Download HEMODYNAMICS of Pericardial Disease

Constrictive & Restrictive
physiology - clinical &
diagnostic differentiation
Dr.DayaSagar Rao.V
DM(Cardiology)
FRCP(Canada)
FRCP(Edinburgh)
Anatomy
• Lt. Atrium is not
completely
intrapericardial
• All other cardiac
chambers are
completely
intrapericardial
• Pulmonary Veins are
completely
intrathoracic
Pericardial disease
Restrictive cardiomyopathy
•
Epicardial tethering
Pericardial constraints
•
Predominantly subendocardial
dysfunction
•
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
•
Constrained in longitudinal direction
with preserved circumferential strain
•
Diastolic recoil is attenuated in
longitudinal direction
Reduced longitudinal displacement
with preserved circumferential strain
•
•
•
CXR
CT
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
BNP
Constrictive pericarditis
Restrictive cardiomyopathy
• CP : 6pts :
• RC : 5pts :
128pg/ml
825.8pd/ml
JACC 2005 Leya PR et al
BNP
Constrictive pericarditis
Restrictive cardiomyopathy
• CP :
• CP+CKD : levels higher :
• RC :
116pg/ml
433pg/ml
728pg/ml
JACC 2007 Reddy PR et al
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)
PRESSURES & RESPIRATION
• Inspiration - Negative Intrathoracic pressure
- Lungs ( Pulmonary vessels)
- Heart ( through pericardium)
Pressure
Flow
Rt side
Decrease
Increase
Lt side
Decrease
Decrease
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
Effect of Inspiration
• Normal Pericardium:
– Inspiratory decrease in intrathoracic pressure is
uniformly transmitted to the lungs, PVs, LA, LV,
RA, and RV
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
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
Dissociation of Intrathoracic and
Intracardiac Pressures
The inciting
Physiologic
Event.
Hatle LK, et. al.
Circ. 1989;79357-370
Ventricular Interdependence
Hatle LK, et. al.
Circ. 1989;79357-370
Ventricular Pressures
Insp
Expir
Are DISCORDANT
Traditional v.s. Dynamic
Catheterization Hemodynamics
These
measurments
aregiven
only
Why bother
with Echo
Possible
The
greatusing
utilityHigh-fidelity
of Dynamic
Micromanometer
systems
Respiratory
cath measurments?
(not a common practice).
Dissociation of Intrathoracic
and Intracardiac Pressures
Effect of Inspiration: Constriction
Inspir.Insp.
PCWP
Expir.
PCWP
PCWP
Inspir.
No proportionate decrease in LV diastolic pressure
Decreased transmitral gradient => Transmitral flow
LV SV
RV SV
Expir.
Expir.
Pathophysiologic Differences
Constriction
Restriction
Myocardial compliance is NL
No impedence to
Diastolic EARLY FILLING
Total cardiac volume is fixed by
the pericardium
Ab-Nl Myocardial compliance
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
Impedence to filling increases
throughout the diastole
Pericardium is compliant
Septum is non-compliant
Minimal Respiratory effect of
RV on the LV
Specific Echocardiographic Criteria for
Constriction/Restriction
• Mitral E wave pattern
• Pulmonary Vein pattern
• Hepatic Vein pattern
Mitral E wave
Criteria for Constriction
• Decrease in of 25% in
Mitral “E” velocity on
inspiration.
• In RESTRICTION:
There is no respiratory
Mitral inflow
variation of
Hepatic Vein Doppler: Normal
Normal
Systolic and diastolic forward flow
S-vel. > D-vel.
Diastolic flow reversal:
Expir.>>Insp.
Hepatic Vein Doppler: Constriction
Constriction
Diastolic flow reversal is
augmented in expiration.
DFRexp.>25% forward
diastolic velocity
Hepatic Vein Doppler: Restriction
Restriction
Forward flow primarily in
Diastole.
Inspiration increases both
>systolic, and
>Diastolic
Flow reversals.
Hepatic Vein Doppler: Compilation
Mixed physiology
(restriction/constriction)
Diastolic flow reversal
during both Ispiration
and expiration
Constriction Doppler
Inspiration
Expiration
Pitfalls and Caveats
• Subgroup of patients with constriction who
do not exhibit respiratory changes
• COPD
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
Deduced post
Stripping, as Sx
Not improve
• Mixed Restriction and Constriction
• Marked increase in Preload
Preload reduction to
unmask the respiratory
variation
Effect of changing loading conditions w/
VALSALVA in RESTRICTION
E 20%
A to a lesser degree
COPD v.s. Constriction
100% change in E Velocity
• Individual Mitral flow
velocity
profiles are not restrictive as
LV filling pressure is not increased.
COPD v.s. Constriction
COPD
COPD: Greater than NL
decrease in intrathroracic
pressure is generated with
inspiration =>
Increased SVC Flow
Const.
Constriction: Minimal change
in SVC velocities with
inspiration.
Tissue Doppler PW Analysis of Mitral Annular
Motion
Physiologic Premise:
Assessment of VELOCITY of LV
-Contraction, and
-Relaxation
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.
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’
• Pericardiectomy NORMALISES
Both annular paradoxus
Annular inversus
• Persistance of annular paradoxus
Annular inversus
? Incomplete Pericardiectomy
• Peak E velocity
>10%
• Peak pulm vein
Diastolic velocity
>18%
• TDI
Peak e’ >8cm/sec
e’ + S ’
e’ + S ’+T(e’-E)
Sensitivity
Specificity
84%
91%
79%
91%
89%
88%
94%
100%
LV and RV High-Fidelity Manometer Pressure Traces From 2
Patients During Expiration and Inspiration
Talreja, D. R. et al. J Am Coll Cardiol 2008;51:315-319
Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply.
THANK YOU
Ventricular Interdependence During Respirations
Differentiates Constrictive Pericarditis from Restrictive
Cardiomyopathy
Constrictive
Pericarditis
(LV and RV discordant)
Hurrell et al, Circulation 1996; 93:2007
Restrictive
Cardiomyopathy
(LV and RV concordant)