3. RCMP vs CP
• Stiff Muscle vs Thick Skin
• Both can be present in the same patient
• Commonest etiology: IHD s/p CABG
– Others: infiltrative diseases (amyloidosis,
sarcoidosis), metastatic cancers, radiotherapy
– with PEff and tamponade physiology -> inflow
patterns mimic constriction but pericardium not
thickened/constrictive
7. CP Etiologies
Etiologies of CP were compared between the period from 1936 to 1982 and the period from 1985 to 1995. The major
change is that cardiac surgery is now the most common known cause of constriction in developed countries. Ling LH, Oh JK et al.
Constrictive pericarditis in the modern era: evolving clinical spectrum and impact on outcome after pericardiectomy. Circulation 1999;
100:1380-6.
8.
9. Ventricular Interdependence
On inspiration (left), there is a shift of the ventricular septum toward the left ventricle; and on expiration (right), there is a shift of the
ventricular septum toward the right ventricle.
10. 1) Annulus Reversus: TDI parameters of septal vs
annular E’
2) Annulus Paradoxus: E/E’ surrogate of filling
pressures (LAP) -> paradoxically improves with
worsening CP as septal E’ increases viz-a-viz increasing
lateral tethering
Echocardiographic Findings
11. M-mode echocardiogram of a typical CP patient with the ventricular septum moving with
respiration toward the left ventricle with inspiration (upward arrow) and toward the right
ventricle with expiration (downward arrow). A simultaneous respirometric recording is shown
at the bottom of the figure.
12. Characteristic PW Doppler echo findings of CP are shown with mitral inflow velocity (top left), tricuspid inflow velocity (top
right), hepatic vein (bottom left), and SVC (bottom right), with simultaneous respirometric recording. E, DRi, and Si represent E velocity,
diastolic reversal velocity, and systolic velocity, respectively, during inspiration. Ee, DRe, and Se represent E velocity, diastolic reversal
velocity, and systolic velocity, respectively, during expiration.
13.
14. Knowledge Checkpoint
• Doppler findings of CP include the following:
1. Mitral inflow: > 10% variation in mitral E during
respiration
2. Tricuspid inflow: > 40% variation in tricuspid E
during respiration
3. Hep Veins: Diastolic flow reversal more
prominent during inspiration
4. Hep Veins: Increased diastolic forward velocities
with small reversals
15. Knowledge Checkpoint
• Doppler findings of CP include the following:
1. Mitral inflow: > 10% variation in mitral E during
respiration
2. Tricuspid inflow: > 40% variation in tricuspid E
during respiration
3. Hep Veins: Diastolic flow reversal more
prominent during inspiration
4. Hep Veins: Increased diastolic forward velocities
with small reversals
16.
17. Knowledge Checkpoint
• Kussmaul’s sign is:
1. Deep and labored breathing pattern often
associated with severe metabolic acidosis
2. A paradoxical rise in JVP on inspiration, or a failure in
the appropriate fall of the JVP with inspiration
3. Can be seen in both constrictive and restrictive
cardiac disease
4. Is a feature of cardiac tamponade
5. 2 and 3 are correct
6. 1, 2 and 4 are correct
18. Knowledge Checkpoint
• Kussmaul’s sign is:
1. Deep and labored breathing pattern often
associated with severe metabolic acidosis
2. A paradoxical rise in JVP on inspiration, or a failure in
the appropriate fall of the JVP with inspiration
3. Can be seen in both constrictive and restrictive
cardiac disease
4. Is a feature of cardiac tamponade
5. 2 and 3 are correct
6. 1, 2 and 4 are correct
19. The Y descent is prominent, and rather than the normal fall in mean pressure
during inspiration, there is an increase noted. This is referred to as a positive
Kussmaul’s sign and is frequently seen in pericardial and right heart disease
20. Normally left ventricular (LV) diastolic and wedge pressures move in synchrony during
respiration, such that the diastolic gradient from wedge to LV remains constant. In constriction,
negative intrathoracic pressure “pulls” wedge pressure below LV diastolic, with the converse
occurring during expiration. This is termed “intrathoracic-intracardiac dissociation” and is a
sensitive and specific sign of constrictive pericarditis
21. As a result of enhanced ventricular interdependence, the systolic area under the
right ventricular (RV) pressure tracing increases during inspiration while the left
ventricular (LV) systolic area decreases (arrows). The opposite occurs during
expiration.
