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©2016 MFMER | slide-1
Mayo Clinic Department of Cardiovascular Diseases
Mayo Clinic Echocardiography Review Course for Boards and Recertification
Constriction vs Restriction Is it still a big deal?
Jae K. Oh, MDSamsung Professor of CV Diseases
Director, Pericardial Disease ClinicCo-Director, Multimodality Imaging
Mantova in Marzo 2017
SfideIn Cardiologia Clinica
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©2016 MFMER | slide-2©2011
MFME
Restriction vs Constriction Paradoxical DHF or HFpEF
CP983059-3
No paradoxical Pulse Paradoxical
No variation Diastolic Filling Variation
Decreased Relaxation (e’) Paradoxical
Inspiration HV reversal Expiration
Concordant LV/RV SP Discordant
Diagnosis should be based on their characteristic
HEMODYNAMICS
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©2016 MFMER | slide-3
Constrictive Pericarditis
CP992397-39
E
E
1.Dissociation between intrathoracic and
intracardiac pressures
2. Interventricular Dependence
Mitral Inflow vs Cath
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©2016 MFMER | slide-4
Hemodynamics in Constriction
CP1051850-19
Intracardiac pressure Δ < intrathoracic pressure Δ
Interventricular dependence
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©2016 MFMER | slide-5
ConstrictionAbnormal septal motion
Interventricular Dependence
Inspir Expir
“Consider constriction if there is
septal motion abnormality in patients
with HF and preserved EF (HFpEF)”
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©2016 MFMER | slide-6
Mitral Annulus Motion by Tissue Doppler
e’ is noninvasive tau (relaxation)
Myocardial relaxation (e’) is reduced in all forms of myopathies CP1254003-8
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©2016 MFMER | slide-7
Tissue Doppler in Constriction vs Restriction
E’ normal to high in constriction, low in myocardial disease
E’ > 8 cm/sec E’ < 7 cm/sec E’ > 8 cm/sec
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©2016 MFMER | slide-8©2011
MFME
Normal vs RCM vs CPMedial Mitral e’ velocity (LV Relaxation)
Medial e’ 13 cm/s Medial e’ 3 cm/s Medial e’ 14 cm/sUsually > Lateral e’
(Annulus Reversus)
Normal RCM CP
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©2016 MFMER | slide-9
Mayo Echo Diagnostic Criteria
Septal motion abnormality MV Flow Velocity
Restrictive (E/A >1)
Hepatic Vein Diastolic
reversal with expiration
Sensitivity 87 %
Specificity 91 %
Welch et al Circ Imaging 2014
Medial e’ ≥ 8 cm/s
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©2016 MFMER | slide-10
Illustrative CasesIs it a still big deal to separate CP from RCM?
Transient or Effusive CPRole of Multi-modality Imaging
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©2016 MFMER | slide-11
71 yo man with Heart Failure 2 yrs after CABGReferred for Pericardiectomy
• Physical Examination
• JVP elevation
• Prominent S3
• Peripheral edema
• CT was obtained: Calcified Pericardium
• Cath : Equalization of End-diastolic pressures
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©2016 MFMER | slide-12
71 year old man with calcified pericardium
Mitral inflow
E= 0.8 A= 0.2Medial e’ = 3 cm/s
Cardiac Amyloidosis
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©2016 MFMER | slide-13
©2011
MFMER |
slide-13
Constrictive Pericarditis
• Increased atrial pressure
• Rapid rise in ventricular diastolic pressure
• Equalization of end-diastolic pressures
Cath Hemodynamic Criteria
Bloomfield and Cournand et al: JCI, 1946
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©2016 MFMER | slide-14
Constrictive Pericarditis in the Modern EraNovel Criteria for Diagnosis in the Cardiac Cath Laboratory(Talreja, Nishimura, Oh, Holmes. Jan. 2008 JACC)
ConstrictionRestriction(RMC)
Concordant change
Discordant change
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©2016 MFMER | slide-15
An e-mail from a junior staff at a major MC52 year old man waiting for heart transplantation(Had Echo, MRI, and cardiac cath performed)
Medial e’ = 20 cm/sec
Diastolic Reversal
Flow with Expiration
Dx= RCM
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©2016 MFMER | slide-16
.What would you recommend?
