Echocardiographic Echocardiographic Evaluation of Evaluation of Constrictive Constrictive PericarditisPericarditisAngela Morello, M.D.Angela Morello, M.D.

December 18, 2007December 18, 2007

The PericardiumThe Pericardium Fibroelastic sac Fibroelastic sac

surrounding heartsurrounding heart Composed of 2 Composed of 2

layers: serous layers: serous parietal and parietal and fibrous visceral fibrous visceral pericardiumpericardium

Forms a sac-like Forms a sac-like potential space: potential space: contains thin layer contains thin layer of fluid (5-10 cc)of fluid (5-10 cc)

The Pericardium:The Pericardium: Pericardial reflections: Pericardial reflections:

surround pulmonary surround pulmonary and systemic inflow and systemic inflow and great vesselsand great vessels

Transverse sinus: Transverse sinus: great arteries great arteries posteriorlyposteriorly

Oblique sinus: Oblique sinus: posterior to LA posterior to LA between pulmonary between pulmonary veinsveins

Constrictive Pericarditis:Constrictive Pericarditis:

Pericardium becomes thickened and Pericardium becomes thickened and fibroticfibrotic

Loss of elasticity and complianceLoss of elasticity and compliance Can follow (usually late) any Can follow (usually late) any

pericardial inflammatory processpericardial inflammatory process

Etiologies:Etiologies:

Idiopathic or Viral: Idiopathic or Viral: 42-49%42-49%

Post cardiac Post cardiac surgery: 11-37%surgery: 11-37%

Post Radiation: 9-Post Radiation: 9-31%31%

CT disease: 3-7%CT disease: 3-7% Postinfectious: 3-6%Postinfectious: 3-6%

TBTB Bacterial/purulentBacterial/purulent

Others: 1-10%Others: 1-10% MalignancyMalignancy TraumaTrauma AsbestosisAsbestosis SarcoidosisSarcoidosis DrugsDrugs UremiaUremia

Physiology of Physiology of Constriction:Constriction:

Rapid early diastolic fillingRapid early diastolic filling Impaired late diastolic filling due toImpaired late diastolic filling due to

inelastic pericardiuminelastic pericardium Pericardium acts as a calcified shell:Pericardium acts as a calcified shell:

Decreased compliance: fills to a point and Decreased compliance: fills to a point and abruptly stopsabruptly stops

Pressure/Volume changes within the heart affect Pressure/Volume changes within the heart affect other chambers: Interdependenceother chambers: Interdependence

Nothing gets in: Intrathoracic pressures not Nothing gets in: Intrathoracic pressures not transmitted to cardiac chambers and encased transmitted to cardiac chambers and encased great vesselsgreat vessels

Hemodynamics:Hemodynamics:

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

Hemodynamics:Hemodynamics:

Ventricular Ventricular tracing: rapid early tracing: rapid early diastolic filling diastolic filling with abrupt halt with abrupt halt and plateau:and plateau: Square-root signSquare-root sign Dip-and-plateauDip-and-plateau

Equalization of Equalization of diastolic pressuresdiastolic pressures

Respiratory Respiratory Hemodynamics:Hemodynamics:

Intrathoracic pressure not Intrathoracic pressure not transmitted to cardiac chamberstransmitted to cardiac chambers

Right-sided venous return does not Right-sided venous return does not increaseincrease as significantly with as significantly with inspiration:inspiration: Increase in RV inflow across TVIncrease in RV inflow across TV

Pulmonary venous pressure still Pulmonary venous pressure still decreasesdecreases with inspiration: with inspiration: Decrease in LV inflow across MVDecrease in LV inflow across MV

Goldstein J. Curr Probl Cardiol 2004.