22. Knowledge Checkpoint
• The following haemodynamic finding(s) is/are
true of constrictive pericarditis:
1. There is prominent Y descent in the right atrial
pressure tracing
2. There is ventricular concordance in the
simultaneous or superimposed LV and RV pressure
tracings
3. There is diastolic equalization of pressures between
the RV and RA waveforms
4. LVEDP and RVEDP pressures are within 15mmHg of
each other
23. Knowledge Checkpoint
• The following haemodynamic finding(s) is/are
true of constrictive pericarditis:
1. There is prominent Y descent in the right atrial
pressure tracing
2. There is ventricular concordance in the
simultaneous or superimposed LV and RV pressure
tracings
3. There is diastolic equalization of pressures
between the RV and RA waveforms
4. LVEDP and RVEDP pressures are within 15mmHg of
each other
27. CP: apical four-chamber view with PW Doppler recording of the mitral inflow in a
patient with CP.
(Left) The respirometer waveform is indistinguishable because of poor gain.
After adjustment (right) the respiratory waves are now able to clearly distinguish
inspiration and expiration
Optimising the Respirometer Waveform
28. CP: 2D parasternal long-axis view demonstrating proper use of a respirometer in a patient with
CP. A high-quality tracing demonstrating both inspiration and expiration is essential.
The left panel and arrow point to upslope in inspiration only .
The right panel and arrows point to the peak of inspiration and expiration after an adjustment
of the respirometer was made
Optimising the Respirometer Waveform
29. CP: 2D parasternal long-axis view in a patient with CP. The arrow points to a focal region
of pericardial calcification extending from the atrioventricular groove to the posterior LV
wall. This finding, in conjunction with an interventricular septal bounce, is consistent with
CP.
Optimising the PLAX Depth
30. CP: M-mode of parasternal short-axis view. Several M-mode features of CP are
seen, including diastolic flattening of the posterior wall, pericardial calcification
(better seen in the right panel with a reduced 2D gain and fundamental imaging),
a septal diastolic shudder consistent with the septal bounce seen by 2D imaging,
and respiratory variation in LV cavity size.
31.
32.
33. CP: apical four-chamber view with PW Doppler of the mitral inflow in a patient with CP.
(Left) The sweep speed is set to 100 mm/sec, and the mitral inflow in inspiration and
expiration cannot be distinguished on the same image.
After adjustment to a sweep speed of 33 mm/sec (usually 25–50 mm/sec is suitable), the
mitral inflow can be clearly distinguished to show onset of in inspiration and expiration
Optimising Inflow Doppler
34. CP: apical four-chamber view with pulsed Doppler of mitral inflow in a patient with CP. The mitral E and
A waves are labeled. The first beat of inspiration is recorded, and peak expiration beat is recorded and
can be used to determine respiratory variation from expiration using the formula (expiration-
inspiration)/expiration. At least three beats should be averaged. Significant respiratory variation is
considered to be present when there is an inspiratory decrease of mitral inflow is >25%.
However, maneuvers (preload reduction as in sitting up or increase in volume loading) may be required
to demonstrate variation.
Calculating Inflow Variation
35. CP: apical 4-chamber view of the tricuspid inflow with PW Doppler in a patient with CP. Measurements of
peak E-wave velocity in inspiration and expiration are made. However, respiratory variation from
expiration is determined by the formula (expiration - inspiration)/expiration or, in this example, (25 -
41)/25 = -76%. A >40% respiratory variation of tricuspid inflow is considered consistent with CP.
36. CP apical four-chamber view with PW Doppler of the right upper pulmonary vein in a
patient with CP. The S (systolic), D (diastolic), and AR (atrial reversal waves) are noted.
Respiratory variation of the D wave should be determined similar to the method used for
the mitral E wave
37. CP: apical four-chamber view with PW Doppler of the mitral inflow in a patient with CP. The
study is performed with the patient in the upright position to decrease preload and
increase respiratory variation.
Marked respiratory variation of mitral inflow E wave is apparent. This maneuver should be
performed if CP is suspected but not readily evident in the basal state.
38. (Left) M-mode demonstrating a dilated and plethoric IVC;
(Right) HV flow with reduced diastolic (D) flow during expiration
and prominent AR reversals during expiration.
IVC and Hep Veins Doppler
39. CP: SVC flow as obtained from the right subclavicular fossa in a patient with CP.
(Left) A 2D image of the SVC.
