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Constrictive Cardiomyopathy Versus Restrictive Cardiomyopathy Echocardiography Dr Djilali Hanzal Cardiologist National Guard Hospital Outline Background Physiology Clinical Features Echocardiography : 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