1. Constrictive & Restrictive physiology - clinical & diagnostic differentiation Dr.DayaSagar Rao.V DM(Cardiology) FRCP(Canada) FRCP(Edinburgh)

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

4. Pericardial disease Epicardial tethering Pericardial constraints Deformation of LV is constrained circumferential direction in constrictive pericarditis Diastolic recoil is also attenuated in same direction (circumferential ) Reduced circumferential strain Early diastolic apical untwisting Preserved basal at base N Restrictive cardiomyopathy Predominantly subendocardial dysfunction Constrained in longitudinal direction with preserved circumferential strain Diastolic recoil is attenuated in longitudinal direction Reduced longitudinal displacement with preserved circumferential strain

5. CXR

6. CT

7. Constrictive - Restrictive History : Previous H/o :Surgery,Radiation,Infection,Pericarditis Physical Exam PND/orthopnea Precordial impulse Ascites(precox) ECG : Chamber enlargement Conduction disturbances CXR : Pericardial calcification

8. BNP Constrictive pericarditis Restrictive cardiomyopathy CP : 6pts : 128pg/ml RC : 5pts : 825.8pd/ml JACC 2005 Leya PR et al

9. CP : 116pg/ml CP+CKD : levels higher : 433pg/ml RC : 728pg/ml JACC 2007 Reddy PR et al BNP Constrictive pericarditis Restrictive cardiomyopathy

10. Normal Pressures Pericardial : Sub Atmospheric ( -2 to -5 mmHg) RA mean pressure ( 5-6 mmHg) LA / PAW pressure ( 10-12mmHg) Transmural pressure = Intracavitatory pressure – - Intrapericardial pressure - (5 mmHg- (-2 mmHg)

11. PRESSURES & RESPIRATION Inspiration - Negative Intrathoracic pressure - Lungs ( Pulmonary vessels) - Heart ( through pericardium) PressureFlow Rt sideDecreaseIncrease Lt sideDecrease

12. PRESSURES & RESPIRATION Left Heart Hemodynamics Inspiration – Decrease LV stroke volume Systolic BP Pulse pressure Ventricular Ejection Time Q – A2 Interval Mitral E – wave velocity Expiration - Increase

13. Effect of Inspiration Normal Pericardium: – Inspiratory decrease in intrathoracic pressure is uniformly transmitted to the lungs, PVs, LA, LV, RA, and RV

14. Effect of Inspiration Constrictive Pericarditis: – Thickened pericardium isolates the heart form transmission of intrathoracic pressure changes – Increased inspiratory capacitance of the Lungs PVs, and LA => PCWP decrease BUT – The decrease in intrathoracic pressure is not transmitted to the LV, RV, RA

15. Dissociation Dissociation of Intrathoracic and Intracardiac Pressures First demonstrated to be present in constrictive pericarditis using Doppler techniques in 1989, by Hatle in her landmark study. Hatle LK, Appleton CP, Popp RL. Differentiation of constrictive pericarditis And restrictive cardiomyopathy by Doppler Echocardiography. Circ. 1989;79357-370

16. Dissociation Dissociation of Intrathoracic and Intracardiac Pressures The inciting Physiologic Event. Hatle LK, et. al. Circ. 1989;79357-370

17. Ventricular Interdependence InspExpir Hatle LK, et. al. Circ. 1989;79357-370 Ventricular Pressures Are DISCORDANT

18. Traditional v.s. Dynamic Catheterization Hemodynamics Dissociation Dissociation of Intrathoracic and Intracardiac Pressures Why bother with Echo given The great utility of Dynamic Respiratory cath measurments? These measurments are only Possible using High-fidelity Micromanometer systems (not a common practice).

