Constrictive pericarditis versus restrictive cardiomyopathy: a reappraisal and update of diagnostic criteria

Constrictive pericarditis in the new millennium

Constrictive pericarditis (CP) is a complex clinical syndrome in which an inflamed pericardium becomes fibrotic and non-compliant, ultimately reducing cardiac pump performance. Although we have known about CP for centuries, it remains a challenge to diagnose. Recent advances in cardiac imaging, along with an expanding armamentarium of treatment options, have improved the quality and precision of care for patients with CP. This article reviews important historical and contemporary perspectives on the pathophysiology of CP, as well as our approach to diagnosis and management.

Constrictive pericarditis: rare but reversible cause of protein losing enteropathy

Constrictive pericarditis is uncommon in children. It results from scarring and consequent loss of the normal elasticity of the pericardial sac and is most commonly seen as a late sequelae of idiopathic or viral pericarditis. Here, we report a case of protein losing enteropathy as a complication of constrictive pericarditis in a 2-year-old child. Pericardial thickening was demonstrated by cardiac MRI and subsequent pericardiectomy led to remarkable improvement and resolution of protein losing enteropathy.

Short term clinical and echocardiography outcomes of pericardiectomy in constrictive pericarditis

Introduction: Tuberculous pericarditis continues to be a leading cause of chronic constrictive pericarditis (CCP) in developing countries. Echocardiography plays a key role in the assessment and diagnosis.

Methods: Twelve patients who underwent pericardiectomy for CCP in last 18 months of the study period were subjected to clinical and New York Heart Association (NYHA) functional class assessment along with comprehensive echocardiographic evaluation. The data were compared with their preprocedural status.

Results: Significant reduction was noted in the incidence of inferior vena cava (IVC) congestion(P < 0.001) and mean left atrial (LA) size from 43.75 ± 4.43 mm to 31.58 ± 3.03 mm (P < 0.001), post pericardiectomy.Respiratory variation of 34.17 ± 8.76 % in the mitral E velocity was significantly reduced to 17 ± 3.69 % (P < 0.001) after surgery. Similarly, respiratory variation in tricuspid E velocities showed significant reduction from 62.17 ± 13.16 % to 32.58 ± 4.7 % (P < 0.001).Prior to pericardiectomy, medial e’ and lateral e’ mitral annular velocities was 15.5±1.24 cm/sec and13.08 ± 1.08 cm/sec, respectively. Following surgery, the medial e’ and lateral e’ was 12.5±1.17 cm/sec(P = 0.001) and 15.42±1.83 (P = 0.004), respectively.

Conclusion: Echocardiography provides useful insight in pericardial constriction hemodynamics and worthwhile effects of pericardiectomy.

Multimodality Imaging in Restrictive Cardiomyopathies: An EACVI expert consensus document In collaboration with the "Working Group on myocardial and pericardial diseases" of the European Society of Cardiology Endorsed by The Indian Academy of Echocardiography

Restrictive cardiomyopathies (RCMs) are a diverse group of myocardial diseases with a wide range of aetiologies, including familial, genetic and acquired diseases and ranging from very rare to relatively frequent cardiac disorders. In all these diseases, imaging techniques play a central role. Advanced imaging techniques provide important novel data on the diagnostic and prognostic assessment of RCMs. This EACVI consensus document provides comprehensive information for the appropriateness of all non-invasive imaging techniques for the diagnosis, prognostic evaluation, and management of patients with RCM.

Constrictive pericarditis: diagnosis, management and clinical outcomes

Constrictive pericarditis (CP) is a form of diastolic heart failure that arises because an inelastic pericardium inhibits cardiac filling. This disorder must be considered in the differential diagnosis for unexplained heart failure, particularly when the left ventricular ejection fraction is preserved. Risk factors for the development of CP include prior cardiac surgery and radiation therapy, but most cases are still deemed to be idiopathic. Making the diagnosis may be challenging and requires meticulous echocardiographic assessment, often supplemented by cross-sectional cardiac imaging and haemodynamic catheterisation. The key pathophysiological concepts, which serve as the basis for many of the diagnostic criteria, remain: (1) dissociation of intrathoracic and intracardiac pressures and (2) enhanced ventricular interaction. Complete surgical pericardiectomy is the only effective treatment for chronic CP. A subset of patients with subacute inflammatory CP, often identified by cardiac MRI, may respond to anti-inflammatory treatments.

