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. 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

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, th 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: 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

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. 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’) /- 32 ms
Restriction:
E’ 4.7 +/- 1.6 cm/s
S’ 4.6 +/- 1.9 cm/s
T(E-E’) / ms
●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.

51. Cardiac MR: Normal Pericardium

52. Cardiac MR: Constrictive Pericarditis

53. Thanks!