Transcript Constrictive Restrictive

The Hemodynamics of
Restrictive & Constrictive
Cardiomyopathy
Jad Skaf, M.D.
11/02/2010
Definition
• Heart disease resulting in impaired
ventricular filling. High diastolic pressures
are required to maintain cardiac output
• Systolic function is usually normal
• Presentation: LV or RV failure or
biventricular HF
Idiopathic (Familial) Restrictive Cardiomyopathy
Secondary Restrictive Cardiomyopathies
• Infiltrative
Amyloidosis
Gaucher’s
Hunter’s, Hurler’s
• Storage disease
Hemochromatosis
Pompey (glycogen)
Fabry’s (glycolipid)
• Endomyocardial
Radiation-induced
Eosinophilic syndromes
Carcinoid heart disease
• Inflammatory
Sarcoidosis
Constrictive Cardiomyopathy
1-Cardiac Tamponade
2-Constrictive pericarditis
3-Effusive-constrictive
pericarditis
Differentiation of Constriction vs.
Restriction
•
•
•
•
Similar clinical presentations
Different etiologies
Similar physical exam signs
Thick pericardium is not necessary or
sufficient to make diagnosis of constriction
• Overlapping echo and hemodynamic
features
• Important therapeutic implications
Before Cath
• HISTORY
– Pericarditis, TB, CTD, Malignancy – Trauma
– Amyloidosis, Sarcoidosis
– Mantle radiation, cardiac surgery
• PHYSICAL
Both exhibit Impaired Diastolic Filling:
dyspnea, edema, fatigue, ascites… RHF
– JVP
• CP
• RCM
• TR with an enlarged
compliant RA
• RHF (pulm HTN, RV-MI)
• Circulatory overload with
systemic congestion
– Kussmaul’s sign
• RHF
• Systemic venous
congestion
• Severe TR
ECHO
Constriction
•
•
•
•
Pericardial calcium
Small LV, RV
Dilated LA, RA
Doppler: ventricular
discordance
• TDE: E’> 8
• PA syst us < 40
• Thick pericardium
usual; no biopsy
Restriction
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•
•
•
None
Small LV , RV
Dilated LA, RA
Doppler: minimal
respiratory variation
• TDE: E’<7
• PA syst often > 40
• Pericardium not
thickened; abnl
biopsy
ECHO RULES OUT
• Systolic Dysfunction
• Valvular Dysfunction
• Peric. Effusion with
early tamponade
physiology
VENTRICULAR FILLING PHYSIOLOGY
RCM
Pericardial
Space
Visceral
Pericardium
Impedance throughout Diastole
Compliance
Atrial filling at end of Diastole
Parietal
Pericardium
VENTRICULAR FILLING PHYSIOLOGY
CP
Early Diastole
Mid-Diastole
Normal Compliance
Abrupt cessation of
ventricular filling
End Diastole
-Fixed intracardiac volume
-Ventricular Coupling
-Pressure dissociation
CATH
D
LV
RV
D
D
D
D
D
D
D
Traditional Criteria:
Constrictive
Restrictive
EDP equalisation
LVEDP-RVEDP < 5 mmHg
LVEDP-RVEDP > 5 mmHg
High RVEDP
RVEDP/RVESP > 1/3
RVEDP/RVESP < 1/3
PAP
PASP < 55 mmHg
PASP > 55 mmHg
Dip Plateau
LV rapid filling wave> 7 mmHg
LV rapid filling wave < 7mmHg
Kussmaul’s
No Resp Var in mean RAP(<3)
Resp Var in mean RAP (fall)
Hurrell et al.
Traditional Criteria:
Constrictive
Restrictive
Sensitivity
Specificity
PPV
NPV
EDP equalisation
LVEDP-RVEDP < 5 mmHg
EDP equalisation
60
PAP
PASP < 55 mmHg
PAP
93
High RVEDP
RVEDP/RVESP > 1/3
High RVEDP
93
Dip Plateau
LV rapid filling wave> 7 mmHg
Dip Plateau
93
Kussmaul’s
No Resp Var in mean RAP(<3)
Kussmaul’s
93
38
LVEDP-RVEDP > 5 mmHg
4
57
PASP > 55 mmHg
24
38
57
48
47
25
RVEDP/RVESP < 1/3
52
89
LV rapid filling wave < 7mmHg
61
92
Resp Var in mean RAP (fall)
58
92
n=19
p<0.05
Hurrell et al.
Respiratory Dynamic Criteria
Sharp et al. - 1960
Cardiac Tamponade Physiology
NORMAL
PULMONARY
WEDGE
PRESSURE
“E.F.G.”
INTRAPERICARDIAL
PRESSURE
i
e
INTRATHORACIC
PRESSURE
“E.F.G.” = Estimated Filling Gradient
Tamponade
PULMONARY
WEDGE
PRESSURE
“E.F.G.”
INTRAPERICARDIAL
PRESSURE
i
e
“E.F.G.” = Estimated Filling Gradient
INTRATHORACIC
PRESSURE
Hatle et al, 1989
Constrictive
Sensitivity
Specificity
PPV
NPV
EDP equalisation
60
38
4
57
PAP
93
24
47
25
High RVEDP
93
38
52
89
Dip Plateau
93
57
61
92
Kussmaul’s
93
48
58
92
PCW-LV resp Gdt
93
81
78
94
LV/RV ID
100
95
94
100
Hurrell et al.
Respiratory changes in the early diastolic transmitral pressure gradient
as estimated by PCWP and left ventricular (LV) minimum pressure
n=36
n=15
p<0.05
Hurrell, D. G. et al. Circulation 1996;93:2007-2013
Respiratory changes in LVSP and RVSP
Hurrell, D. G. et al. Circulation 1996;93:2007-2013
Hatle et al, 1989
Thank you …