constrictive & restrictive physiology - clinical & diagnostic differentiation dr.dayasagar...

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