Invasive Hemodynamics of Pericardial Disease

Pericardial diseases can be classified broadly as 3 entities: acute pericarditis, cardiac tamponade, and constrictive pericarditis. These disorders can be diagnosed and managed with noninvasive studies following a comprehensive history and physical examination, without the need for cardiac catheterization in most patients. Despite the advances in noninvasive cardiac imaging, there are limitations to their diagnostic accuracy. The invasive hemodynamic study offers the advantage of simultaneous, direct pressure measurement across multiple chambers, with direct examination of blood flow. Herein, the authors review the techniques for obtaining and interpreting invasive hemodynamic data in patients with suspected pericardial disease.

Echocardiographic parameters in clinical responders to surgical pericardiectomy - A single center experience with chronic constrictive pericarditis

BACKGROUND

Chronic constrictive pericarditis (CCP) is the end result of chronic inflammation of the pericardium. Developing countries continue to face a significant burden of CCP secondary to tuberculous pericarditis. Surgical pericardiectomy offers potential cure. However, there is paucity of echocardiography data in post-pericardiectomy patients vis-a-vis their clinical status. We studied the changes in multiple echocardiographic parameters in these patients before and after pericardiectomy.

METHODS

Twenty-three patients (14 men, 9 women) who underwent pericardiectomy for CCP in the last 5 years (from January 2009 to December 2014) were subjected to detailed clinical and echocardiographic evaluation during the study period (between June 2013 and December 2014). Patients with residual symptoms of NYHA class II and below were considered as 'responders'. The data thus obtained were compared to the pre-operative parameters.

RESULTS

After pericardiectomy, the incidence of vena caval congestion decreased from 100% to 15% (p<0.001). There was significant reduction in the mean left atrial size from 39.33±10.52mm to 34.45±10.08mm (p<0.001) and also the ratio of left atrium to aortic annulus from 1.93 to 1.69 (p<0.001) among 'responders' to pericardiectomy. Septal bounce was observed to persist in 5 (25%) patients after pericardiectomy. There was significant respiratory variation of 39.23±15.11% in the mitral E velocity before pericardiectomy. After pericardiectomy, this variation reduced to 14.43±7.76% (p<0.001). There was also significant reduction in the respiratory variation in tricuspid E velocities from 31.33±18.81% to 17.35±16.26% (p<0.001). After pericardiectomy, the mean ratio of mitral annular velocities, medial e': lateral e', reduced from 1.08 to 0.87 (p<0.03). The phenomenon of 'annulus reversus' was found to persist in 6 'responders', thereby reflecting a 50% reduction in its incidence after pericardiectomy (p<0.001). The ratio of mitral E to medial e' (E/e') increased from 4.21±1.35 before pericardiectomy to 6.91±2.62 after pericardiectomy (p=0.001).

CONCLUSION

Among clinical responders to surgical pericardiectomy, echocardiographic assessment revealed a significant reduction in vena caval congestion, LA size, ratio of LA to aortic annulus, septal bounce, respiratory variation in mitral and tricuspid E velocities, mitral annular medial e' and the phenomenon of annulus reversus. Also, there was a significant rise in minimum tricuspid and mitral E velocities and the E/e' ratio.

NT pro B type natriuretic peptide levels in constrictive pericarditis and restrictive cardiomyopathy

BACKGROUND

The differentiation of constrictive pericarditis (CP) from restrictive cardiomyopathy (RCM) may be clinically difficult and may require multiple investigations. Even though brain natriuretic peptide (BNP) is shown to be higher in patients with RCM as compared to CP, the clinical utility is not fully established especially in Indian patients known to have advanced CP and myocardial involvement.