Respiratory Respiratory Hemodynamics:Hemodynamics:

Increased Interdependence of RV and Increased Interdependence of RV and LV:LV: Inspiration: Right-sided filling > Left-sided Inspiration: Right-sided filling > Left-sided

fillingfilling LV output is minimized by decreased inflowLV output is minimized by decreased inflow RV septum bows into LVRV septum bows into LV further decrease further decrease

in COin CO Result:Result:

Decrease in LV systolic pressure Decrease in LV systolic pressure Relative increase in RV systolic pressureRelative increase in RV systolic pressure

Inspiratory Discordance:Inspiratory Discordance:

Discordance vs Discordance vs Concordance:Concordance:

Grossman, 2000 6th edition.

Echocardiographic Echocardiographic Evaluation:Evaluation:

Preferred modality for assessing the Preferred modality for assessing the pericardium and pericardial diseasepericardium and pericardial disease

Less reliable that MR or CT for Less reliable that MR or CT for pericardial thickening, calcification, pericardial thickening, calcification, or constrictionor constriction Still employed as initial diagnostic testStill employed as initial diagnostic test Recommended by the ACC/AHARecommended by the ACC/AHA

Normal Pericardium:Normal Pericardium:

M-Mode:M-Mode: Systolic separation of the visceral and Systolic separation of the visceral and

parietal pericardiumparietal pericardium 2 layers move in parallel 2 layers move in parallel

Two-Dimensional:Two-Dimensional: Brightest structureBrightest structure Heart/Visceral pericardium slide/twist Heart/Visceral pericardium slide/twist

within the parietal pericardiumwithin the parietal pericardium

M-ModeM-Mode

M-Mode: ConstrictionM-Mode: Constriction

Dense-echos posterior to LV:Dense-echos posterior to LV: Move in parallel Move in parallel

Abrupt, posterior motion of the Abrupt, posterior motion of the ventricular septum in early diastole (dip):ventricular septum in early diastole (dip): Flat in mid-diastole (plateau with equal RV Flat in mid-diastole (plateau with equal RV

and LV)and LV) Abrupt anterior motion in atrial contraction Abrupt anterior motion in atrial contraction

(RV filling)(RV filling) IVC and hepatic vein dilatationIVC and hepatic vein dilatation

Normal Pericardium:Normal Pericardium:

2D: Constriction2D: Constriction Increased echogenicity of the pericardium Increased echogenicity of the pericardium

from thickeningfrom thickening Loss of movement of heart within Loss of movement of heart within

pericardium:pericardium: Fixed and adherentFixed and adherent

May see effusion (effusive-constrictive)May see effusion (effusive-constrictive) Septal shudder or bounceSeptal shudder or bounce

Abrupt posterior movement of septumAbrupt posterior movement of septum In inspiration with underfilling of LVIn inspiration with underfilling of LV

Fixed& echogenic Fixed& echogenic pericardium:pericardium:

Pericardial thickening:Pericardial thickening:

Subcostal:Subcostal:

Septal Bounce:Septal Bounce:

Septal Bounce:Septal Bounce:

Septal Bounce:Septal Bounce:

Other 2D Findings:Other 2D Findings:

Dilation of IVCDilation of IVC Decreased collapse of IVC w/ Decreased collapse of IVC w/

inspirationinspiration Hepatic vein plethoraHepatic vein plethora Biatrial enlargementBiatrial enlargement Abrupt stop in diastolic filling of Abrupt stop in diastolic filling of

ventriclesventricles

Doppler Doppler Echocardiography:Echocardiography:

Crucial component in the evaluation Crucial component in the evaluation of constrictionof constriction

Corresponds with the physiology and Corresponds with the physiology and reflects the hemodynamics reflects the hemodynamics previously discussedpreviously discussed

Doppler Findings:Doppler Findings: RV and LV inflow RV and LV inflow

show prominent E show prominent E wave due to rapid wave due to rapid early diastolic fillingearly diastolic filling

Short deceleration Short deceleration time of E wave as time of E wave as filling abruptly stopsfilling abruptly stops

Small A wave as little Small A wave as little filling occurs in late filling occurs in late diastole following diastole following atrial contractionatrial contraction

Otto. Textbook of Clinical Echocardiography, 3rd Edition, 2004.