1. Being a junior staff, keep quiet
2. Believing in Echo-Doppler, un-list him and further evaluation
3. Proceed with transplantation
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©2016 MFMER | slide-17
Explanted Heart
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©2016 MFMER | slide-18
67 yo man with severe aortic stenosis and HFCame to Valve Clinic for AVR (LFLG Severe AS)
Stroke volume = (1.9) 2 x 0.785 x 21 = 60 cc
AVA = 60 / 76 = 0.79 cm2
MG 26 mmHg
TVI 76
LVOT D = 1.9 cm LVOT TVI = 21cm
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©2016 MFMER | slide-19
67 year old man with AS and heart failure Mitral Annulus Tissue Doppler E’ Velocity
1. OK for aortic stenosis
2. Not OK for AS
3. Does not matter
Medial
Lateral
E = 100 cm/s
Medial e’ = 9 cm/s
Lateral e’ = 6 cm/s
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©2016 MFMER | slide-20
Tissue Doppler and Strain Imaging in Constriction (Annulus Reversus)
Medial e’ 15 cm/s
Lateral e’ = 10 cm/s
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©2016 MFMER | slide-21
67 year old man with AS and Constriction Hepatic Vein Doppler c/w constriction
Radiation Heart Disease
Circulation CV Imaging 2015
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©2016 MFMER | slide-22
77 yo man with severe aortic stenosisTAVR and PM implantation & RV Perforation
Pericardiocentesis yielded 125 cc of
bloody fluid
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©2016 MFMER | slide-23
77 yo man with severe aortic stenosisIncreasing dyspnea 2 months after pericardiocentesis
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©2016 MFMER | slide-24
Effusive-Constrictive Pericarditis
Interventricular Dependence
Expiratory diastolic flow reversal
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©2016 MFMER | slide-25
©2011
MFMER |
slide-25
MRI DE in 2 patients with Constriction
Circulation Oct 3rd 2011
Baseline
Medical
RX
3 Months
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©2016 MFMER | slide-26
©2011
MFMER |
slide-26
Transient ConstrictionReversible (N=14) Persistent (N=15)
Age 54 ± 17 59 ± 16
LVEF 57 ± 3 60 ± 3
E’ (cm/sec) 12 ± 1 11 ± 1
Steroid Rx 71 % 53 %
Pericardium 3.8 ± 0.6 mm 4.0 ± 0.6 mm
DE Pericardium 4.4 ± 0.4 mm 2.1 ± 0.4mm
Grade 3-4/4 DE 93 % 33 %
Sed rate 45 to 4 25 to 20
CRP 75 to 2 14 to 15
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©2016 MFMER | slide-27
©2011
MFMER |
slide-27
One week of Steroid RxTransient Constrictive Pericarditis
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©2016 MFMER | slide-28
SA Chang, JK Oh et al JACC Feb 2017
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©2016 MFMER | slide-29
Constrictive PericarditisCT for anatomy and calcification
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©2016 MFMER | slide-30
A 26 year old woman with a previous pericardiectomy, presenting with edema
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©2016 MFMER | slide-31
Hepatic Vein Doppler and TDI
Medial e’ 12 cm/s Lateral 2’ = 8 cm/s
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©2016 MFMER | slide-32
Chronic constriction requires Complete Pericardiectomy
©2012
MFMER |
3213949-32Cho and Mayo CV et al. Annal Thorac Surgery 2012
41 pts
1993 -2010
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©2016 MFMER | slide-33
Constriction or Myocardial Disease ? Diagnostic Algorithm
Syed, Schaff, Oh Nature Review Sep 2014
Medial e’ 12 cm/sMedial e’ 5 cm/s
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©2016 MFMER | slide-34
Do not let a quick look fool you !
