Diagnosis of constrictive pericarditis by pulsed Doppler echocardiography

Constrictive pericarditis with a calcific mass invading into the right ventricular myocardium

We present a rare and unique case of calcific constrictive pericarditis with a calcified pericardial mass invading the right ventricular myocardium. Perioperative two-dimensional and three-dimensional transesophageal echocardiography revealed the extent and structure of the pericardial mass and led to the repair of the right ventricular free wall as a surgical intervention.

Pericardial disease: diagnosis and management

Pericardial diseases can present clinically as acute pericarditis, pericardial effusion, cardiac tamponade, and constrictive pericarditis. Patients can subsequently develop chronic or recurrent pericarditis. Structural abnormalities including congenitally absent pericardium and pericardial cysts are usually asymptomatic and are uncommon. Clinicians are often faced with several diagnostic and management questions relating to the various pericardial syndromes: What are the diagnostic criteria for the vast array of pericardial diseases? Which diagnostic tools should be used? Who requires hospitalization and who can be treated as an outpatient? Which medical management strategies have the best evidence base? When should corticosteroids be used? When should surgical pericardiectomy be considered? To identify relevant literature, we searched PubMed and MEDLINE using the keywords diagnosis, treatment, management, acute pericarditis, relapsing or recurrent pericarditis, pericardial effusion, cardiac tamponade, constrictive pericarditis, and restrictive cardiomyopathy. Studies were selected on the basis of clinical relevance and the impact on clinical practice. This review represents the currently available evidence and the experiences from the pericardial clinic at our institution to help guide the clinician in answering difficult diagnostic and management questions on pericardial diseases.

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.

Value of dynamic respiratory changes in left and right ventricular pressures for the diagnosis of constrictive pericarditis

BACKGROUND

Conventional cardiac catheterization criteria for the diagnosis of constrictive pericarditis (CP) rely on equalization of intracardiac pressures and have many recognized limitations. Recently, Doppler echocardiographic methods have been used to examine dynamic respiratory changes of increased ventricular interdependence and dissociation of intrathoracic and intracardiac pressures for the diagnosis of CP. These pathophysiological features may be best delineated by cardiac catheterization. Therefore, we studied the accuracy of these dynamic respiratory changes in left ventricular and right ventricular pressure for the diagnosis of CP at cardiac catheterization.

METHODS AND RESULTS

High-fidelity manometric catheters and respirometry were used to study 36 patients: 15 patients with surgically proven CP (group 1) and 21 patients with other causes of heart failure (group 2). Conventional cardiac catheterization variables used to establish the diagnosis of CP lacked sensitivity and specificity and failed to distinguish between these groups. However, the finding of discordance between right ventricular and left ventricular pressures during inspiration, a sign of increased ventricular interdependence, accurately distinguished patients in group 1 from those in group 2 (P < .05).

CONCLUSIONS

Examination of dynamic respiratory changes indicating increased ventricular interdependence may be helpful in the diagnosis of CP in the cardiac catheterization laboratory.

Diagnostic role of Doppler echocardiography in constrictive pericarditis

OBJECTIVES

This study was conducted to assess the diagnostic role of Doppler echocardiography in constrictive pericarditis.

BACKGROUND

It has been observed that patients with constrictive pericarditis have a characteristic Doppler pattern of respiratory variation in ventricular filling and central venous flow velocities. However, the observation was based on a small number of patients with known diagnosis.

METHODS

We reviewed the echocardiographic features of 28 patients (21 men and 7 women; mean age +/- SD 55 +/- 15 years) with suspected constrictive pericarditis who underwent exploratory thoracotomy or pericardiectomy.

RESULTS

At operation, constrictive pericarditis was diagnosed in 25 patients, restriction in 1 and normal pericardium in 2. Of the 25 patients with constriction, correct preoperative Doppler diagnosis was made in 22 (88%) and Doppler echocardiography showed restriction in 3. In two patients with a normal pericardium, Doppler features were consistent with constriction in one patient and were normal in the other. In the one patient with restriction, Doppler echocardiography showed restriction. In 19 patients with surgically proved constriction, repeat Doppler study after pericardiectomy showed normal findings in 14 and restriction in 5. Twelve of the 14 patients with normalized Doppler findings became asymptomatic, whereas all 5 with restrictive Doppler features remained symptomatic.

CONCLUSIONS

Doppler echocardiography performed simultaneously with respiratory recording is highly sensitive for diagnosing constrictive pericarditis, and it appears to predict functional response to pericardiectomy.