Doppler Findings:Doppler Findings:

Redfield MM, et al. JAMA 2003.

Review of Doppler:Review of Doppler:

Pulmonary vein flow Pulmonary vein flow (on apical 4 (on apical 4 chamber):chamber): Correspond to LA Correspond to LA

fillingfilling Prominent a waveProminent a wave Prominent y descentProminent y descent Prominent diastolic Prominent diastolic

filling phasefilling phase Blunted systolic filling Blunted systolic filling

following atrial following atrial contraction contraction

Doppler: Mitral and Doppler: Mitral and Tricuspid InflowTricuspid Inflow

Marked respiratory variation in Marked respiratory variation in biventricular inflowbiventricular inflow

Inspiration: Inspiration: Negative intrapleural pressureNegative intrapleural pressure Increased RV inflow velocity and Increased RV inflow velocity and

diastolic fillingdiastolic filling Decreased LV inflow velocity Decreased LV inflow velocity Greater than 25% respiratory variation Greater than 25% respiratory variation

Mitral Inflow:Mitral Inflow:

Turkish Society of Cardiology, 2007.

CXR: Transmitral Doppler:

Respiratory Mitral Respiratory Mitral Inflow:Inflow:

Respiratory Tricuspid Respiratory Tricuspid Inflow:Inflow:

Tissue Doppler:Tissue Doppler:

Important in Important in differentiating differentiating restriction and restriction and constrictionconstriction

Prominent E’, Loss Prominent E’, Loss of A’of A’

Gorcsan, J. Japanese Circ Society, 2000

Tissue Doppler:Tissue Doppler:

Annular Paradox:Annular Paradox: E/E’ increasedE/E’ increased Mean LAP decreasedMean LAP decreased High pressure and low ratioHigh pressure and low ratio

Peak E’ ≥ 8 cm/s: Peak E’ ≥ 8 cm/s: (Rajagopalan, N. at al. (Rajagopalan, N. at al. AJC 2001.)AJC 2001.) 89% senstive for constriction89% senstive for constriction 100% specific 100% specific

Improving Sensitivity:Improving Sensitivity:

Choi et al. J Am Soc Echo, 2007 Jun.Choi et al. J Am Soc Echo, 2007 Jun.

To evaluate additional value of systolic To evaluate additional value of systolic mitral annular velocity (S’) and time mitral annular velocity (S’) and time difference between onset of mitral difference between onset of mitral inflow (T(E’-E)) and onset of E’ to inflow (T(E’-E)) and onset of E’ to differentiate constriction and restrictiondifferentiate constriction and restriction

Normal Tissue Doppler:Normal Tissue Doppler:

Nurcan,et al. Turkish Society of Cardiology, 2006.

The Study:The Study:

44 patients:44 patients: 28 male, 16 female28 male, 16 female Mean age 47 years (10-76 years)Mean age 47 years (10-76 years) 17 patients with constrictive pericarditis17 patients with constrictive pericarditis 12 patients with restrictive 12 patients with restrictive

cardiomyopathycardiomyopathy 15 control subjects15 control subjects

Standard mitral inflow doppler and Standard mitral inflow doppler and tissue doppler performedtissue doppler performed

Study Results:Study Results:

Constriction:Constriction: E’ 9.5 +/- 1.7 cm/sE’ 9.5 +/- 1.7 cm/s S’ 7.7 +/-1.3 cm/sS’ 7.7 +/-1.3 cm/s

T(E-E’) 21.0 +/- 32 T(E-E’) 21.0 +/- 32 msms

Restriction:Restriction: E’ 4.7 +/- 1.6 cm/sE’ 4.7 +/- 1.6 cm/s S’ 4.6 +/- 1.9 cm/sS’ 4.6 +/- 1.9 cm/s

T(E-E’) 53.1 +/- T(E-E’) 53.1 +/- 30.4 ms30.4 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:Study Results:

Diagnostic accuracy of E’ > S’ >T(E-Diagnostic accuracy of E’ > S’ >T(E-E’) for differentiation of constriction E’) for differentiation of constriction vs restriction:vs restriction: AUC: 0.99 vs 0.87 vs 0.74, resp.AUC: 0.99 vs 0.87 vs 0.74, resp.

