Constrictive Cardiomyopathy Versus Restrictive Cardiomyopathy Echocardiography Dr Djilali Hanzal Cardiologist National Guard Hospital Outline Background Physiology Clinical Features Echocardiography : M mode 2D Doppler Tissue Doppler Strain Imaging Conclusion.
Download ReportTranscript Constrictive Cardiomyopathy Versus Restrictive Cardiomyopathy Echocardiography Dr Djilali Hanzal Cardiologist National Guard Hospital Outline Background Physiology Clinical Features Echocardiography : M mode 2D Doppler Tissue Doppler Strain Imaging Conclusion.
Slide 1
Constrictive Cardiomyopathy
Versus
Restrictive Cardiomyopathy
Echocardiography
Dr Djilali Hanzal
Cardiologist
National Guard Hospital
Slide 2
Outline
Background
Physiology
Clinical Features
Echocardiography :
M mode
2D
Doppler
Tissue Doppler
Strain Imaging
Conclusion
Slide 3
Etiology CP
Bertog SC, J Am Coll Cardiol. 2004;43(8):1445.
Slide 4
Symptoms
Tajik AJ Circulation. 1999;100(13):1380.
Slide 5
Varieties of constrictive pericarditis
Rien muller et al .J Thorac Imaging 1993
Slide 6
J Am Coll Cardiol 2004;43;1445-52
Slide 7
Anatomy
Lt. Atrium is not
Completely
intrapericardial
All other cardiac chambers are
completely intrapericardial
Pulmonary Veins are
completely intrathoracic
Slide 8
Effect of Inspiration
Normal Pericardium
Intra thoracic pressure
Venous return
Constrictive Pericarditis
Intra thoracic pressure
Venous return
Transient size of RV
RV not expanded
Normal LV filling
Abnormal LV filling
Uptodate 2011
Slide 9
Mechanism
• FILLING
IMPAIREMENT
• LV-RV
INTERDEPENDANCE
Slide 10
Physiology
CP vs RCM
Constrictive Pericarditis
Myocardial compliance is NL
Pericardium not compliant
Septum compliant
Rapid early diastolic filling
cardiac volume is fixed by the
pericardium
Respiratory effect of LV
on the RV
Restrictive
Ab-Nl Myocardial compliance
Pericardium compliant
Septum not compliant
Impedence to filling increases
throughout the diastole
No Respiratory effect of
RV and the LV
Slide 11
Restrictive
Cardiomyopathy
(Myocardial Disorders)
Myocardial
disease
Endomyocardial
disease
Storage disease
Endomyocardial
fibrosis
Infiltrative
Noninfiltrative
Amyloidosis
Sarcoidosis
Idiopathic CMP
Diabetic CMP
Hemochromatosis
E William Hancok, Heart 2001, 86 343-349
Slide 12
Why is it important to make the distinction
RCM vs CP?
Associated with significant morbidity and
mortality
Restriction rarely treatable/curable
Constriction may be curable with surgery.
Slide 13
Inexplained CHF
CXray: No Cardiomegaly ( Clinically, Cxray, BNP..)
Echo: Normal LV systolic
function
Trans mitral Doppler:
Restrictive Pattern: E/A>2
TDI:
(E’>8cm/s, E/E’<15
Normal S wave)
CP
TDI:
E’<8cm/s,E/E’>15
CP
RCM
Cho YH and Schaff.Heart Fail Rev 2012
Slide 14
Inexplained CHF
CXray: No Cardiomegaly ( Clinically, Cxray, BNP..)
Echo: M-Mode, 2-D
Normal LV Systolic Function
Slide 15
M-mode and 2-D
CP
Pericardial thickening and calcification
Septal bounce
Dilated not collapsing Inferior Vena Cava
Flattening of LV post wall
Early pathological outward and inward
movement of the IVS
Color M-mode Propagation
Slide 16
18% of PC had normal thickness
Slide 17
CP
Differential Dx:
Constrictive Pericarditis
Pericardial Tamponade
Pulmonary Hypertension
LBBB
Right Ventricular Pacing
.
Paradoxal motion of the IVS
occurring in early diastole
Sensibility 62%,Specificity 93%
Journal of Thoracic Imaging. 27(1):w1, January 2012.
Slide 18
Slide 19
M-Mode CP
•
Signs reflecting increased
ventricular interdependence
Abrupt early diastolic anterior
motion of the IVS followed by a
rebound toward the LV post wall.
Mastouri et al. Expert Rev Cardiovasc 2010
.
Slide 20
M-Mode CP
Signs reflecting rapid early
•
ventricular diastolic filling:
Flattening at the LV post wall
Sensitivity 92%, Specificity 100%
Voelkel et al ,Circulation. 1978 Nov;58(5):871-5.
Slide 21
M-Mode CP
Signs reflecting
increased Right Ventr
diastolic pressure
above Pulmonary Art
pressure
• Premature opening of the
pulmonary valve
Sensibility 14%,Specificity 100%
Mastouri et al. Expert Rev Cardiovasc 2010
Slide 22
Sensibility 74%,Specificity 91%
Am J 2001,87,86-94
Slide 23
RCM 2-D
Small LV cavity with
large atria
Increased wall
thickness ( especially
in interatrial septum in
Amyloidosis)
Thickened valves and
granular sparkling
texture (amyloidosis)
Slide 24
Inexplained CHF
CXray: No Cardiomegaly ( Clinically, Cxray, BNP..)