Accurate preoperative diagnosis of pericardial constriction using cine computed tomography

OBJECTIVES

The purpose of this study was to determine the accuracy of cine computed tomography in the diagnosis of constrictive pericarditis.

BACKGROUND

Constrictive pericarditis is characterized by abnormalities of both cardiac structure and function. Accurate diagnosis requires detection of both a thickened pericardium and abnormal ventricular diastolic filling. At present, no one diagnostic technique has demonstrated sufficient accuracy in this setting. Cine computed tomography is a relatively new cardiac imaging mode with very high time and spatial resolution that has the potential to accurately diagnose constrictive pericarditis.

METHODS

Twelve consecutive patients were retrospectively identified who had catheterization findings suggestive of constrictive physiology, had undergone a cine computed tomographic examination and had pathologic data that delineated the status of the pericardium. Group 1 (with constrictive pericarditis; n = 5) had surgical confirmation of thickened pericardium and improved clinically after pericardiectomy. Group 2 (no constrictive pericarditis; n = 7) had cardiomyopathy with normal pericardium. Seven normal volunteers (Group 3) were also studied. Cine computed tomograms were obtained for the entire heart (8-mm slices, 17 frames/s, nonionic contrast medium). Pericardial thickness was measured at 10 degrees intervals at three ventricular levels in each subject. The rapidity of diastolic filling was assessed by calculating the percent filling fraction in early diastole.

RESULTS

Pericardial thickness was 10 +/- 2 mm (mean +/- SD) in Group 1, 2 +/- 1 mm in Group 2 and 1 +/- 1 mm in Group 3 (p < 0.05, constrictive pericarditis vs. no constrictive pericarditis). Left ventricular filling fraction was 83 +/- 6% in Group 1, 62 +/- 9% in Group 2 and 44 +/- 5% in Group 3. Right ventricular filling fraction was 93 +/- 5% in Group 1, 62 +/- 14% in Group 2 and 35 +/- 6% in Group 3 (p < 0.05, Group 1 vs. Groups 2 and 3). Both indexes provided a clear-cut distinction between patients with and without constriction.

CONCLUSIONS

Cine computed tomography simultaneously provides both anatomic and physiologic data that allow accurate preoperative diagnosis of pericardial constriction.

Pitfalls in the echo-Doppler assessment of diastolic dysfunction

The Doppler echocardiographic assessment of diastolic function is an essential part of the evaluation of heart failure, pericardial diseases, restrictive and infiltrative cardiomyopathies, and many other conditions. However, the echocardiographic evaluation of diastolic function has several limitations. The sonographer and physician must understand the technical factors, the effects of physiological and pathophysiological conditions, and the dynamics of pseudonormalization, all of which affect the evaluation. This article will review the most recent data essential for the proper performance and interpretation of a transthoracic or transesophageal Doppler echocardiographic examination of diastolic function.

Impact of hemodialysis on left and right ventricular Doppler diastolic filling indices

Hemodialysis is associated with acute reduction in intravascular volume. To assess the impact of volume reduction on left and right ventricular diastolic filling indexes obtained by Doppler echocardiography, 24 patients on chronic hemodialysis were consecutively studied before, during, and immediately after one hemodialysis session. Twenty four normal sex and age-matched volunteers served as a control group. Study patients had abnormal diastolic indexes when compared to controls. At 2 hours of dialysis (mid dialysis) there was a significant decrease in peak early mitral flow velocity (E), no change in peak atrial filling velocity (A), and a reduction in the E/A ratio. The deceleration time of the mitral E wave also was prolonged compared to baseline. Similar findings were observed with respect to right ventricular filling indices. These changes occurred during the first 2 hours of dialysis and remained unaltered at end dialysis. When patients were subdivided according to weight loss, only the group that lost 1 or more kilograms had significant changes in the Doppler parameters of the left and right ventricle, as well as reduction of the left ventricular dimensions. These findings suggest that preload reduction is the main mechanism that accounts for acute changes in Doppler diastolic indices observed during hemodialysis.

