UPDATE ON CONSTRICTIVE PERICARDITIS ECHOCARDIOGRAPHY AND CARDIAC CATHETERISATION

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1 Arsen D. Ristić, MD, PhD, FESC (no conflicts of interest to disclose regarding this presentation) UPDATE ON CONSTRICTIVE PERICARDITIS ECHOCARDIOGRAPHY AND CARDIAC CATHETERISATION Department of Cardiology, Clinical Center of Serbia, Belgrade University School of Medicine, Belgrade, Serbia

2 UPDATE ON CONSTRICTIVE PERICARDITIS ECHOCARDIOGRAPHY AND CARDIAC CATHETERISATION Annular form Left-sided form Right sided form Global form with Global form with Global form MYOCARDIAL ATROPHY MYOCARDIAL FIBROSIS Very high mortality in pericardiectomy Rienmüller et al. J Thorac Imaging 1993 Morphology Hemodynamics Structural changes Evolution in time Comorbidities DDg.

3 KAPOSI SARCOMA OF THE PERICARDIUM

4 TERTIARY LUES CAUSING CONSTRICTIVE PERICARDITIS Maisch, Seferovic, Ristic et al. ESC guidelines on pericardial diseases, Eur Heart J 2004 Courtesy of Prof. V. Tatić

5 CLINICAL SUSPICION FOR: CHRONIC PERICARDIAL EFFUSION CONSTRICTIVE PERICARDITIS EFFUSIVE-CONSTRICTIVE PERICARDITIS RECURRENT PERICARDITIS If symptomatic for >2 years ECHOCARDIOGRAPHY CARDIAC CATHETERIZATION Congestive heart failure therapy Symptomatic management Hospitalisation and exercise restriction Pain management - Ibuprofen, mg tid or qid - Colchicine, 0.5 mg bid - Prednisone mg qd PERCUTANEOUS BALLOON PERICARDIOTOMY PERICARDIECTOMY Maisch, Seferović, Ristić et al. ESC guidelines on pericardial diseases, Eur Heart J 2004

6 Constrictive pericarditis: DIAGNOSTIC ALGORITHM

7 Constrictive pericarditis DIAGNOSTIC ALGORITHM Cho YH & Schaff HV. Heart Fail Rev 2012

8 Restrictive cardiomyopathy vs. constrictive pericarditis 2D-ECHOCARDIOGRAPHY RESTRICTIVE CARDIOMYOPATHY Small LV cavity with large atria Increased wall thickness (especially interatrial septum in amyloidosis) Thickened valves & granular sparkling CONSTRICTIVE PERICARDITIS Normal wall thickness Pericardial thickening Prominent early diastolic filling with abrupt displacement of interventricular septum texture (amyloidosis)

9 Guidelines on the Diagnosis and Management of Pericardial Diseases CONSTRICTIVE PERICARDITIS M mode/2d echocardiogram Pericardial thickening (>4 mm) and calcifications Indirect signs of constriction Maisch, Seferovic, Ristic et al. ESC guidelines on pericardial diseases, Eur Heart J 2004

10 Guidelines on the Diagnosis and Management of Pericardial Diseases CONSTRICTIVE PERICARDITIS Indirect echo signs of constriction RA & LA enlargement with normal ventricles, and systolic function. Early pathological outward and inward movement of the interventricular septum ( dip-plateau phenomenon ) Flattering waves at the LV posterior wall LV diameter is not increasing after the early rapid filling phase. VCI and the hepatic veins are dilated with restricted respiratory fluctuations. Maisch, Seferovic, Ristic et al. ESC guidelines on pericardial diseases, Eur Heart J 2004

11 Constrictive pericarditis M-mode Echocardiography Mastouri et al. Expert Rev Cardiovasc Ther 2010

12 Constrictive pericarditis 2D-Echocardiography Exaggerated septal movements Mastouri et al. Expert Rev Cardiovasc Ther 2010