METHODS AND RESULTS

We measured NT-pro-BNP levels in 49 patients suspected of having either CP or RCM, diagnosed on the basis of echocardiography, computed tomography, magnetic resonance imaging, endomyocardial biopsy and cardiac catheterization data as needed. Twenty nine patients (Mean age - 26 yrs, 24 males) had CP and 20 patients (Mean age - 39 yrs, 14 males) had RCM. The median plasma NT-pro-BNP levels were significantly higher in RCM as compared to CP [1775 (208-7500) pg/ml vs 124 (68-718) pg/ml, respectively; p = 0.001]. A cut off value of 459 pg/ml had sensitivity, specificity and overall accuracy of 90%, 86% and 88% respectively, for differentiating CP from RCM.

CONCLUSIONS

The NT-pro-BNP levels are significantly elevated in RCM as compared to CP.

Diagnostic concordance of echocardiography and cardiac magnetic resonance-based tissue tracking for differentiating constrictive pericarditis from restrictive cardiomyopathy

BACKGROUND

Variations in longitudinal deformation of the left ventricle have been suggested to be useful for differentiating chronic constrictive pericarditis (CP) and restrictive cardiomyopathy (RCM). We assessed left ventricular mechanics derived from cardiac magnetic resonance (CMR) cine-based and 2-dimensional echocardiography-based tissue tracking to determine intermodality consistency of diagnostic information for differentiating CP from RCM.

METHODS AND RESULTS

We retrospectively identified 92 patients who underwent both CMR and 2-dimensional echocardiography and who had a final diagnosis of CP (n=28), RCM (n=30), or no structural heart disease (n=34). Global longitudinal strain from long-axis views and circumferential strain from short-axis views were measured on 2-dimensional echocardiographic and CMR cine images using the same offline software. Logistic regression models with receiver operating characteristics curves, continuous net reclassification improvement, and the integrated discrimination improvement (IDI) were used for assessing the incremental predictive performance. Global longitudinal strain was higher in patients with CP than in those with RCM (P<0.001), and both techniques were found to have similar diagnostic value (area under the curve, 0.84 versus 0.88 for CMR and echocardiography, respectively). For echocardiography, the addition of global longitudinal strain to respiratory septal shift and early diastolic mitral annular velocity resulted in improved continuous net reclassification improvement (P<0.001 for both) and integrated discrimination improvement (P=0.005 and 0.024) for both models. Similarly, for CMR, the addition of global longitudinal strain to septal shift and pericardial thickness resulted in improved continuous net reclassification improvement (P<0.001 for both) and integrated discrimination improvement (P=0.003 and <0.001).

CONCLUSIONS

CMR and echocardiography tissue tracking-derived left ventricular mechanics provide comparable diagnostic information for differentiating CP from RCM.

Hiding in plain sight; constrictive pericarditis

We present a case of constrictive pericarditis that was especially difficult to diagnose. The patient presented with generalised oedema, dyspnoea and pleural effusions. History was significant for prior polysubstance abuse but was otherwise unremarkable. Physical examination revealed only jugular venous distention. CT demonstrated a normal pericardium with pleural effusions. Echocardiography showed mildly elevated right ventricular pressures with dyssynergic motion of the ventricular septum. No intervention was being carried out, but 1 month later further evaluation with a right and left heart catheterisation showed the classical square-root sign with equalisation of diastolic pressures in both ventricles as well as ventricular interdependence. Idiopathic constrictive pericarditis was thus diagnosed with a subsequent pericardial stripping which confirmed a thickened pericardium encasing the heart.

Disproportionate elevation of jugular venous pressure in pleural effusion

Constrictive pericarditis is characterized by elevation in jugular venous pressure disproportionate to the severity of concurrent breathlessness. As pleural effusion may be an associated feature it is recommended that jugular venous pressure should be documented in all patients who present with pleural effusion.

Cardiovascular magnetic resonance in the evaluation of heart failure: a luxury or a need?

