Constrictive & Restrictive physiology - clinical & diagnostic differentiation Dr.DayaSagar Rao.V...
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Transcript of Constrictive & Restrictive physiology - clinical & diagnostic differentiation Dr.DayaSagar Rao.V...
Constrictive & Restrictive physiology -
clinical & diagnostic differentiation
Dr.DayaSagar Rao.VDM(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
• Epicardial tethering Pericardial constraints
• 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
Restrictive cardiomyopathy
• Predominantly subendocardial dysfunction
• 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 ExamPND/orthopneaPrecordial impulseAscites(precox)
• ECG : Chamber enlargement Conduction disturbances
• CXR : Pericardial calcification
BNP Constrictive pericarditis
Restrictive cardiomyopathy
• CP : 6pts : 128pg/ml• RC : 5pts : 825.8pd/ml
JACC 2005 Leya PR et al
• CP : 116pg/ml• CP+CKD : levels higher : 433pg/ml• RC : 728pg/ml
JACC 2007 Reddy PR et al
BNP Constrictive pericarditis
Restrictive cardiomyopathy
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
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
DissociationDissociation 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 pericarditisAnd restrictive cardiomyopathy by DopplerEchocardiography. Circ. 1989;79357-370
DissociationDissociation of Intrathoracic and Intracardiac Pressures
The incitingPhysiologic Event.
Hatle LK, et. al.
Circ. 1989;79357-370
Ventricular Interdependence
Insp Expir
Hatle LK, et. al.Circ. 1989;79357-370
Ventricular Pressures
Are DISCORDANT
Traditional v.s. DynamicCatheterization Hemodynamics
DissociationDissociation of Intrathoracic and Intracardiac Pressures
Why bother with Echo givenThe great utility of Dynamic
Respiratory cath measurments?
These measurments are only Possible using High-fidelityMicromanometer systems (not a common practice).
Effect of Inspiration: Constriction
PCWP
Inspir.
No proportionate decrease in LV diastolic pressure
PCWP
Inspir. Expir.Expir.Insp.
Expir.PCWP
Decreased transmitral gradient => Transmitral flow
RV SV LV SV
Pathophysiologic Differences
ConstrictionMyocardial compliance is NL
RestrictionAb-Nl Myocardial compliance
No impedence to Diastolic EARLY FILLING
Total cardiac volume is fixed by the pericardium
Impedence to filling increases throughout the diastolePericardium is compliantSeptum is non-compliant
Atria are able to empty into theVentricles, though at higher Press.
Reduction of the proportion ofLV filling with atrial contraction:=> Atrial enlargement
Marked Respiratory effect ofLV on the RV
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 waveCriteria for Constriction
• Decrease in of 25% in Mitral “E” velocity on inspiration.
• In RESTRICTION:
There is no respiratory variation of Mitral inflow
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
RestrictionForward flow primarily in Diastole.
Inspiration increases both>systolic, and>Diastolic
Flow reversals.
Hepatic Vein Doppler: Compilation
Mixed physiology(restriction/constriction)
Diastolic flow reversalduring both Ispirationand 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• Mixed Restriction and Constriction• Marked increase in Preload
Deduced postStripping, as SxNot improve
Preload reduction to unmask the respiratoryvariation
Effect of changing loading conditions w/ VALSALVA in RESTRICTION
E 20%
A to a lesser degree
COPD v.s. Constriction
• Individual Mitral flow velocity profiles are not restrictive as LV filling pressure is not increased.
100% change in E Velocity
COPD v.s. Constriction
Constriction: Minimal change in SVC velocities with inspiration.
COPD
Const.
COPD: Greater than NL
decrease in intrathroracic pressure is generated with inspiration =>
Increased SVC Flow
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 paradoxusVery tall e’ – even though LA pressure is
elevated
• Annular InversusN lateral – mitral annulus e’ is more steeper than medial e’
Constrictive pericarditisLateral annulus e’ is less than medial e’
• Pericardiectomy NORMALISES Both annular paradoxusAnnular inversus
• Persistance of annular paradoxusAnnular inversus
? Incomplete Pericardiectomy
SensitivitySpecificity
• Peak E velocity 84% 91%>10%
• Peak pulm vein 79% 91%Diastolic velocity>18%
• TDIPeak e’ >8cm/sec 89% 100%e’ + S ’ 88%e’ + S ’+T(e’-E) 94%
Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply.
Talreja, D. R. et al. J Am Coll Cardiol 2008;51:315-319
LV and RV High-Fidelity Manometer Pressure Traces From 2 Patients During Expiration and Inspiration
THANK YOU
Ventricular Interdependence During Respirations Differentiates Constrictive Pericarditis from Restrictive
Cardiomyopathy
ConstrictivePericarditis(LV and RV discordant)
Restrictive Cardiomyopathy(LV and RV concordant)
Hurrell et al, Circulation 1996; 93:2007