13 Constrictive Pericarditis Dilated, Non-collapsing Inferior Vena Cava

14 S. George Heart 2004 Unresolved issues in the management of tuberculous pericarditis SPECIFICITY OF ECHOCARDIOGRAPHY Liu et al. Am J Cardiol 2001

15 Guidelines on the Diagnosis and Management of Pericardial Diseases CONSTRICTIVE PERICARDITIS Doppler echocardiography MITRAL INFLOW DOPPLER, BOONYARATAVEJ ET AL. JACC 1998 Restricted filling of both ventricles with respiratory variation >25% over the AVvalves). In mixed constriction-restriction and increased atrial pressures respiratory changes are <25%. In atrial fibrillation flow velocity pattern is inconclusive, but hepatic diastolic vein flow reversal in expirium is observed. Provocation test with head-up tilting or sitting position with decrease of preload may unmask the constrictive pericarditis. Maisch, Seferovic, Ristic et al. ESC guidelines on pericardial diseases, Eur Heart J 2004

16 JACC 2012

17 Constrictive Pericarditis Hepatic Vein Expiratory Diastolic Reversal Insp Exp

18 Tissue Doppler in Constriction E normal to high in constriction, low in myocardial disease

19 Restrictive cardiomyopathy vs. constrictive pericarditis TISSUE DOPPLER ECHOCARDIOGRAPHY 11 pts 19 pts Peak early velocity of longitudinal expansion (peak Ea) of > 8.0 cm/s differentiated pts with constriction from restriction with 89% sensitivity and 100% specificity. (Rajagopalan et al. Am J Cardiol 2001)

20 Restrictive cardiomyopathy vs. constrictive pericarditis MITRAL ANNULUS REVERSUS 14 pts with CP, 10 RCM, 17 healthy controls The normal relationship between lateral mitral e and medial mitral e is REVERSED in constrictive pericarditis but NOT in restrictive cardiomyopathy Reuss et al. Eur J Echocardiography 2009

21 Constrictive pericarditis TDI and Pericardial Thickness 37 CP pts 35 RCM pts 70 controls Measurements of early diastolic mitral annular velocity (E') of septal annulus (SE'), E' of lateral mitral annulus (LE') and right lateral tricuspid annulus (RE') Choi et al. JACC Cardiovasc Imag 2011

22 Constrictive pericarditis TDI and Pericardial Thickness The ratio between lateral and septal E' was significantly reduced in CP pts (vs controls and RCM pts) Reduced lateral E' was correlated with the pericardial thickness on the respective sides. CP pts LE'/SE' 0.94 ± 0.17 RE'/SE' 0.81 ± 0.26 Normal controls LE'/SE' 1.36 ± 0.24 RE'/SE' 1.30 ± 0.32 RCM LE'/SE' 1.35 ± 0.31 RE'/SE' 1.96 ± 0.71 Choi et al. JACC Cardiovasc Imag 2011

23 ESC Abstract: 2113 The ratio between the lateral and septal Ea-velocities of the mitral annulus is significantly reduced in constrictive pericarditis in comparison to RCM T. Butz, L. Faber, C. Piper, G. Plehn, D. Horstkotte, H.J. Trappe, Bochum and Bad Oeynhausen, Germany 54 CP pts with heart failure of either proven pericardial (CP) or myocardial origin (27 with RCM; biopsy proven cardiac amyloidosis). TDI analysis of MA motion demonstrated decreased systolic and diastolic velocities in pts with RCM as well as a reduced E'lateral/E'septal ratio in CP: CP RCM P S' septal MA: 7.1±2.4 cm/s 4.2±1.6 cm/s <0.001 S' lateral MA: 6.8±2.2 cm/s 4.4±1.9 cm/s <0.001 E' on the septal M 13.7±5.4 cm/s 4.3±1.8 cm/s <0.001 E' on the lateral MA 11.4±4.2 cm/s 4.9±2.0 cm/s <0.001 E'lateral/E'septal 0.9± ±0.3 <0.01