E’ of 8 cm/s: 100% specific, 70% E’ of 8 cm/s: 100% specific, 70% sensitive at differentiationsensitive at differentiation

Study Results:Study Results:

Combining E’ with S’ and T(E-E’):Combining E’ with S’ and T(E-E’): Sensitivity increased compared to E’ Sensitivity increased compared to E’

alone:alone: 70% sensitive with E’ alone70% sensitive with E’ alone 88% sensitive with E’ + S’88% sensitive with E’ + S’ 94% sensitive with E’ + S’ + T(E-E’)94% sensitive with E’ + S’ + T(E-E’) P = 0.001P = 0.001

Study Conclusion:Study Conclusion:

Additional Measurement of S’ and Additional Measurement of S’ and T(E-E’) can be incrementally helpful T(E-E’) can be incrementally helpful in differentiation of constrictive in differentiation of constrictive pericarditis from restrictive pericarditis from restrictive cardiomyopathy when added to E’cardiomyopathy when added to E’

Other Echo techniques:Other Echo techniques:

Rajagopalan, et al. Am J Cardiol 2001:Rajagopalan, et al. Am J Cardiol 2001: Evaluate Tissue Doppler and Color M-Evaluate Tissue Doppler and Color M-

Mode flow propagation to distinguish CP Mode flow propagation to distinguish CP and RCMand RCM

30 patients:30 patients: 19 Constrictive pericarditis19 Constrictive pericarditis 11 Restrictive cardiomayopathy11 Restrictive cardiomayopathy Confirmed by other modalitiesConfirmed by other modalities

Compared with mitral inflow respiratory Compared with mitral inflow respiratory variationvariation

Propagation Velocity:Propagation Velocity: Color M-Mode of Color M-Mode of

diastolic flow from diastolic flow from LA to apex in 4 LA to apex in 4 chamber viewchamber view

20 by TTE, 10 by TEE20 by TTE, 10 by TEE Flow propagation Flow propagation

slope of first aliasing slope of first aliasing contour (white line):contour (white line): Steep at 110 cm/s in Steep at 110 cm/s in

CPCP Less steep at 35 cm/s Less steep at 35 cm/s

in RCMin RCM

Rajagopalan N. Am J Cardiol 2001;87:86

Results:Results: Slope of first Slope of first

aliasing contour of aliasing contour of > 100 cm/s > 100 cm/s differentiated CP differentiated CP from RCM:from RCM:

91% specificity91% specificity 74% sensitivity74% sensitivity

Other Results:Other Results:

Respiratory variation of the mitral Respiratory variation of the mitral inflow peak early velocity of ≥10%: inflow peak early velocity of ≥10%: 84% sensitivity and 91% specificity 84% sensitivity and 91% specificity

Variation in the pulmonary venous Variation in the pulmonary venous peak diastolic velocity of ≥18%: 79% peak diastolic velocity of ≥18%: 79% sensitivity and 91% specificitysensitivity and 91% specificity

Tissue Doppler peak E’ of ≥8.0 cm/s: Tissue Doppler peak E’ of ≥8.0 cm/s: 89% sensitivity and 100% specificity. 89% sensitivity and 100% specificity.

Echo is still not Echo is still not perfect….perfect….

Other modalities to aid in diagnosis Other modalities to aid in diagnosis of constrictive pericarditis:of constrictive pericarditis: CXRCXR CTCT CMRCMR Cardiac catheterizationCardiac catheterization Surgical biopsySurgical biopsy

Multislice Cardiac CT:Multislice Cardiac CT:

Langher, et al. Heart 2006.

Cardiac MR: Normal Cardiac MR: Normal PericardiumPericardium

Cardiac MR: Constrictive Cardiac MR: Constrictive PericarditisPericarditis

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