Heart failure is a common syndrome with multiple causes. Cardiovascular magnetic resonance (CMR), using the available range of technique, is establishing itself as the gold standard noninvasive test for determining the underlying causes, and adding prognostic value, guiding therapy. Progress is continuing and rapid with promising new techniques such as diffuse fibrosis assessment. This article discusses the diverse roles of CMR in heart failure.

Canadian Cardiovascular Society Consensus Conference guidelines on heart failure, update 2009: diagnosis and management of right-sided heart failure, myocarditis, device therapy and recent important clinical trials

The Canadian Cardiovascular Society published a comprehensive set of recommendations on the diagnosis and management of heart failure in January 2006. Based on feedback obtained through a national program of heart failure workshops and through active solicitation of stakeholders, several topics were identified because of their importance to the practicing clinician. Topics chosen for the present update include best practices for the diagnosis and management of right-sided heart failure, myocarditis and device therapy, and a review of recent important or landmark clinical trials. These recommendations were developed using the structured approach for the review and assessment of evidence adopted and previously described by the Society. The present update has been written from a clinical perspective to provide a user-friendly and practical approach. Specific clinical questions that are addressed include: What is right-sided heart failure and how should one approach the diagnostic work-up? What other clinical entities may masquerade as this nebulous condition and how can we tell them apart? When should we be concerned about the presence of myocarditis and how quickly should patients with this condition be referred to an experienced centre? Among the myriad of recently published landmark clinical trials, which ones will impact our standards of clinical care? The goals are to aid physicians and other health care providers to optimally treat heart failure patients, resulting in a measurable impact on patient health and clinical outcomes in Canada.

Mixed constrictive pericarditis and restrictive cardiomyopathy in a child: treatment guided by tissue Doppler imaging

Mixed lesions of restrictive cardiomyopathy and constrictive pericarditis have been reported rarely and represent a diagnostic and therapeutic dilemma. Restrictive cardiomyopathy has a poor prognosis with an average 2-year survival rate of less than 50% from the time of diagnosis. Heart transplantation is usually the only treatment option available. On the other hand, constrictive pericarditis may be surgically treated by pericardiectomy with low mortality. When these two lesions coexist, the inappropriate selection of treatment may be disastrous. We report a case of this mixed lesion in a child in which tissue Doppler echocardiography provided important information indicating that pericardectomy might be successful.

Constrictive pericarditis in the modern era: novel criteria for diagnosis in the cardiac catheterization laboratory

OBJECTIVES

This study sought to determine the clinical utility of a new catheterization criterion for the diagnosis of constrictive pericarditis (CP).

BACKGROUND

The finding of early rapid filling and equalization of end-diastolic pressures obtained by cardiac catheterization are necessary for the diagnosis of CP, but these findings are also present in patients with restrictive myocardial disease (RMD). Enhanced ventricular interaction is unique to CP.

METHODS

High-fidelity intracardiac pressure waveforms from 100 consecutive patients undergoing hemodynamic catheterization for diagnosis of CP versus RMD were examined. Fifty-nine patients had surgically documented CP and comprised group 1; the remaining 41 patients with RMD comprised group 2. The ratio of the right ventricular to left ventricular systolic pressure-time area during inspiration versus expiration (systolic area index) was used as a measurement of enhanced ventricular interaction.

RESULTS

There were statistically significant differences in the conventional catheterization criteria between CP and RMD, but the predictive accuracy of any of the criteria was <75%. The systolic area index had a sensitivity of 97% and a predictive accuracy of 100% for the identification of patients with surgically proven CP.

CONCLUSIONS

The ratio of right ventricular to left ventricular systolic area during inspiration and expiration is a reliable catheterization criterion for differentiating CP from RMD, which incorporates the concept of enhanced ventricular interdependence.

Is It Constrictive Pericarditis or Restrictive Cardiomyopathy? A Systematic Approach

In this case review, the authors propose a fluent diagnostic algorithm for the consideration and therapeutic approach to either constrictive pericarditis or restrictive cardiomyopathy. Additionally, while focusing on the differential diagnosis of these clinically vexing entities, the authors outline the therapeutic expectations from surgical pericardiectomy in constrictive pericarditis.

