Constrictive Pericarditis

1
Constrictive Pericarditis

• Nisha I. Parikh, MD MPH
• July 21st 2009
• Echo Conference

2
Summary of Talk

• Background
• Clinical features
• Echocardiographic diagnosis
• M-mode
• Doppler
• Constriction versus restriction
• Treatment and prognosis

3
Historical Perspective

• The history of constrictive pericarditis is
  replete with famous names in medicine
• Richard Lower described a patient with dyspnea
  and an intermittent pulse in 1669
• Lancisi first reported on the constrictive
  syndrome in 1828
• Corrigan described the pericardial knock in 1842
• Kussmaul described his sign and the associated
  paradoxical pulse in 1873.

4
Pericardium
Parietal and visceral layers
Usually 5-10 mL fluid
5
Pericardium

• When larger amounts of fluid accumulate
  (pericardial effusion) or when the pericardium
  becomes scarred and inelastic, one of three
  pericardial compressive syndromes may occur

6

• 1. Cardiac tamponade characterized by the
  accumulation of pericardial fluid under pressure.
• 2. Constrictive pericarditis result of scarring
  and consequent loss of elasticity of the
  pericardial sac. Typically chronic. The
  pathological changes are inflammation, sometimes
  calcification. Grossly, pericardium thicker than
  normal -80 of time.
• 3. Effusive-constrictive pericarditis
  characterized by constrictive physiology with a
  coexisting pericardial effusion, usually with
  tamponade.

7
Epidemiology

• 9 of patients with acute pericarditis for any
  reason go on to develop constrictive physiology.
• Acute pericarditis is only clinically diagnosed
  in 1 in 1,000 hospital admissions
• Frequency of a diagnosis of constrictive
  pericarditis is less than 1 in 10,000 hospital
  admissions.

8
Constrictive Pericarditis - HPI

• 67 presented with symptoms of heart failure
  (HF)
• 8 with chest pain
• 6 with abdominal symptoms
• 4 with atrial arrhythmia
• 5 with symptoms of cardiac tamponade

9
Constrictive Pericarditis - Etiology

• Idiopathic or viral 42 to 49
• Post cardiac surgery 11 to 37
• Post radiation therapy 9 to 31
• Connective tissue disorder 3 to 7
• Postinfectious (tuberculous or purulent
  pericarditis) 3 to 6
• Miscellaneous causes (malignancy, trauma,
  drug-induced, asbestosis, sarcoidosis, uremic
  pericarditis) 1 to 10

10
Constricitve Pericarditis - PE

• Elevated JVP
• Peripheral edema
• Ascites
• Hepatomegaly
• Pleural effusion
• S3
• Pulsus paradoxus
• Kussmauls sign
• Cachexia- late stages

11
Kussmauls sign

• The observation of a jugular venous pressure
  (JVP) that rises with inspiration.
• Respiratory variation in intrathoracic pressure
  with inspiration is not transmitted to the heart
  chambers.

12
Physiology of constriction

• In the pericardial compressive syndromes, the
  pericardium is inelastic and total cardiac volume
  cannot change
• The result is enhanced ventricular interaction
  or ventricular interdependence

13
Physiology of constriction

• Pericardial constriction leads to impairment of
  ventricular filling, usually affecting all four
  cardiac chambers, preventing ventricular filling
  in mid and late diastole.
• As a result, the majority of ventricular filling
  occurs rapidly in early diastole and the
  ventricular volume does not increase after the
  end of the early filling period.

14
Pericardial Effusion

• M-Mode

15
Pericardial effusion

• M-mode Cannot determine volume of accumulated
  fluid accurately

16
Pericardial thickening

• This can be visualized by transesophageal echo
  (often requiring multiple views), however, this
  is best seen using other imaging modalities such
  as CT or MRI.

17
Calcified Pericardium
18
Pericardial calcifications CT
19
Pericardial calcification on echo

• Normal pericardium is highly reflective
• Bright pericardial echo cannot alone diagnose
  constrictive pericarditis

20
Specific echo exam for constriction

• Neither sensitive nor specific
• Must diagnose via a combination of physical exam/
  history findings and echo findings

21
M-mode findings in constriction

• Abrupt relaxation of the posterior wall with
  flattening of endocardial motion during diastole
• Abnormal septal motion
• Mimics conduction disturbances
• Mimics RV p/v overload
• Early diastolic notching followed by paradoxical
  and then normal motion of the ventricular septum

22
diastolic septal bounce

• Thought to be due to the rapid filling during
  early diastole leading to asymmetrical filling of
  the right and left ventricals which creates a
  fluctuating pressure gradient that manifests as
  an abrupt shift of the septum.

23
? Subtle septal bounce
24
Bouncy Septum
25
Dilation and lack of respiratory variation in IVC
26
Doppler echo findings in constriction

• Mitral inflow
• Exaggerated E/A ratio
• Short deceleration time
• Exaggerated respiratory variation in E-wave
  velocity gt25
• Seen more reliably when patients are well
  hydrated
• Can also be seen in pulmonary disease
• Hepatic Veins
• Expiratory increase in diastolic flow reversal

27
Hepatic flow reversal

• Secondary to elevated right atrial pressures.
  Hepatic vein doppler reveals pressure tracings
  significant for a prominant "a" wave and
  prominent "y" descent.