Effect of postural changes and isometric exercise on Doppler-derived measurements of diastolic function in normal subjects

To determine if simple maneuvers that occur in daily life, such as changes in body position and isometric handgrip exercise, affect Doppler-derived measurements of diastolic function, we studied 22 normal male subjects in the supine position at rest and during several postural manipulations and during handgrip exercise. Comparison of values obtained in the 80 degrees upright tilt position with those obtained in the standard supine position revealed significant decreases in early diastolic flow velocity (peak E) (-25 +/- 3 percent; p less than 0.001), late diastolic flow velocity (peak A) (-9 +/- 3 percent; p less than 0.01), and the ratio of early to late flow velocities (E/A ratio) (-17 +/- 4 percent; significant increases in deceleration time (+55 +/- 10 percent; p less than 0.001) and isovolumic relaxation time (+38 +/- 4 percent; p less than 0.001). Comparison of values obtained with supine isometric exercise with those obtained during the preceding supine resting state revealed significant decreases in peak E (-12 +/- 3 percent; p less than 0.001) and the E/A ratio (-21 +/- 4 percent; p less than 0.001) and significant increases in peak A (+15 +/- 4 percent; p less than 0.001) and isovolumic relaxation time (+16 +/- 3 percent; p less than 0.001). The response of Doppler-derived measurements of diastolic function to postural changes and isometric exercise is complex and multifactorial. Interpretation of these measurements must take into account changes in loading conditions.

Reduction of left ventricular preload by lower body negative pressure alters Doppler transmitral filling patterns

The objective of this study was to evaluate the effect of alterations in preload induced by lower body negative pressure on Doppler transmitral filling patterns. Echocardiograms and Doppler recordings were performed in 18 normal young men (aged 23 to 32 years) during various levels of lower body negative pressure (0, -20 and -50 mm Hg). Lower body negative pressure induced a reduction in diastolic velocity integral (from 12.17 +/- 0.79 to 8.42 +/- 0.71 cm, p = 0.0067) and consequently left ventricular diastolic diameter (from 5.11 +/- 0.09 to 4.45 +/- 0.1 cm, p less than 0.0001). There was a significant reflex increase in heart rate from 59.9 +/- 1.9 to 77.1 +/- 2.4 beats/min (p less than 0.0001), but blood pressure was unchanged. This reduction in preload altered Doppler transmittral filling patterns as follows: 1) peak early velocity (E) decreased from 59.2 +/- 3.8 to 39.1 +/- 1.7 cm/s (p less than 0.0001); 2) atrial filing velocity (A) was unchanged (35.58 +/- 1.5 to 33.52 +/- 1.4 cm/s, p = 0.517); 3) E/A ratio decreased from 1.7 +/- 0.13 to 1.19 +/- 0.08 (p = 0.0087); 4) mean acceleration (from 482 +/- 37 to 390 +/- 27 cm/s2, p = 0.03) and mean deceleration (from 327 +/- 31 to 169 +/- 21 cm/s2, p less than 0.001) of the early filling wave were significantly reduced; and 5) peak acceleration (from 907 +/- 42 to 829 +/- 29 cm/s2) and peak deceleration (from 771 +/- 94 to 547 +/- 76 cm/s2) also decreased, but not significantly.(ABSTRACT TRUNCATED AT 250 WORDS)

The pathophysiology of pericardial disease--contributions derived from echocardiography/Doppler studies in animal models

The use of acute and chronically prepared animal models of pericardial disease free of the confounding influences of other disease processes have greatly accelerated the development of echocardiographic and Doppler diagnostic methods and have allowed the correlation of these noninvasive findings with hemodynamic abnormalities.

Influence of alteration in preload on the pattern of left ventricular diastolic filling as assessed by Doppler echocardiography in humans

We examined the influence of alterations in preload on pulsed Doppler indexes of left ventricular diastolic function in 50 patients including 12 without cardiovascular disease, 29 with coronary artery disease, and nine with critical aortic stenosis. Micromanometer left ventricular pressure was recorded simultaneously with pulsed Doppler echocardiography of left ventricular inflow and M-mode echocardiography of left ventricular diameter. Chamber stiffness constants, kd and kv, were obtained from the diastolic pressure-diameter and pressure-volume relations, respectively. Relaxation was measured by the isovolumic relaxation time constants, TL and TD, derived from the exponential left ventricular pressure decay and maximum negative dP/dt. In 41 patients after nitroglycerin treatment, left ventricular end-diastolic pressure decreased from 18 +/- 5 to 13 +/- 4 mm Hg (p less than 0.001). The ratio of peak early to peak atrial filling velocities and time-velocity integral ratios decreased from 1.08 +/- 0.57 to 0.90 +/- 0.42 (p less than 0.001) and from 1.77 +/- 0.95 to 1.41 +/- 0.71 (p less than 0.001), respectively. The peak early filling velocity and time-velocity integral decreased from 56.1 +/- 15.7 to 49.9 +/- 14.5 cm/sec (p less than 0.001) and from 7.9 +/- 2.7 to 6.8 +/- 2.8 cm (p less than 0.001), respectively. Relaxation (TL, TD, and maximum negative dP/dt) and chamber stiffness (kd and kv) were not impaired after nitroglycerin administration. In 48 patients after ventriculography, left ventricular end-diastolic pressure increased from 18 +/- 6 to 22 +/- 8 mm Hg (p less than 0.001). The peak early and peak atrial filling velocities increased from 57.4 +/- 15.2 to 68.3 +/- 19.7 cm/sec (p less than 0.001) and from 61.0 +/- 22.7 to 69.4 +/- 23.2 cm/sec (p less than 0.01), respectively. As a result, the ratio of peak early to peak atrial filling velocity was unchanged. However, in the aortic stenosis group, the ratio of peak early to peak atrial filling velocity increased from 0.95 +/- 0.64 to 1.10 +/- 0.72 (p less than 0.02). Relaxation and chamber stiffness were unchanged. Thus, a reduction or increase in preload may induce a diastolic filling pattern that mimics or masks diastolic dysfunction, respectively. Preload conditions need to be accounted for when the status of diastolic function is extrapolated from the pulsed Doppler mitral inflow velocity profile.