Constrictive pericarditis: A reminder of a not so rare disease

Constrictive pericarditis is a rare condition characterized by clinical signs of right heart failure subsequent to loss of pericardial compliance. The etiology of constrictive pericarditis has changed during the last decades in developed countries. While, in the past, tuberculosis and idiopathic pericardial constriction were the prevalent causes of the disease, cardiac surgery has become one of the main reasons for its development in recent years. However, cases defined as idiopathic constrictive pericarditis are still observed. In addition to the classical chronic and subacute forms, new presentations, such as effusive-constrictive, localized, transient, occult, and constrictive pericarditis with normal pericardial thickness, have been described. Although conservative treatment may alleviate the patient's symptoms, pericardiectomy remains the only definitive treatment for the disease. It is worth noting that the sooner the diagnosis of pericardial constriction is established, the better the outcome is. The pathophysiological features, clinical findings, diagnostic tools, and therapeutic approach to constrictive pericarditis are detailed in this review.

Doppler echocardiographic evaluation of pulmonary regurgitation facilitates the diagnosis of constrictive pericarditis

Diagnosing constrictive pericarditis (CP) remains a clinical challenge. Ventricular interdependence and dissociation of intrathoracic and intracardiac pressures are hallmark features that are readily recognized by invasive and noninvasive hemodynamics. The Doppler echocardiographic signal from pulmonic valve regurgitation depends on the relationship between pulmonary artery (intrathoracic) and right ventricular (intracardiac) pressure. Respiration-associated changes in this signal may aid in the evaluation of pericardial constriction. We demonstrate here that early diastolic cessation with inspiration can indicate a CP process. Early diastolic cessation with inspiration was shown to have correctly diagnosed CP in 70% of the patients in this study, with a sensitivity of 77%, specificity of 64%, positive predictive value of 67%, and negative predictive value of 75%. This noninvasive insight into dissociation of intracardiac and intrathoracic pressures, although not sufficient on its own, may be a valuable tool for aiding in the diagnosis of CP.

Cardiac tamponade, constrictive pericarditis, and restrictive cardiomyopathy

The pericardium envelopes the cardiac chambers and under physiological conditions exerts subtle functions, including mechanical effects that enhance normal ventricular interactions that contribute to balancing left and right cardiac outputs. Because the pericardium is non-compliant, conditions that cause intrapericardial crowding elevate intrapericardial pressure, which may be the mediator of adverse cardiac compressive effects. Elevated intrapericardial pressure may result from primary disease of the pericardium itself (tamponade or constriction) or from abrupt chamber dilatation (eg, right ventricular infarction). Regardless of the mechanism leading to increased intrapericardial pressure, the resultant pericardial constraint exerts adverse effects on cardiac filling and output. Constriction and restrictive cardiomyopathy share common pathophysiological and clinical features; their differentiation can be quite challenging. This review will consider the physiology of the normal pericardium and its dynamic interactions with the heart and review in detail the pathophysiology and clinical manifestations of cardiac tamponade, constrictive pericarditis, and restrictive cardiomyopathy.

Differentiation of constrictive pericarditis from restrictive cardiomyopathy using mitral annular velocity by tissue Doppler echocardiography

This study evaluated the diagnostic role of early diastolic mitral annular velocity (E') by tissue Doppler echocardiography for differentiating constrictive pericarditis from restrictive cardiomyopathy (primary restrictive cardiomyopathy and cardiac amyloidosis). The study group consisted of 75 patients (53 men, 22 women; mean age 62 years, range 27 to 87). Of these, 23 patients had surgically confirmed constrictive pericarditis, 38 had biopsy-proved systemic amyloidosis and typical echocardiographic features of cardiac involvement, and 14 had primary restrictive cardiomyopathy. Standard mitral inflow characteristics were measured. Tissue Doppler echocardiography was used to measure E' at the septal annulus. E' was significantly higher in patients with constrictive pericarditis than in those with primary restrictive cardiomyopathy or cardiac amyloidosis (12.3 vs 5.1 cm/second, p <0.001). An E' cut-off value > or =8 cm/second resulted in 95% sensitivity and 96% specificity for the diagnosis of constrictive pericarditis. There was no overlap of E' between patients who had constrictive pericarditis and those who had cardiac amyloidosis. In a subgroup analysis of restrictive cardiomyopathy, E' of patients who had cardiac amyloidosis was significantly lower than that of patients who had primary restrictive cardiomyopathy (4.6 vs 6.3 cm/second, p <0.001). Thus, E' velocity can distinguish between constrictive pericarditis and restrictive cardiomyopathy with a specific cut-off value in patients with clinical and echocardiographic evidence of diastolic heart failure.