28
Atrial dilation

• Mild
• Secondary to elevated atrial pressures
• More severe atrial dilatation seen in
  restrictive cardiomyopathy.

29
Constrictive Pericarditis other tests?

• CT not very sens/spec
• Cardiac MRI growing in favor
• BNP usually only a mild elevation due to
  limited wall stretch
• Cath GOLD STANDARD

30
Effusive constrictive pericarditis

• Combination of tamponade and constriction
• Common etiologies malignancy and radiation
  therapy
• Pericardial thickening may prevent RA collapse
• Hemodynamic compromise and JVD persist even after
  tap

31
Effusive Constrictive Pericarditis- Prospective
Study

• Methods From 1986 through 2001, all patients with
  effusiveconstrictive pericarditis were
  prospectively evaluated. Combined
  pericardiocentesis and cardiac catheterization
  were performed in all patients, and
  pericardiectomy was performed in those with
  persistent constriction. Follow-up ranged from 1
  month to 15 years (median, 7 years).
• Results
• 1184 patients with pericarditis were evaluated,
• 218 with tamponade.
• 190 underwent combined pericardiocentesis and
  catheterization.
• Fifteen of these patients had effusiveconstrictiv
  e pericarditis and were included in the study.
  All patients presented with clinical tamponade
• however, concomitant constriction was recognized
  in only seven patients.
• At catheterization, all patients had elevated
  intrapericardial pressure (median, 12 mm Hg
  interquartile range, 7 to 18) and elevated right
  atrial and end-diastolic right and left
  ventricular pressures. After pericardiocentesis,
  the intrapericardial pressure decreased (median
  value, 5 mm Hg interquartile range, 5 to 0),
  whereas right atrial and end-diastolic right and
  left ventricular pressures, although slightly
  reduced, remained elevated, with a dipplateau
  morphology. The causes were diverse, and death
  was mainly related to the underlying disease.
• Pericardiectomy was required in seven patients,
  all of whom had involvement of the visceral
  pericardium. Three patients had spontaneous
  resolution.
• Conclusions Effusiveconstrictive pericarditis is
  an uncommon pericardial syndrome that may be
  missed in some patients who present with
  tamponade. Although evolution to persistent
  constriction is frequent, idiopathic cases may
  resolve spontaneously. In our opinion, extensive
  epicardiectomy is the procedure of choice in
  patients requiring surgery.

32
Constriction versus Restriction

• Restrictive Cardiomyopathy
• Pure diastolic dysfunction
• Systolic function preserved
• Usually due to infiltrative process
• Several echo signs overlap with constrictive
  pericarditis

33
Restrictive versus Constrictive
Restrictive Cardiomyopathy Constrictive Pericarditis
History Infiltrative disease Pericarditis, trauma, surgery
Mantle radiation, cardiac surgery Mantle radiation, cardiac surgery
Respiratory effects No bulging Increased ventricular interaction- bulging of the septum towards LV
CMR C/w infiltrative disease Increased pericardial thickness (gt 5 mm
34
Comparison of Pericardial Constriction and
Restrictive Cardiomyopathy
Constrictive Pericarditis Restrictive Cardiomyopathy
Right Atrial Pressure
RV/LV filling pressures RVLV LV gt RV
PASP Mild elevation 35-40 mmHg Moderate-to-severe ( 60 mmHg)
2D Echo Pericardial thickening, no effusion LVH, normal systolic function
Doppler Echo E gt a on LV inflow Prominent y descent in hepatic vein Pulm venous flow prominent a wave, reduced systolic phase Resp variation in IVRT and E velocity Atria mildly enlarged Early in disease E lt a Late in disease E gt a Constant IVRT Absence of significant respiratory variation Marked enlarged atria
35
Tissue Doppler to distinguish entities
Dimunitive E lt8 cm/s
E similar to E gt12cm/s
36
Treatment

• Definitive treatment is surgical
• Earlier the better
• Extensive decortication favored, especially at
  the diaphragmatic-ventricular contact regions. 
• Complications
• excessive bleeding
• atrial and ventricular arrhythmias
• ventricular wall ruptures.
• Published surgical mortality 5-15.
• Perioperative mortality rate (within 30 days) was
  found to be 6.1. 
• progressive heart failure
• Sepsis
• renal failure
• respiratory failure
• arrhythmia

37
Post-op course

• 80-90 achieve NYHA class I or II
  postoperatively.
• Abnormal diastolic filling (which can be
  correlated with clinical status) often remains
• Only 60 of patients have complete normalization
  of cardiac hemodynamics.
• In 58 patients who underwent total pericardectomy
  for constriction, 30 still had some significant
  symptoms after 4 years.
• These patients were more likely to have a
  persistent restrictive or constrictive pattern to
  their transmitral and transtricuspid Doppler
  signals as determined by respiratory recording.

38
Survival post pericardiectomy

• Long-term survival after pericardiectomy depends
  on the underlying cause.
• Idiopathic with best prognosis (88 survival at 7
  yrs),
• Constriction due to cardiac surgery (66 at 7
  years).
• Worst prognosis occurs in postradiation
  constrictive pericarditis (27 survival at 7
  years). (likely represents confounding
  comorbidities). 
• Predictors of poor outcomes in patients who
  undergo pericardiectomy
• history of prior radiation
• worsening renal function
• pulmonary hypertension
• systolic heart failure
• Hyponatremia
• advanced age.

39

• Thanks
• For
• Listening!!