Diagnosis of constrictive pericarditis by pulsed Doppler echocardiography of the hepatic vein

The diagnostic value of hepatic venous flow patterns was evaluated for constrictive pericarditis by pulsed Doppler. A characteristic flow pattern was assumed to be associated with the well-known atrial pressure curve. Thirteen patients with constrictive pericarditis were compared to 13 control subjects and to 25 patients with right ventricular pressure overload including 13 patients with tricuspid regurgitation. The characteristic finding in constrictive pericarditis was a W-wave pattern of flow velocities in the dilated hepatic veins, with abrupt reversal of flow late in systole and diastole before the A wave (100% specificity, 68% sensitivity). This depends, however, on the absence of tricuspid regurgitation (for its systolic component) or fast sinus rhythm (for its diastolic component). Additional diagnostic markers were systolic deceleration time of forward flow (40 to 130 ms) and systolic integral of flow velocities (4.3 to -4.0 cm) (sensitivity and specificity greater than or equal to 92%). In the presence of tricuspid regurgitation, diastolic deceleration time less than 150 ms and diastolic integral of flow velocities less than 6 cm were useful diagnostic signs. If combined, these criteria had 100% sensitivity and specificity for the diagnosis. Thus, pulsed Doppler assessment of flow velocities in the hepatic vein facilitates the diagnosis of constrictive pericarditis in clinical routine, using an auxiliary site with unlimited diagnostic access to the characteristic flow velocity pattern, which reflects right atrial pressure curve and filling abnormalities.

Differentiation of constrictive pericarditis and restrictive cardiomyopathy by Doppler echocardiography

Doppler ultrasound recordings of mitral, tricuspid, aortic, and pulmonary flow velocities, and their variation with respiration, were recorded in 12 patients with a restrictive cardiomyopathy and seven patients with constrictive pericarditis. Twenty healthy adults served as controls. The patients with constrictive pericarditis showed marked changes in left ventricular isovolumic relaxation time and in early mitral and tricuspid flow velocities at the onset of inspiration and expiration. These changes disappeared after pericardiectomy and were not seen in patients with restrictive cardiomyopathy or in normal subjects. The deceleration time of early mitral and tricuspid flow velocity was shorter than normal in both groups, indicating an early cessation of ventricular filling, but only patients with restrictive cardiomyopathy showed a further shortening of the tricuspid deceleration time with inspiration. Diastolic mitral and tricuspid regurgitation was also more common in the patients with restrictive cardiomyopathy. These results suggest that patients with constrictive pericarditis and restrictive cardiomyopathy can be differentiated by comparing respiratory changes in transvalvular flow velocities. In addition, although baseline hemodynamics in the two groups were similar, characteristic changes were seen with respiration that suggest differentiation of these disease states may also be possible from hemodynamic data.

Assessment of diastolic function of the heart: background and current applications of Doppler echocardiography. Part II. Clinical studies

Evaluation of diastolic filling of the heart has been difficult because of its complexity and the numerous interrelated contributing factors. Previous determinations have depended on high-fidelity, invasive measurements of instantaneous pressure, volume, mass, and wall stress, which could not be done on a routine clinical basis. With the advent of Doppler echocardiography, intracardiac blood flow velocities can now be noninvasively assessed. For application of this technique to evaluation of diastolic function in patients with heart disease, it is necessary to understand what the Doppler-derived variables represent. It is also necessary to know how they are affected by changes in loading conditions and changes in myocardial relaxation. In this review, we provide an interpretation of the mitral valve, tricuspid valve, and systemic and pulmonary venous inflow velocities in the normal patient and in various disease states.