Constrictive pericarditis: etiology and cause-specific survival after pericardiectomy

OBJECTIVES

We sought to determine the association of etiology of constrictive pericarditis (CP), pericardial calcification (CA), and other clinical variables with long-term survival after pericardiectomy.

BACKGROUND

Constrictive pericarditis is the result of a spectrum of primary cardiac and noncardiac conditions. Few data exist on the cause-specific survival after pericardiectomy. The impact of CA on survival is unclear.

METHODS

A total of 163 patients who underwent pericardiectomy for CP over a 24-year period at a single surgical center were studied. Constrictive pericarditis was confirmed by the surgical report. Vital status was obtained from the Social Security Death Index.

RESULTS

Etiology of CP was idiopathic in 75 patients (46%), prior cardiac surgery in 60 patients (37%), radiation treatment in 15 patients (9%), and miscellaneous in 13 patients (8%). Median follow-up among survivors was 6.9 years (range 0.8 to 24.5 years), during which time there were 61 deaths. Perioperative mortality was 6%. Idiopathic CP had the best prognosis (7-year Kaplan-Meier survival: 88%, 95% confidence interval [CI] 76% to 94%) followed by postsurgical (66%, 95% CI 52% to 78%) and postradiation CP (27%, 95% CI 9% to 58%). In bootstrap-validated proportional hazards analyses, predictors of poor overall survival were prior radiation, worse renal function, higher pulmonary artery systolic pressure (PAP), abnormal left ventricular (LV) systolic function, lower serum sodium level, and older age. Pericardial calcification had no impact on survival.

CONCLUSIONS

Long-term survival after pericardiectomy for CP is related to underlying etiology, LV systolic function, renal function, serum sodium, and PAP. The relatively good survival with idiopathic CP emphasizes the safety of pericardiectomy in this subgroup.

Pericarditis

Pericarditis is a common disorder that has multiple causes and presents in various primary-care and secondary-care settings. New diagnostic techniques have improved the sampling and analysis of pericardial fluid and allow comprehensive characterisation of cause. Despite this advance, pericarditis is most commonly idiopathic, and radiation therapy, cardiac surgery, and percutaneous procedures have become important causes. Pericarditis is frequently self-limiting, and non-steroidal anti-inflammatory agents remain the first-line treatment for uncomplicated cases. Integrated use of new imaging methods facilitates accurate detection and management of complications such as pericardial effusion or constriction. Differentiation of constrictive pericarditis from restrictive cardiomyopathy remains a clinical challenge but is facilitated by tissue doppler and colour M-mode echocardiography. Most pericardial effusions can be safely managed with an echo-guided percutaneous approach. Pericardiectomy remains the definitive treatment for constrictive pericarditis and provides symptomatic relief in most cases. In the future, the pericardial space might become a conduit for treatments directed at the pericardium and myocardium.

Familial restrictive cardiomyopathy with skeletal abnormalities

A family is described in which 5 of 9 living children were found to have restrictive cardiomyopathy associated with skeletal muscle and orthopedic abnormalities. In the absence of another identifiable etiology, a genetic cause for restrictive cardiomyopathy in this family is probable. Consistent with the poor prognosis encountered for children with restrictive cardiomyopathy, 2 children in this family died, whereas a third was symptomatic by age 3 years.

