Constriction vs Restriction Case-based Discussion
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1 Mayo Clinic Department of Cardiovascular Diseases Mayo Clinic Echocardiography Review Course for Boards and Recertification Constriction vs Restriction Case-based Discussion Jae K. Oh, MD Samsung Professor of CV Diseases Echo Hawaii MFMER slide-1 Learning Objectives Based 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 Mixed diseases Interventricular dependence of other causes 2016 MFMER slide-2 1
2 Restriction vs Constriction Paradoxical DHF or HFpEF 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 CP MFMER slide MFME Hemodynamics of Myocardial Disease Concordant change in PCWP and LVDP 80 LV 40 PCW 0 Inspiration Expiration Inspiration Hatle et al. Circ MFMER CP slide MFMER slide-4 2
3 Constrictive Pericarditis E E Mitral Inflow vs Cath 1. Dissociation between intrathoracic and intracardiac pressures 2. Interventricular Dependence CP MFMER slide-5 Hemodynamics in Constriction Intracardiac pressure Δ < intrathoracic pressure Δ Interventricular dependence CP MFMER slide-6 3
4 Echo Dx of Constriction Abnormal Septal Motion 2. Restrictive Mitral Inflow with Respiratory Variation > 25% 3. Hepatic Vein Diastolic Flow Reversals with Expiration Mitral Inflow Hepatic vein Insp Exp Hatle, Appleton Circ 1989, Oh, Hatle JACC 1994, Oh, Circ MFMER slide-7 Constriction Abnormal septal motion Interventricular Dependence Consider constriction if there is septal motion abnormality in patients with HF and preserved EF (HFpEF) Inspir Expir 2016 MFMER slide-8 4
5 Tissue Doppler in Constriction vs Restriction E normal to high in constriction, low in myocardial disease 2016 MFMER slide-9 Normal vs RCM vs CP Medial Mitral e velocity (LV Relaxation) Normal RCM CP Medial e 13 cm/s Medial e 3 cm/s Medial e 14 cm/s Usually > Lateral e (Annulus Reversus) 2011 MFME 2016 MFMER slide-10 5
6 Septal motion abnormality Mayo Echo Diagnostic Criteria MV Flow Velocity Restrictive (E/A >1) Medial e 8 cm/s Hepatic Vein Diastolic reversal with expiration Sensitivity 87 % Specificity 91 % Welch et al Circ Imaging MFMER slide-11 Illustrative Cases 2016 MFMER slide-12 6
7 71 yo man with RUQ discomfort and dyspnea 2 years after CABG Physical Examination JVP elevation Prominent S3 Peripheral edema CT was obtained: Calcified Pericardium 2016 MFMER slide yo man with calcified pericardium Referred for Pericardiectomy Cardiac Cath Normal Coronaries Elevated RAP, RVEDP, LVEDP Equalized LV/RV EDP 2016 MFMER slide-14 7
8 71 year old man with calcified pericardium Referred for Pericardiectomy Mitral inflow E= 0.8 A= 0.2 Medial e = 3 cm/s What would you do next? 1= Pericardiectomy 2= HF Medical Rx 3= Myocardial Biopsy 4= MRI Lateral e = 4 cm/s 2016 MFMER slide year old man with calcified pericardium MRI : Patchy myocardial delayed enhancement and increased wall thickness Cardiac Amyloidosis 2016 MFMER slide-16 8
9 Constrictive Pericarditis in the Modern Era Novel Criteria for Diagnosis in the Cardiac Cath Laboratory (Talreja, Nishimura, Oh, Holmes. Jan JACC) Discordant change Restriction(RMC) Concordant change Constriction 2016 MFMER slide-17 An from a junior staff at a major MC 52 year old man waiting for heart transplantation (Had Echo, MRI, and cardiac cath performed) Dx= RCM Diastolic Reversal Flow with Expiration Medial e = 20 cm/sec 2016 MFMER slide-18 9
10 . 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 2016 MFMER slide-19 Explanted Heart 2016 MFMER slide-20 10
11 67 yo man with severe aortic stenosis and HF Came to Valve Clinic for AVR (LFLG Severe AS) LVOT D = 1.9 cm LVOT TVI = 21cm MG 26 mmhg TVI 76 Stroke volume = (1.9) 2 x x 21 = 60 cc AVA = 60 / 76 = 0.79 cm MFMER slide year old man with AS and heart failure Mitral Annulus Tissue Doppler E Velocity Medial E = 100 cm/s Medial e = 9 cm/s 1. OK for aortic stenosis 2. Not OK for AS 3. Does not matter Lateral Lateral e = 6 cm/s 2016 MFMER slide-22 11
12 Tissue Doppler and Strain Imaging in Constriction (Annulus Reversus) Medial e 15 cm/s Lateral e = 10 cm/s 2016 MFMER slide year old man with AS and Constriction Hepatic Vein Doppler c/w constriction Radiation Heart Disease Circulation CV Imaging MFMER slide-24 12
13 Heart failure with ascites and leg edema 1= Severe TR 2=Constriction 3= TR + CP 4= TR and RV dysfunction 2011 MFMER slide MFMER slide-25 Annulus Reversus Severe TR and CP Medial e = 12 cm/sec Lateral e = 9 c/sec 2011 MFMER slide MFMER slide-26 13
14 Constriction or Myocardial Disease? Diagnostic Algorithm Medial e 12 cm/s Medial e 5 cm/s Syed, Schaff, Oh Nature Review Sep MFMER slide-27 Take Home Point :Restriction or Constriction? Diagnosis based on Hemodynamics Medial e = 5 cm/s Medial e = 11 cm/s 2016 MFMER slide-28 14
15 Thanks for listening! 2016 MFMER slide-29 E velocity is inversely proportional to pericardial thickness in the AV groove JACC CV Imaging June MFMER slide MFMER slide-30 15
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