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

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)

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

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

Etiologies: 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

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

Hemodynamics: CVP tracing: Rapid descent of RAP with ventricular filling (y descent)

Hemodynamics: Ventricular tracing: rapid early diastolic filling with abrupt halt and plateau: Square-root sign Dip-and-plateau Equalization of diastolic pressures

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

Goldstein J. Curr Probl Cardiol 2004.

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

Inspiratory Discordance:

Discordance vs Concordance: Grossman, 2000 6th edition.

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

Normal Pericardium: M-Mode: Two-Dimensional: 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

M-Mode

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

Normal Pericardium:

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

Fixed& echogenic pericardium:

Pericardial thickening:

Subcostal:

Septal Bounce:

Septal Bounce:

Septal Bounce:

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

Doppler Echocardiography: Crucial component in the evaluation of constriction Corresponds with the physiology and reflects the hemodynamics previously discussed

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.

Doppler Findings: Redfield MM, et al. JAMA 2003.

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

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

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

Respiratory Mitral Inflow:

Respiratory Tricuspid Inflow:

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

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

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

Normal Tissue Doppler: Nurcan,et al. Turkish Society of Cardiology, 2006.

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

Study Results: ●E’ and S’ significantly higher in constrictive group: 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 ●E’ and S’ significantly higher in constrictive group: (P< 0.001) ●T(E-E’) significantly shorter in constrictive group: (P= 0.02)

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

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

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’

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

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

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

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.

Echo is still not perfect…. Other modalities to aid in diagnosis of constrictive pericarditis: CXR CT CMR Cardiac catheterization Surgical biopsy

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

Cardiac MR: Normal Pericardium

Cardiac MR: Constrictive Pericarditis

Thanks!