Minimaster Ecocardiografia: Quadri costrittivi

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Minimaster EcocardiografiaQuadri costrittivi

• M.Imazio
• Dipartimento di Cardiologia, ospedale Maria
  Vittoria, Torino

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Recommendations for echocardiography in
pericardial diseases (class I)

1. Patients with suspected pericardial disease,
   including effusion, constriction, or
   effusive-constrictive process.
2. Patients with suspected bleeding in the
   pericardial space, eg. trauma, perforation, etc.
3. Follow-up study to evaluate recurrence of
   effusion or to diagnose early constriction.
   Repeat studies may be goal directed to answer a
   specific clinical question.
4. Pericardial friction rub developing in acute
   myocardial infaction accompanied by symptoms such
   as persistent pain, hypotension, and nausea.

AHA/ACC/ASE 2003. Circulation 2003,1081146-62
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Etiology of constrictive pericarditis
Idiopathic or viral 42-49
Following cardiac surgery (risk of CP0.025-0.15) 11-37
Following radiation-therapy 9-31
Connective tissue disease 3-7
Post-infectious (tbc/purulent) 3-6
Other (malignancy, trauma, uremic) 1-10
Standford University (95 pts) Am Heart J
1987113354 Mayo Clinic (135 pts) Circulation
1999,1001380 Cleveland Clinic (163 pts) JACC
2004431445
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Parallel motion of the epicardium and the
pericardium

• TTE is not sensitive for detection of pericardial
  thickening.
• Pericardial thickening may be asimmetric.

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Septal notch and reduced motion of PW

• M-mode
• reduced posterior motion of LV posterior wall
  endocardium in diastole (lt2mm)
• Brief rapid posterior motion of the LV septum in
  early diastole

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M-mode echocardiography

1. Parallel motion of the epicardium and the
   pericardium
2. Septal notch in early diastole
3. Flattened posterior wall of LV myocardium
4. Diminished A wave of the mitral valve and
   premature pulmonary valve opening

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2D-echo evidence of constriction

• No specific 2D-imaging findings (suspicion of
  pericardial thickening, mild atrial enlargement)

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Pericardial thickening and adhesion, plethoric IVC

• IVC plethoric (gt20mm) and unresponsive to
  respiration, hepatic veins dilated

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2D-echocardiography

1. Pericardial thickening and adhesion
2. Septal bounce abrupt transient rightward
   movement
3. IVC plethoric and unresponsive to respiration
   hepatic veins dilated
4. LV and RV size decreased
5. Mild atrial enlargement

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Pericardial thickness measured by TEE
Mean normal thickness 1.2/-0.8mm, in CP
thickness3mm
Ling LH et al. JACC 1997291317-23
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Doppler studies to diagnose constriction
Hatle LK et al. Circulation 198979357-70 Oh JK
et al. J Am Coll Cardiol 199423154-62
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E/Agt1.5
?Elt10
?Egt25
?Elt10
?DRlt20D
?DR(i)gt20D
?DR(e)gt25D
Oh JK et al. J Am Coll Cardiol 199423154-62
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A variationgt18 in peak D differentiate CP and
R-CMP with a 79 sensitivity and 91 specificity,
a variationgt10 in peak E shows a 84 sensitivity
and 91 specificity
Am J Cardiol 20018786-94
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A value of peak Eagt8cm/sec differentiated pts
with CP vs. restrictive CMP with a 89
sensitivity and 100 specificity
CP
Restrictive CMP
Am J Cardiol 20018786-94
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A flow-propagation slope gt100cm/sec
differentiated pts with CP vs. restrictive CMP
with a 74 sensitivity and 91 specificity
CP
Restrictive CMP
Am J Cardiol 20018786-94
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Am J Cardiol 20018786-94
Doppler method Sensitivity Specificity
Doppler peak E 10 84 91
Doppler peak D 18 79 91
TDI peak Ea 8.0cm/s 89 100
A slope100cm/s (Color Doppler M-mode) 74 91
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Early diastolic MV and PV velocity increase after
a long filling interval (long RR) in pts in AF
without CP
JACC 2001371936-42
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A decrease in the MV-E and PV-D velocities after
a long filling interval (long RR) and the onset
of inspiration in pts in AF with CP
JACC 2001371936-42
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Distinguish constriction from restriction
Imazio M, Trinchero R. Ital Heart J
20045(11)803-17
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Retrospective review from Mayo Clinic in 212 pts
submitted to pericardiectomy 36 pts (16.9) had
resolution of constriction. Resolution occurred
at an average of 8.3months.
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92 had at lest 1 symptom
A trial of conservative therapy in pts with CP
features and who are stable is warranted before
pericardiectomy
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Occult constriction is identified following iv
administration of 1000ml of normal saline over 6
to 8 minutes.
Circulation 197756924-30
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26/143 pts (18) thickness 2mm. Causes
previous cardiac surgery (42), irradiation
(19), previous AMI (12), and idiopathic (12)
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Effusive-constrictive pericarditis
Diagnostic criterion tamponade that evolved into
constriction (with failure of the right atrial
pressure to fall by 50 or more or to a level
below 10mmHg after intrapericardial pressure was
lowered to near 0mmHg by pericardiocentesis).
15/190 consecutive pts with cardiac tamponade
(7.8)
Sagrista-Sauleda J et al. NEJM 2004350469-75
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Mixed forms constriction plus restriction
1. Diastolic filling remains abnormal in many
cases 2. Diastolic abnormalities correlate with
symptoms and longer preoperative course
Before (A) and after pericardiectomy (B)
JACC 1999331182-8
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JACC 2004431445-52
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Echocardiographic steps

1. Look for evidence of pericardial thickening
2. Evaluate for anatomic evidence of constriction
3. Perform Doppler studies to diagnose constriction
4. Distinguish constriction from restriction
5. Identify peculiar forms of constriction

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Identify peculiar forms of constriction

1. Classical pericardial constriction (thickened
   pericardium)
2. Transient pericardial constriction
3. Occult pericardial constriction
4. Constriction with normal pericardial thickness
5. Effusive-constrictive pericarditis
6. Mixed forms of constriction/restriction