(Right) S and D waves appearing similar to hepatic vein flow. Note the lack of significant
respiratory variation of systolic flow in CP, which is different from the finding of marked
respiratory variation of systolic flow noted in chronic obstructive pulmonary disease
40. Knowledge Checkpoint
• With regard to optimising echo in the evaluation
of CP,
1. Increase the sweep speed to assess respiratory
variation
2. SVC Doppler is not useful to differentiate between
COPD and CP
3. Respiratory variation is calculated by: [Expiration –
Inspiration] ÷ Inspiration
4. Take the first beat of inspiration and the last beat of
expiration
5. Respiratory variation of the Pulm Vein D wave can
be used
41. Knowledge Checkpoint
• With regard to optimising echo in the evaluation
of CP,
1. Increase the sweep speed to assess respiratory
variation
2. SVC Doppler is not useful to differentiate between
COPD and CP
3. Respiratory variation is calculated by: [Expiration –
Inspiration] ÷ Inspiration
4. Take the first beat of inspiration and the last beat of
expiration
5. Respiratory variation of the Pulm Vein D wave can
be used
44. RCMP
• Definition*:
– On the basis of anatomic, histological and
physiological criteria
• Abnormal LV diastolic filling (physio)
• Intracellular or interstitial infiltration / fibrosis (histo)
• Abnormal LV wall thickness + absence of LV dilatation
(anatomic) <although some RCMP disorders can present
with dilated LV>
– WHO: disease of the myocardium characterized by
restrictive filling and reduced diastolic volume of
either or both ventricles, with normal or near-normal
systolic function
– Essentially -> Diastolic Dysfunction, may be HFpEF
*Constrictive Pericarditis Versus Restrictive Cardiomyopathy? J Am Coll Cardiol
2016;67:2061-2076
51. Hep Vein Doppler
The following correspond to the above HV doppler findings:
1. A: RCMP, B: TR, C: Pulm Hypt, D: CP
2. A: PH, B: RCMP, C: TR, D: CP
3. A: RCMP, B: CP, C: PH, D: TR
4. A: TR, B: CP, C: RCMP, D: PH
52. Hep Vein Doppler
The following correspond to the above HV doppler findings:
1. A: RCMP, B: TR, C: Pulm Hypt, D: CP
2. A: PH, B: RCMP, C: TR, D: CP
3. A: RCMP, B: CP, C: PH, D: TR
4. A: TR, B: CP, C: RCMP, D: PH
53.
54. Algorithm comparing constrictive pericarditis and restrictive cardiomyopathy. Note restriction is associated with elevated
E/A ratio, short DT and decreased mitral annular velocity (<6 cm/sec). The figure is based on data from Welch TD, Ling LH, Espinosa
RE, et al. Echocardiographic diagnosis of constrictive pericarditis: Mayo Clinic criteria. Circ Cardiovasc Imaging 2014;7:526–34.
55. References
• American Society of Echocardiography Clinical
Recommendations for Multimodality Cardiovascular
Imaging of Patients with Pericardial Disease J Am Soc
Echocardiogr 2013;26:965-1012
• Recommendations for the Evaluation of Left
Ventricular Diastolic Function by Echocardiography J
Am Soc Echocardiogr 2016;29:277-314
• ACC SAP 9 Chapters on Heart Failure / Pericardial
Disease
• Constrictive Pericarditis Versus Restrictive
Cardiomyopathy? J Am Coll Cardiol 2016;67:2061-2076
Constrictive pericarditis is a potentially curable condition caused by a variety of situations which result in inflamed, scarred, thickened, or calcified pericardium. When the abnormal pericardium limits diastolic filling, there are a series of hemodynamic consequences which manifest as fatigue, dyspnea, abdominal bloating, peripheral edema, or right heart failure. These clinical manifestations of constrictive pericarditis are similar to those due to a cardiomyopathy. Since their hemodynamic and clinical features are similar, it is often challenging to distinguish constrictive pericarditis from a myocardial disease. Even the traditional invasive hemodynamic criteria of "equalization of end-diastolic pressures" is not specific for constrictive pericarditis. Despite many similarities between myocardial and pericardial diseases, there are several unique features of constriction that allow a reliable diagnosis. Those features are 1. Respiratory variation in ventricular filling 2. Interventricular dependence and 3. Augmented longitudinal motion of the heart.
Respiratory variation in ventricular filling arises from the dissociation of intrathoracic and intracardiac pressure change and enhanced ventricular interaction in constrictive pericarditis. Inspiration reduces intrathoracic pressure which usually is fully transmitted to intracardiac pressures, but in constriction, the intracardiac pressures falls much less than intrathoracic pressure because of pericardial constraint. This difference in pressure change with inspiration results in reduced filling to left side of the heart. The reduction in left heart filling during inspiration causes a reduction in mitral inflow velocity and a shift of the interventricular septum toward the left ventricle. With expiration, left heart filling increases which shifts the interventricular septum back toward the right ventricle, leading to reduced filling to right side of the heart and a late-diastolic reversal of flow in the hepatic veins.