19. Effect of Inspiration: Constriction PCWP Inspir. No proportionate decrease in LV diastolic pressure PCWP Inspir. Expir. Insp. Expir. PCWP Decreased transmitral gradient => Transmitral flow RV SV LV SV

20. Pathophysiologic Differences Constriction Myocardial compliance is NL Restriction Ab-Nl Myocardial compliance No impedence to Diastolic EARLY FILLING To tal cardiac volume is fixed by the pericardium Impedence to filling increases throughout the diastole Pericardium is compliant Septum is non-compliant Atria are able to empty into the Ventricles, though at higher Press. Reduction of the proportion of LV filling with atrial contraction: => Atrial enlargement Marked Respiratory effect of LV on the RV Minimal Respiratory effect of RV on the LV

21. Specific Echocardiographic Criteria for Constriction/Restriction Mitral E wave pattern Pulmonary Vein pattern Hepatic Vein pattern

22. Mitral E wave Criteria for Constriction Decrease in of 25% in Mitral “E” velocity on inspiration.

23. In RESTRICTION: There is no respiratory variation of Mitral inflow

24. Hepatic Vein Doppler: Normal Normal Systolic and diastolic forward flow S-vel. > D- vel. Diastolic flow reversal: Expir.>>Insp.

25. Hepatic Vein Doppler: Constriction Constriction Diastolic flow reversal is augmented in expiration. DFR exp. >25% forward diastolic velocity

26. Hepatic Vein Doppler: Restriction Restriction Forward flow primarily in Diastole. Inspiration increases both >systolic, and >Diastolic Flow reversals.

27. Hepatic Vein Doppler: Compilation Mixed physiology (restriction/constriction) Diastolic flow reversal during both Ispiration and expiration

28. Constriction Doppler Inspiration Expiration

29. Pitfalls and Caveats Subgroup of patients with constriction who do not exhibit respiratory changes COPD

30. Constriction: Non-respirophasic Oh et. al. Circ. 1997;95:796-799 12 Pts. W/ confirmed constriction, but without the classic findings – Etiology of Non-respirophasic pattern Mixed Restriction and Constriction Marked increase in Preload Deduced post Stripping, as Sx Not improve Preload reduction to unmask the respiratory variation

31. Effect of changing loading conditions w/ VALSALVA in RESTRICTION E 20% A to a lesser degree

32. COPD v.s. Constriction Individual Mitral flow velocity profiles are not restrictive as LV filling pressure is not increased. 100% change in E Velocity

33. COPD v.s. Constriction Constriction: Minimal change in SVC velocities with inspiration. COPD Const. COPD: Greater than NL decrease in intrathroracic pressure is generated with inspiration => Increased SVC Flow

34. Tissue Doppler PW Analysis of Mitral Annular Motion Physiologic Premise: Assessment of VELOCITY of LV -Contraction, and -Relaxation

35. Tissue Doppler: Restriction and Constriction Mitral inflow E wave is elevated in both Annular E wave – Restriction, peak E-wave < 8 cm/sec – Constriction, Peak E-wave > 8 cm/sec The above is Premised on the assumption that: Annular E wave is preload independent. Both Pro- and Con- studies regarding this premise exist.

38. Mitral Annular - TDI Annular paradoxus Very tall e’ – even though LA pressure is elevated Annular Inversus N lateral – mitral annulus e’ is more steeper than medial e’ Constrictive pericarditis Lateral annulus e’ is less than medial e’

40. Pericardiectomy NORMALISES Both annular paradoxus Annular inversus Persistance of annular paradoxus Annular inversus ? Incomplete Pericardiectomy

41. SensitivitySpecificity Peak E velocity84%91% >10% Peak pulm vein79%91% Diastolic velocity >18% TDI Peak e’ >8cm/sec89%100% e’ + S ’88% e’ + S ’+T(e’-E)94%

43. Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply. Talreja, D. R. et al. J Am Coll Cardiol 2008;51:315-319 LV and RV High-Fidelity Manometer Pressure Traces From 2 Patients During Expiration and Inspiration

44. THANK YOU

46. Ventricular Interdependence During Respirations Differentiates Constrictive Pericarditis from Restrictive Cardiomyopathy Constrictive Pericarditis (LV and RV discordant) Restrictive Cardiomyopathy (LV and RV concordant) Hurrell et al, Circulation 1996; 93:2007