constrictive cardiomyopathy versus restrictive cardiomyopathy echocardiography dr djilali hanzal...
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Constrictive Cardiomyopathy Constrictive Cardiomyopathy Versus Versus
Restrictive Cardiomyopathy Restrictive Cardiomyopathy EchocardiographyEchocardiography
Dr Djilali HanzalDr Djilali Hanzal
Cardiologist Cardiologist
National Guard Hospital National Guard Hospital
OutlineOutline
BackgroundBackground PhysiologyPhysiology Clinical FeaturesClinical Features Echocardiography :Echocardiography : M modeM mode 2D2D DopplerDoppler Tissue Doppler Tissue Doppler Strain ImagingStrain Imaging ConclusionConclusion
Etiology CP
Bertog SC, J Am Coll Cardiol. 2004;43(8):1445.
Tajik AJ Circulation. 1999;100(13):1380.
Symptoms
Varieties of constrictive pericarditis
Rien muller et al .J Thorac Imaging 1993
J Am Coll Cardiol 2004;43;1445-52
Anatomy Anatomy
Lt. Atrium Lt. Atrium is notis not Completely Completely intrapericardialintrapericardial
All other cardiac chambers All other cardiac chambers areare completely intrapericardialcompletely intrapericardial
Pulmonary Veins are Pulmonary Veins are completely intrathoraciccompletely intrathoracic
Effect of InspirationEffect of Inspiration
Normal PericardiumNormal PericardiumIntra thoracic pressureIntra thoracic pressure
Venous returnVenous return
Transient size of RVTransient size of RV
Normal LV fillingNormal LV filling
Constrictive PericarditisConstrictive Pericarditis Intra thoracic pressureIntra thoracic pressure
Venous returnVenous return
RV not expandedRV not expanded
Abnormal LV fillingAbnormal LV filling
Uptodate 2011
Mechanism
• FILLING FILLING IMPAIREMENTIMPAIREMENT
• LV-RV LV-RV INTERDEPENDANCEINTERDEPENDANCE
PhysiologyPhysiologyCP vs RCMCP vs RCM
Constrictive PericarditisMyocardial compliance is NLMyocardial compliance is NL
Pericardium not compliantPericardium not compliant
Septum compliantSeptum compliant
Rapid early diastolic Rapid early diastolic fillingfilling
cardiac volume is fixed by the cardiac volume is fixed by the pericardiumpericardium
Respiratory effect of LV Respiratory effect of LV on the RVon the RV
Restrictive Ab-Nl Myocardial complianceAb-Nl Myocardial compliance
Pericardium compliantPericardium compliant
Septum not compliantSeptum not compliant
Impedence to Impedence to fillingfilling increases increases throughout the diastolethroughout the diastole
No Respiratory effect of No Respiratory effect of RV and the LVRV and the LV
Restrictive Cardiomyopathy
(Myocardial Disorders)
Myocardial disease
Endomyocardial disease Storage disease
Infiltrative Noninfiltrative
Endomyocardial fibrosis
Hemochromatosis
AmyloidosisSarcoidosis
Idiopathic CMPDiabetic CMP
E William Hancok, Heart 2001, 86 343-349
Why is it important to make the distinction Why is it important to make the distinction RCM vs CP?RCM vs CP?
Associated with significant morbidity and Associated with significant morbidity and mortalitymortality
Restriction rarely treatable/curableRestriction rarely treatable/curable
Constriction may be curable with surgery. Constriction may be curable with surgery.
Inexplained CHF CXray: No Cardiomegaly ( Clinically, Cxray, BNP..)
Echo: Normal LV systolic function
Echo: Normal LV systolic function
Trans mitral Doppler: Restrictive Pattern: E/A>2Trans mitral Doppler: Restrictive Pattern: E/A>2
TDI:(E’>8cm/s, E/E’<15
Normal S wave)
TDI:(E’>8cm/s, E/E’<15
Normal S wave)
CPCP
TDI:E’<8cm/s,E/E’>15
TDI:E’<8cm/s,E/E’>15
RCMRCMCPCPCho 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-DM-mode and 2-DCPCP
Pericardial thickening and calcificationPericardial thickening and calcificationSeptal bounceSeptal bounceDilated not collapsing Inferior Vena CavaDilated not collapsing Inferior Vena CavaFlattening of LV post wallFlattening of LV post wallEarly pathological outward and inward Early pathological outward and inward
movement of the IVSmovement of the IVSColor M-mode PropagationColor M-mode Propagation
18% of PC had normal thickness
CPCP
Differential Dx:Differential Dx: Constrictive PericarditisConstrictive Pericarditis Pericardial TamponadePericardial Tamponade Pulmonary HypertensionPulmonary Hypertension LBBBLBBB Right Ventricular PacingRight Ventricular Pacing
..
