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Constrictive Cardiomyopathy
Versus
Restrictive Cardiomyopathy
Echocardiography
Dr Djilali Hanzal
Cardiologist
National Guard Hospital
Outline
 Background
 Physiology
 Clinical Features
 Echocardiography :
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




M mode
2D
Doppler
Tissue Doppler
Strain Imaging
Conclusion
Etiology CP
Bertog SC, J Am Coll Cardiol. 2004;43(8):1445.
Symptoms
Tajik AJ Circulation. 1999;100(13):1380.
Varieties of constrictive pericarditis
Rien muller et al .J Thorac Imaging 1993
J Am Coll Cardiol 2004;43;1445-52
Anatomy
Lt. Atrium is not
Completely
intrapericardial
All other cardiac chambers are
completely intrapericardial
Pulmonary Veins are
completely intrathoracic
Effect of Inspiration
Normal Pericardium
Intra thoracic pressure
Venous return
Constrictive Pericarditis
 Intra thoracic pressure
 Venous return
Transient size of RV
 RV not expanded
Normal LV filling
 Abnormal LV filling
Uptodate 2011
Mechanism
• FILLING
IMPAIREMENT
• LV-RV
INTERDEPENDANCE
Physiology
CP vs RCM
Constrictive Pericarditis
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
Restrictive
Ab-Nl Myocardial compliance
Pericardium compliant
Septum not compliant
Impedence to filling increases
throughout the diastole
No Respiratory effect of
RV and the LV
Restrictive
Cardiomyopathy
(Myocardial Disorders)
Myocardial
disease
Endomyocardial
disease
Storage disease
Endomyocardial
fibrosis
Infiltrative
Noninfiltrative
Amyloidosis
Sarcoidosis
Idiopathic CMP
Diabetic CMP
Hemochromatosis
E William Hancok, Heart 2001, 86 343-349
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.
Inexplained CHF
CXray: No Cardiomegaly ( Clinically, Cxray, BNP..)
Echo: Normal LV systolic
function
Trans mitral Doppler:
Restrictive Pattern: E/A>2
TDI:
(E’>8cm/s, E/E’<15
Normal S wave)
CP
TDI:
E’<8cm/s,E/E’>15
CP
RCM
Cho YH and Schaff.Heart Fail Rev 2012
Inexplained CHF
CXray: No Cardiomegaly ( Clinically, Cxray, BNP..)
Echo: M-Mode, 2-D
Normal LV Systolic Function
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
18% of PC had normal thickness
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.
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
.
M-Mode CP
 Signs reflecting rapid early
•
ventricular diastolic filling:
Flattening at the LV post wall
 Sensitivity 92%, Specificity 100%
Voelkel et al ,Circulation. 1978 Nov;58(5):871-5.
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
Sensibility 74%,Specificity 91%
Am J 2001,87,86-94
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)
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
Echo-Doppler
 Mitral and Tricuspid Inflow
 IVRT
 TR
 Hepatic Veins
 Pulmonary Regurgitation
 Pulmonary Veins
 Superior Vena Cava
CP
Specificity
67%,
Sensibility
86%
JACC,1994 Jan;23(1):154-62
J Am Coll Cardio 1994 jan.23,154-
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
AF and CP
AF and CP
J Am Coll Cardio 2001;37:1936-42
CP
JACC 1994 Jan;23(1):154-62
Diagrammatic representation of the transmitral early (E-wave) and late (A-wave) velocities
during diastole throughout the respiratory cycle.
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
2009. For permissions please email: [email protected]
CP
CP
Normal
CP
Specificity79%,
Sensitivity 86%
Circulation 2002, Rajagopalan et al. AJC 2001
CP
Normal
CP
RCM
PV is Respirophasic
PV is not Respirophasic
CP
CP vs COPD
CP
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
Specificity 89%,Sensibility100%
Rajagopalan et al
.Am.J.Cardio 2001
E/e’=6
Am J Cardiol 2004;93:886-890
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
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
Strain Imaging
Myocardial Mechanics in RCM and CP
Deformation
Parameter
Longitudinal
Strain
Circumferential
Strain
CP
Normal
Decreased
JACC Cardiovasc Imaging. 2008 Jan;1(1):29-38
RCM
Decreased
Normal
CP
RCM
J Am Soc Echocardiogr 2009:22:24-33
2-D Speckle-tracking
CP
RCM
Em: Longitudinal early diastolic
lengthening velocity
J Am Soc Echocardiogr 2009:22:24-33
Too much for Diastology
Conclusions
 Dx has important therapeutic implications
 Clinical Presentaion similar
 Echocardiography (Doppler,TDI, Strain/Strain
rate) have increased yield.
 Cardiac catheterisation still considered
mandatory.
End
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
QTDI
CP
Normal
International J of Cardio
137(2009)22-39
RCM
International J of Cardio 137(2009)22-39
Major historical events in CP
Korean Circ J 2012;42:143-150