24 Restrictive cardiomyopathy vs. constrictive pericarditis SPECKLE TRACKING Markedly attenuated early diastolic rate of untwisting in CP vs. RCM Sengupta et al. JACC Imaging 2008

25 ESC Abstract: 2112 Left and right ventricular mechanics before and after pericardiectomy in pts with constrictive pericarditis K. Kusunose, A. Dahiya, M.C. Alraies, D. Kwon, T.H. Marwick, A.L. Klein Cleveland Clinic - Cleveland - United States of America, 46 CP patients (41 men, mean age 58±13 years) Pre and post-operative echo examinations Longitudinal strain (LS) in LV and RV were calculated by 2D-ST Preoperative CMR examination No significant differences in LVEF, transmitral E wave and A wave and E/A before and after pericardiectomy. Septal, inferior, and anteroseptal wall LS did not change after pericardiectomy Lateral, anterior, posterior wall LS and RV free wall strain were increased. The ratio of lateral and septal LS normalized after pericardiectomy (0.83±+0.18 and 0.95±0.12 p<0.001).

26 Update on Constrictive Pericarditis Sensitivity and Specificity of Echocardiography Mookadam et al. Future Cardiol 2011

27 Restrictive cardiomyopathy vs. constrictive pericarditis CARDIAC CATHETERISATION RESTRICTIVE CARDIOMYOPATHY CONSTRICTIVE PERICARDITIS LVEDP often >5 mmhg greater than RVEDP, but may be identical RVEDP > 1/3 of RV systolic pressure RVEDP & LVEDP usually equal With inspiration increase in RV systolic pressure, decrease in LV systolic pressure RV systolic pressure <50 mmhg With expiration, opposite changes Mukhopadhyay IJC 2006

28 Restrictive cardiomyopathy vs. constrictive pericarditis CARDIAC CATHETERIZATION Hemodynamic changes common in both conditions Prominent X and Y descent on right atrial pressure curve Diastolic ventricular pressure waveform, "square root" or "dip and plateau" sign Equalisation of diastolic pressures (<5 mmhg) Increased mean atrial pressure > 10 mmhg

29 Constrictive pericarditis POSITIVE KUSSMAUL'S SIGN Hutchison`s Atlas of Pericardial Diseases Saunders 2009

30 Constrictive Pericarditis PERICARDIECTOMY PREDICTORS OF POOR SURVIVAL Prior radiation Renal insufficiency Pulmonary hypertension Poor LV systolic function (cardiac index <1.2 L/m 2 /min) Lower serum sodium level Advanced age Cachexia Shabetai & Nishimura UpToDate Online 14.2 Atrial fibrillation Hypoalbuminemia due to protein losing enteropathy Impaired hepatic function (chronic congestion or cardiogenic cirrhosis) Pericardial calcification had no impact on survival Bertog et al. JACC 2004

31 Effusive-constrictive pericarditis HEMODYNAMIC DIAGNOSIS Sagrista-Sauleda et al. N Engl J Med 2004

32 Update on Constrictive Pericarditis Sensitivity and Specificity of Cardiac Cath Mookadam et al. Future Cardiol 2011

33 N=100 pts JACC 2008

34 Restrictive cardiomyopathy vs. constrictive pericarditis ENDOMYOCARDIAL BIOPSY RESTRICTIVE CARDIOMYOPATHY May reveal specific cause of restrictive cardiomyopathy CONSTRICTIVE PERICARDITIS May be normal or show nonspecific myocyte Positive pathohistology = diagnostic (restriction) Negative pathohistology = diagnostic (constriction)

35 Update on constrictive pericarditis: echocardiography & cardiac catheterisation CONCLUSIONS Contemporary echocardiography (3D, Doppler, TDI, strain/strain rate) have increased the diagnostic yield and enabled risk stratification. Cardiac catheterisation is however still considered mandatory to confirm the diagnosis and potential comorbidities. Swan-Ganz catheterisation should be performed in all patients, and endomyocardial biopsy in unlclear cases.