1. Dr Djilali Hanzal Cardiologist National Guard Hospital
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. Symptoms
Tajik AJ Circulation. 1999;100(13):1380.

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 Constrictive Pericarditis
Intra thoracic pressure
Venous return
Transient size of RV
Normal LV filling
Intra thoracic pressure
Venous return
RV not expanded
Abnormal LV filling
Uptodate 2011

9. Mechanism
FILLING IMPAIREMENT
LV-RV INTERDEPENDANCE

10. Physiology CP vs RCM Constrictive Pericarditis Restrictive
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
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)
Endomyocardial disease
Myocardial disease
Storage disease
Endomyocardial fibrosis
Hemochromatosis
Infiltrative
Noninfiltrative
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. RCM Findings CP Inexplained CHF
CXray: No Cardiomegaly ( Clinically, Cxray, BNP..)
Echo: Normal LV systolic function
Findings
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
RCM CP CP
Cho YH and Schaff.Heart Fail Rev 2012

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

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.

19. Mastouri et al. Expert Rev Cardiovasc 2010
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.
Mastouri et al. Expert Rev Cardiovasc 2010 .

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

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

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. CXray: No Cardiomegaly ( Clinically, Cxray, BNP..)
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
Findings

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

26. CP Specificity 67%, Sensibility 86% JACC,1994 Jan;23(1):154-62
J Am Coll Cardio 1994 jan.23,154-
JACC,1994 Jan;23(1):154-62

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.
Maisch, Seferovic, Ristic et al.ESC guidelines on pericardial disease, E J 2004

29. AF and CP

30. AF and CP
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.
Diagrammatic representation of the transmitral early (E-wave) and late (A-wave) velocities during diastole throughout the respiratory cycle. Note the dynamic differences between restrictive cardiomyopathy and constrictive pericarditis during inspiration and expiration. In constrictive pericarditis, the transmitral velocities are reduced while the tricuspid velocities are increased in deep inspiration, while the opposite happens during expiration. In restrictive cardiomyopathy, there is little respiratory variation.
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. CP

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

36. CP

37. PV is not Respirophasic
Normal CP
RCM
PV is Respirophasic
PV is not Respirophasic

38. CP

39. CP vs COPD CP

40. CXray: No Cardiomegaly ( Clinically, Cxray, BNP..)
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
Findings
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”
Normal
E’ Lateral > E’ Septal CP
E’ Lateral< E’Septal
RCM
E’ Lateral =E’ Septal
Reuss et al.Eur J Echocardiography 2009

45. CXray: No Cardiomegaly ( Clinically, Cxray, BNP..)
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
Findings
Strain Imaging

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

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

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

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. CXray: No Cardiomegaly ( Clinically, Cxray, BNP..)
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
Hemodynamic
Strain

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

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

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