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 2017 2016 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
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 CP983059-3 2016 MFMER slide-3 2011 MFME Hemodynamics of Myocardial Disease Concordant change in PCWP and LVDP 80 LV 40 PCW 0 Inspiration Expiration Inspiration Hatle et al. Circ 1989 2011 MFMER CP1105201-1 slide-4 2016 MFMER slide-4 2
Constrictive Pericarditis E E Mitral Inflow vs Cath 1. Dissociation between intrathoracic and intracardiac pressures 2. Interventricular Dependence CP992397-39 2016 MFMER slide-5 Hemodynamics in Constriction Intracardiac pressure Δ < intrathoracic pressure Δ Interventricular dependence CP1051850-19 2016 MFMER slide-6 3
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 Mitral Inflow Hepatic vein Insp Exp Hatle, Appleton Circ 1989, Oh, Hatle JACC 1994, Oh, Circ 1997 2016 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
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
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 2014 2016 MFMER slide-11 Illustrative Cases 2016 MFMER slide-12 6
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-13 71 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
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-15 71 year old man with calcified pericardium MRI : Patchy myocardial delayed enhancement and increased wall thickness Cardiac Amyloidosis 2016 MFMER slide-16 8
Constrictive Pericarditis in the Modern Era Novel Criteria for Diagnosis in the Cardiac Cath Laboratory (Talreja, Nishimura, Oh, Holmes. Jan. 2008 JACC) Discordant change Restriction(RMC) Concordant change Constriction 2016 MFMER slide-17 An e-mail 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
. 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
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 0.785 x 21 = 60 cc AVA = 60 / 76 = 0.79 cm 2 2016 MFMER slide-21 67 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
Tissue Doppler and Strain Imaging in Constriction (Annulus Reversus) Medial e 15 cm/s Lateral e = 10 cm/s 2016 MFMER slide-23 67 year old man with AS and Constriction Hepatic Vein Doppler c/w constriction Radiation Heart Disease Circulation CV Imaging 2015 2016 MFMER slide-24 12
Heart failure with ascites and leg edema 1= Severe TR 2=Constriction 3= TR + CP 4= TR and RV dysfunction 2011 MFMER slide-25 2016 MFMER slide-25 Annulus Reversus Severe TR and CP Medial e = 12 cm/sec Lateral e = 9 c/sec 2011 MFMER slide-26 2016 MFMER slide-26 13
Constriction or Myocardial Disease? Diagnostic Algorithm Medial e 12 cm/s Medial e 5 cm/s Syed, Schaff, Oh Nature Review Sep 2014 2016 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
Thanks for listening! oh.jae@mayo.edu 2016 MFMER slide-29 E velocity is inversely proportional to pericardial thickness in the AV groove JACC CV Imaging June 2011 2011 MFMER slide-30 2016 MFMER slide-30 15