Outcome of idiopathic restrictive cardiomyopathy in children

Eighteen children with idiopathic restrictive cardiomyopathy (IRC) were studied in an attempt to identify potential predictors of poor outcome. Four patients presented with low cardiac output (CO) syndrome. Fourteen remaining patients were minimally symptomatic at presentation but developed a low CO syndrome at a mean of 2.8 +/- 2.3 years after diagnosis. At the time of development of low CO in the 18 patients, mean left ventricular end-diastolic pressure was 27 mm Hg, right ventricular end-diastolic pressure was 18 mm Hg, cardiac index was 2.5 L/min/m(2), and pulmonary vascular resistance index (PVRI) was 8.8 U-m(2). Eleven of the 18 patients underwent cardiac transplantation. One died perioperatively from donor right-sided cardiac failure and 10 survived. Six were not transplanted and died, including 3 in whom transplantation was precluded secondary to extremely elevated PVRI. One patient is alive with right-sided cardiac failure. Ten of our 18 patients had pulmonary hypertension (PVRI >6 U-m(2)) at the time of referral for cardiac transplant and/or development of low CO syndrome. In comparison, children with dilated cardiomyopathy who were referred for heart transplant during the same time period had a PVRI that was significantly lower (5.2 U-m(2)). Elevated PVRI was associated with death (p <0.01) and 40% of our children with pulmonary hypertension were precluded from receiving an orthotopic heart transplant because their pulmonary hypertension was so severe. No risk factors for the development of pulmonary hypertension were identified; therefore, all children with IRC should undergo serial monitoring of their PVRI, and any increase should prompt a transplant evaluation.

Diastolic heart failure: restrictive cardiomyopathy, constrictive pericarditis, and cardiac tamponade: clinical and echocardiographic evaluation

An understanding of the basic principles of diastolic function is important in order to recognize diseases that may result in diastolic dysfunction and diastolic heart failure. Although uncommon, restrictive cardiomyopathy, constrictive pericarditis, and cardiac tamponade are among the disorders that may affect primarily diastolic function with preservation of systolic function. Diastolic heart failure may manifest with chronic nonspecific symptoms or may present with acute hemodynamic compromise. Echocardiography plays a vital role in the diagnosis of diastolic dysfunction and differentiation of these disease processes. It also provides a basis for clinical decisions regarding management and surgical referral. This review summarizes the clinical features, pathophysiology, and hemodynamic and echocardiographic signs of restrictive cardiomyopathy, constrictive pericarditis, and cardiac tamponade.

Pericardial constriction: diagnosis and management

The diagnosis of pericardial constriction is challenging and elusive. It is a postinflammatory condition that occurs when a thickened, fibrotic, scarred and sometimes calcified pericardium firmly encases the cardiac chambers and restricts filling of the heart, causing venous overload and diminished cardiac output. This review includes the diagnosis and management of this condition.

Imaging of the pericardium

Computed tomography (CT) and magnetic resonance imaging (MRI) are modalities well suited for imaging of the pericardium and pericardial disease. Both offer excellent resolution with a wide field of view. Both have advantages and disadvantages when compared with each other and with echocardiography. Establishing the diagnosis of constrictive pericarditis is a common indication for CT or MRI of the pericardium. Pericarditis, neoplasms, effusions, and congenital anomalies are additional conditions involving the pericardium that can be diagnosed with CT and MRI.

Contemporary cardiac imaging: an overview

Comprehensive cardiac assessment embraces virtually every imaging modality and includes information about coronary vascular anatomy as well as cardiac morphology, function, perfusion, metabolism, and tissue characterization. Through sophisticated computer processing and image analysis, newer imaging technologies such as computed tomography (CT), magnetic resonance (MR), MR spectroscopy, and positron emission tomography now provide quantitative information that may obviate more invasive angiographic assessment. Currently, no single imaging technology realizes all questions relating to cardiac form and function, and many of the technologies overlap in the content and quality of information they provide. This overview seeks to provide a broad perspective on current cardiac imaging, articulating the benefits of various technologies and their limitations.