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©2016 MFMER | slide-36
117
26
Talreja, Edwards, Oh et al. Circ 2004
Constrictive PericarditisPericardial Thickness by Surgical Pathology
143 cases (1993-1999)
Constriction
with thick
pericardium
Constriction
with normal
thickness
(2 mm)
18% of all cases of constriction
CP1051850-49
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©2016 MFMER | slide-37
27 yo man with fatigue and dyspnea
• Sep. 2015…Flu-like symptoms, treated with inhaler
• Oct. 2015…Pre-syncopy and palpitation
• Pericardial rub
• Pericardial effusion on Echo
• Treated with Ibuprofen 2400 mg/d, Colchicine 0.6 mg BID
• Not feeling better and CRP 60
• Underwent pericardial window
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©2016 MFMER | slide-38
27 year old man underwent a windowReferred to Mayo
• Pericardial fluid …studies were negative
• Not feeling better
• RUQ abdominal pain and fatigue
• U/S…Enlarged gallbladder and liver
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©2016 MFMER | slide-39
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©2016 MFMER | slide-40
27 yo man after pericardial window
1= CT 2= MRI 3= Cath 4= Pericardiectomy
Hepatic Vein
Expiratory Diastolic
Flow Reversal
Mitral Inflow
Mitral e’ = 15 cm/sec
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©2016 MFMER | slide-41
FDG-PETBaseline 3month later
31 year old man with
Acute Pericarditis
Treated with NSAID
SA Chang, JK Oh et al JACC 2017
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©2016 MFMER | slide-42
Mitral Inflow Hepatic vein
Insp Exp
Hatle, Appleton Circ 1989 , Oh, Hatle JACC 1994 , Oh, Circ 1997
Echo Dx of Constriction
1989-1997
1. Abnormal Septal Motion
2. Restrictive Mitral Inflow with
Respiratory Variation > 25%
3. Hepatic Vein Diastolic Flow
Reversals with Expiration
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©2016 MFMER | slide-43
Removal of LA myxomaPost-op transient constriction
Post-op MRI 3 months later
Postop EchoIntraop TEE
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©2016 MFMER | slide-44
©2011
MFMER |
slide-44
80
0
40
LV
PCW
ExpirationInspiration
CP1105201-1
Hatle et al. Circ 1989
Hemodynamics of Myocardial DiseaseConcordant change in PCWP and LVDP
Inspiration
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©2016 MFMER | slide-45
Pericardiectomy at Mayo ClinicThe first cardiac surgery in 1936
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©2016 MFMER | slide-46
Extensive pericardial enhancement
& adjacent left pleural
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©2016 MFMER | slide-47
Heart failure with ascites and leg edema
©2011
MFMER |
slide-47
1= Severe TR
2=Constriction
3= TR + CP
4= TR and RV dysfunction
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©2016 MFMER | slide-48
Annulus ReversusSevere TR and CP
©2011
MFMER |
slide-48
Medial e’ = 12 cm/sec Lateral e’= 9 c/sec
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©2016 MFMER | slide-49
©2011
MFMER |
slide-49JACC CV Imaging June 2011
E’ velocity is inversely proportional
to pericardial thickness in the AV groove
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©2016 MFMER | slide-50
Take Home Point :Restriction or Constriction?Diagnosis based on Hemodynamics
Medial e’ = 5 cm/s
Medial e’ = 11 cm/s
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©2016 MFMER | slide-51
Learning ObjectivesBased on Cases
• Identify constriction by 4 parameters
• Ventricular septal motion abnormality
• Mitral inflow velocity ≥ Grade 2
• Mitral annulus medial e’ ≥ 8 cm/sec
• Hepatic vein diastolic expiratory flow reversal
• Identify mimickers of constriction
• Restrictive CM
• Severe TR
• Interventricular dependence of other causes
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©2016 MFMER | slide-52
71 yo man with Heart Failure 2 yrs after CABGReferred for Pericardiectomy
• Physical Examination
• JVP elevation
• Prominent S3
• Peripheral edema
• CT was obtained: Calcified Pericardium
• Cath : Equalization of End-diastolic pressures
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©2016 MFMER | slide-53
71 yo man with calcified pericardiumReferred for Pericardiectomy
• Cardiac Cath
• Normal Coronaries
• Elevated RAP, RVEDP, LVEDP Equalized LV/RV EDP
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©2016 MFMER | slide-54
71 year old man with calcified pericardium
MRI : Patchy myocardial delayed
enhancement and increased wall thickness
Cardiac Amyloidosis