Paradoxal motion of the IVS Paradoxal motion of the IVS occurring in early diastoleoccurring in early diastole
Sensibility 62%,Specificity 93% Sensibility 62%,Specificity 93%
Journal of Thoracic Imaging. 27(1):w1, January 2012.
M-Mode CPM-Mode CP
Signs reflecting increased Signs reflecting increased ventricular interdependenceventricular interdependence
• Abrupt early diastolic anterior Abrupt early diastolic anterior motion of the IVS followed by a motion of the IVS followed by a rebound toward the LV post wall. rebound toward the LV post wall.
.Mastouri et al. Expert Rev Cardiovasc 2010
M-Mode CPM-Mode CP
Signs reflecting rapid early Signs reflecting rapid early ventricular diastolic filling:ventricular diastolic filling:
• Flattening at the LV post wallFlattening at the LV post wall
Sensitivity 92%, Specificity 100%
Voelkel et al ,Circulation. 1978 Nov;58(5):871-5.
Signs reflecting Signs reflecting increased Right Ventr increased Right Ventr diastolic pressure above diastolic pressure above Pulmonary Art pressurePulmonary Art pressure
• Premature opening of the Premature opening of the pulmonary valvepulmonary valve
Sensibility 14%,Specificity 100%
Mastouri et al. Expert Rev Cardiovasc 2010
M-Mode CPM-Mode CP
Sensibility 74%,Specificity 91%
Am J 2001,87,86-94
RCM 2-DRCM 2-D
Small LV cavity with Small LV cavity with large atrialarge atria
Increased wall Increased wall thickness ( especially thickness ( especially in interatrial septum in in interatrial septum in Amyloidosis)Amyloidosis)
Thickened valves and Thickened valves and granular sparkling granular sparkling texture (amyloidosis)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-DopplerEcho-Doppler
Mitral and Tricuspid InflowMitral and Tricuspid InflowIVRTIVRTTRTRHepatic Veins Hepatic Veins Pulmonary RegurgitationPulmonary RegurgitationPulmonary VeinsPulmonary VeinsSuperior Vena CavaSuperior Vena Cava
Specificity67%,
Sensibility 86%
J Am Coll Cardio 1994 jan.23,154-JACC,1994 Jan;23(1):154-62
CP
Constriction: Constriction: Non-respirophasicNon-respirophasic
Mixed Restriction and ConstrictionMixed Restriction and Constriction
Marked increase in PreloadMarked increase in Preload• Provocation test with head-up tilting or Provocation test with head-up tilting or
sitting position with decrease of the sitting position with decrease of the preload may unmask the CP.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
CP
Circulation 2002, Rajagopalan et al. AJC 2001
Specificity79%,Sensitivity 86%
Normal
CP
RCMCP
PV is RespirophasicPV is not Respirophasic
Normal
CP
CP vs COPDCP 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”MITRAL “ANNULUS REVERSUS”
E’ Lateral > E’ Septal
E’ Lateral< E’Septal
E’ Lateral =E’ Septal
Normal
CP
RCM
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 CPMyocardial Mechanics in RCM and CP
Deformation Parameter CP RCM
Longitudinal Strain
Normal
Circumferential Strain
Decreased
Decreased Normal
JACC Cardiovasc Imaging. 2008 Jan;1(1):29-38
2-D Speckle-tracking
CP
RCM
J Am Soc Echocardiogr 2009:22:24-33
CP
RCM
Em: Longitudinal early diastolic lengthening velocity J Am Soc Echocardiogr 2009:22:24-33
Too much for Diastology
ConclusionsConclusions
Dx has important therapeutic implicationsDx has important therapeutic implications
Clinical Presentaion similarClinical Presentaion similar
Echocardiography (Doppler,TDI, StrainEchocardiography (Doppler,TDI, Strain/Strain /Strain rate) have increased yield.rate) have increased yield.
Cardiac catheterisation still considered Cardiac catheterisation still considered mandatory.mandatory.
EndEnd
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 DopplerAnnular TDI
Strain Hemodynamic
Normal CP
QTDI
International J of Cardio 137(2009)22-39
RCM
International J of Cardio 137(2009)22-39
Major historical events in CPMajor historical events in CP
Korean Circ J 2012;42:143-150