The advent of tissue Doppler imaging has provided increased diagnostic confidence to separate constriction from a myocardial disease. Tissue Doppler measures myocardial tissue velocity and provides a non-invasive evaluation of myocardial relaxation. The early diastolic mitral annular velocity (e') which reflects the status of LV myocardial relaxation is reduced in most forms of heart failure related to myocardial disease, including restrictive cardiomyopathy. The normal e' velocity from the medial mitral annulus is 9 cm/sec or greater, and it is usually 6cm/sec or less in patients with a myopathy. In contrast, e' is usually preserved or even increased in constrictive pericarditis since the lateral motion of the heart is limited by the constrictive pericardium. Furthermore, the medial mitral annular e' velocity is usually greater than the lateral mitral annular e'. This again stands in contrast to what is expected in other forms of heart failure, and may reflect tethering of the lateral annulus by the constrictive process.
Our group studied the test performance characteristics of these echocardiographic findings in a group of 130 patients with surgically confirmed constrictive pericarditis compared to 36 patients with restrictive cardiomyopathy or severe tricuspid regurgitation.3 Three variables were independently associated with constrictive pericarditis: 1) the presence of ventricular septal shift, 2) medial mitral e' velocity; and 3) the hepatic vein expiratory diastolic reversal ratio. Each of these criteria was also significantly associated with constrictive pericarditis in the subset of patients with atrial fibrillation or flutter. The presence of ventricular septal shift in combination with either medial e' ≥ 9 cm/s or hepatic vein expiratory diastolic reversal ratio ≥ 0.79 (Hepatic vein diastolic reversal velocity / diastolic forward flow velocity) was 87% sensitive and 91% specific for the diagnosis of constrictive pericarditis.
Two other echocardiographic findings are expected in constrictive pericarditis as well as in restrictive cardiomyopathy. The first is a plethoric inferior vena cava, which may appear dilated or collapse insufficiently during inspiration. This is the echocardiographic marker for increased venous pressure. The second is a relatively "flat" Doppler profile of the systolic component of the superior vena cava. In contrast to normal patients and those with obstructive lung physiology, patients with constrictive pericarditis have restricted cardiac filling and exhibit little variation in the superior vena caval inflow velocity during the respiratory cycle. This finding is clinically useful because severe obstructive lung disease or other conditions associated with exaggerated respiratory effort may sometimes cause echocardiographic findings that mimic those of constrictive pericarditis.
In summary, constrictive pericarditis should be considered in patients presenting with heart failure symptoms and preserved ejection fraction. Since echocardiography is usually an initial diagnostic test to evaluate such patients, the following features can aid in the diagnosis of constrictive pericarditis: 1. Ventricular septal motion abnormality (from ventricular interdependence) 2. Medial mitral annulus e' velocity ≥ 9 cm/sec 3. Hepatic vein expiratory diastolic reversal ratio ≥ 0.79 (Figure) in addition to restrictive mitral inflow velocity (E/A ratio > 0.8) and plethoric inferior vena cava.
Doppler evaluation of the pulmonary veins shows marked respiratory change in pulmonary venous flow in CP.
The pulmonary venous systolic wave and early diastolic wave velocities, especially the early diastolic wave velocity, are increased during expiration and decreased during inspiration.
The changes in pulmonary venous flow velocities have been reported to be more pronounced than changes in mitral inflow velocities.
Similar respiratory variation can also be observed in patients with CP and atrial fibrillation.
In contrast, patients with RCM show blunting of the systolic wave velocity and a decrease in the ratio of systolic to early diastolic wave velocity throughout the respiratory cycle, with a large atrial reversal wave and without any significant respiratory variation.
A: RCMP: Systolic forward flow smaller than diastolic forward flow. Insp diastolic flow reversal larger than Exp diastolic flow reversal
B: CP: Exp diastolic flow reversal larger than Insp diastolic reversal
C: PH: No respi variation in diastolic flow reversal
D: TR: Late systolic flow reversal
A: RCMP: Systolic forward flow smaller than diastolic forward flow. Insp diastolic flow reversal larger than Exp diastolic flow reversal
B: CP: Exp diastolic flow reversal larger than Insp diastolic reversal
C: PH: No respi variation in diastolic flow reversal
D: TR: Late systolic flow reversal