiated CP from RCM: • 91% specificity • 74% sensitivity

48. Other Results: • Respiratory variation of the mitral inflow peak early velocity of ≥10%: 84% sensitivity and 91% specificity • Variation in the pulmonary venous peak diastolic velocity of ≥18%: 79% sensitivity and 91% specificity • Tissue 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: • CXR • CT • CMR • Cardiac catheterization • Surgical biopsy

50. Multislice Cardiac CT: Langher, et al. Heart 2006.