Differentiation between restrictive cardiomyopathy and constrictive pericarditis by early diastolic doppler myocardial velocity gradient at the posterior wall

BACKGROUND

The differential diagnosis between restrictive cardiomyopathy (RCM) and constrictive pericarditis (CP) is challenging and, despite combined information from different diagnostic tests, surgical exploration is often necessary.

METHODS AND RESULTS

A group of 55 subjects (mean age, 63+/-11 years; 36 men and 19 women) were enrolled in the study; 15 had RCM, 10 had CP, and 30 were age-matched, normal controls. The diagnosis of RCM was supported by a biopsy; in the CP group, the diagnosis was confirmed either surgically or at autopsy. All patients underwent a transthoracic echocardiogram that included the assessment of Doppler myocardial velocity gradient (MVG), as measured from the left ventricular posterior wall during the predetermined phases of the cardiac cycle. MVG was lower (P<0.01) in RCM patients compared with both CP patients and normal controls during ventricular ejection (2. 8+/-1.2 versus 4.4+/-1.0 and 4.7+/-0.8 s(-1), respectively) and rapid ventricular filling (1.9+/-0.8 versus 8.7+/-1.7 and 3.7+/-1.4 s(-1), respectively). Additionally, during isovolumic relaxation, MVG was positive in RCM patients and negative in both CP patients and normal controls (0.7+/-0.4 versus -1.0+/-0.6 and -0.4+/-0.3 s(-1), respectively; P<0.01). During atrial contraction, MVG was similarly low (P<0.01) in both RCM and CP patients compared with normal controls (1.6+/-1.7 and 1.7+/-1.8 versus 3.8+/-0.9 s(-1), respectively).

CONCLUSIONS

Doppler myocardial imaging-derived MVG, as measured from the left ventricular posterior wall in early diastole during both isovolumic relaxation and rapid ventricular filling, allows for the discrimination of RCM from CP.

Large Pericardial Effusions

Pericardial effusions accompany a number of clinical conditions. The challenges facing the clinician when dealing with a pericardial effusion include assessing the urgency of draining the effusion, choosing the right approach for drainage, determining the mechanics of the effusion, and establishing a cause for the effusion. Currently available diagnostic methods, echocardiographic modalities in particular, greatly aid in the diagnostic assessment as well as in carrying out appropriate therapeutic strategies.

Clinical profile and outcome of idiopathic restrictive cardiomyopathy

BACKGROUND

Idiopathic restrictive cardiomyopathy is a poorly recognized entity of unknown cause characterized by nondilated, nonhypertrophied ventricles with diastolic dysfunction resulting in dilated atria and variable systolic function.

METHODS AND RESULTS

Between 1979 and 1996, 94 patients (61% women) 10 to 90 years old (mean, 64 years) met strict morphological echocardiographic criteria for idiopathic restrictive cardiomyopathy, mainly dilated atria with nonhypertrophied, nondilated ventricles. None had known infiltrative disease, hypertension of >5 years' duration, or cardiac or systemic conditions associated with restrictive filling. Nineteen percent were in NYHA class I, 53% in class II, and 28% in class III or IV. Atrial fibrillation was noted in 74% of patients and systolic dysfunction in 16%. Follow-up (mean, 68 months) was complete for 93 patients (99%). At follow-up, 47 patients (50%) had died, 32 (68%) of cardiovascular causes. Four had heart transplantation. The death rate compared with actuarial statistics was significantly higher than expected (P<0.0001). Kaplan-Meier 5-year survival was 64%, compared with expected survival of 85%. Multivariate analysis using proportional hazards showed that the risk of death approximately doubles with male sex (hazard ratio [HR] = 2.1), left atrial dimension >60 mm (HR = 2.3), age >70 years (HR = 2.0), and each increment of NYHA class (HR = 2.0).

CONCLUSIONS

Idiopathic restrictive cardiomyopathy or nondilated, nonhypertrophic ventricles with marked biatrial dilatation, as defined morphologically by echocardiography, affects predominantly elderly patients but can occur in any age group. Patients present with systemic and pulmonary venous congestion and atrial fibrillation and have a poor prognosis, particularly men >70 years old with higher NYHA class and left atrial dimension >60 mm.