Echo: M-Mode, 2-D
Normal LV Systolic Function
Echo-Doppler:
Restrictive Pattern:
E/A>2,DT<150ms,IVRT<60ms
AV Inflow
Slide 25
Echo-Doppler
Mitral and Tricuspid Inflow
IVRT
TR
Hepatic Veins
Pulmonary Regurgitation
Pulmonary Veins
Superior Vena Cava
Slide 26
CP
Specificity
67%,
Sensibility
86%
JACC,1994 Jan;23(1):154-62
J Am Coll Cardio 1994 jan.23,154-
Slide 27
Constriction: Non-respirophasic
Mixed Restriction and Constriction
Marked increase in Preload
• Provocation test with head-up tilting or
sitting position with decrease of the
preload may unmask the CP.
Maisch, Seferovic, Ristic et al.ESC guidelines on pericardial
disease, E J 2004
Slide 28
Slide 29
AF and CP
Slide 30
AF and CP
J Am Coll Cardio 2001;37:1936-42
Slide 31
CP
JACC 1994 Jan;23(1):154-62
Slide 32
Diagrammatic representation of the transmitral early (E-wave) and late (A-wave) velocities
during diastole throughout the respiratory cycle.
Nihoyannopoulos P , Dawson D Eur J Echocardiogr
2009;10:iii23-iii33
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author
2009. For permissions please email: [email protected]
Slide 33
CP
Slide 34
CP
Slide 35
Normal
CP
Specificity79%,
Sensitivity 86%
Circulation 2002, Rajagopalan et al. AJC 2001
Slide 36
CP
Slide 37
Normal
CP
RCM
PV is Respirophasic
PV is not Respirophasic
Slide 38
CP
Slide 39
CP vs COPD
CP
Slide 40
Inexplained CHF
CXray: No Cardiomegaly ( Clinically, Cxray, BNP..)
Echo: Normal LV systolic
function
Echo-Doppler:
Restrictive Pattern:
E/A>2,DT<150ms,IVRT<60ms
AV Inflow
Tissue Doppler:
Annular TDI
Slide 41
Specificity 89%,Sensibility100%
Rajagopalan et al
.Am.J.Cardio 2001
Slide 42
E/e’=6
Am J Cardiol 2004;93:886-890
Slide 43
MITRAL “ANNULUS REVERSUS”
Normal
E’ Lateral > E’ Septal
CP
E’ Lateral< E’Septal
RCM
E’ Lateral =E’ Septal
Reuss et al.Eur J Echocardiography 2009
Slide 44
Slide 45
Inexplained CHF
CXray: No Cardiomegaly ( Clinically, Cxray, BNP..)
Echo: Normal LV systolic
function
Echo-Doppler:
Restrictive Pattern:
E/A>2,DT<150ms,IVRT<60ms
AV inflow
Tissue Doppler:
Annular TDI
Strain Imaging
Slide 46
Myocardial Mechanics in RCM and CP
Deformation
Parameter
Longitudinal
Strain
Circumferential
Strain
CP
Normal
Decreased
JACC Cardiovasc Imaging. 2008 Jan;1(1):29-38
RCM
Decreased
Normal
Slide 47
Slide 48
CP
RCM
J Am Soc Echocardiogr 2009:22:24-33
2-D Speckle-tracking
Slide 49
CP
RCM
Em: Longitudinal early diastolic
lengthening velocity
J Am Soc Echocardiogr 2009:22:24-33
Slide 50
Slide 51
Slide 52
Too much for Diastology
Slide 53
Conclusions
Dx has important therapeutic implications
Clinical Presentaion similar
Echocardiography (Doppler,TDI, Strain/Strain
rate) have increased yield.
Cardiac catheterisation still considered
mandatory.
Slide 54
End
Slide 55
Inexplained CHF
CXray: No Cardiomegaly ( Clinically, Cxray, BNP..)
Echo: Normal LV systolic
function
Echo-Doppler:
Restrictive Pattern:
E/A>2,DT<150ms,IVRT<60ms
AV inflow
Tissue Doppler
Annular TDI
Hemodynamic
Strain
Slide 56
QTDI
CP
Normal
International J of Cardio
137(2009)22-39
Slide 57
RCM
International J of Cardio 137(2009)22-39
Slide 58
Major historical events in CP
Korean Circ J 2012;42:143-150
Constrictive Cardiomyopathy
Versus
Restrictive Cardiomyopathy
Echocardiography
Dr Djilali Hanzal
Cardiologist
National Guard Hospital
Slide 2
Outline
Background
Physiology
Clinical Features
Echocardiography :
M mode
2D
Doppler
Tissue Doppler
Strain Imaging
Conclusion
Slide 3
Etiology CP
Bertog SC, J Am Coll Cardiol. 2004;43(8):1445.
Slide 4
Symptoms
Tajik AJ Circulation. 1999;100(13):1380.
Slide 5
Varieties of constrictive pericarditis
Rien muller et al .J Thorac Imaging 1993
Slide 6
J Am Coll Cardiol 2004;43;1445-52
Slide 7
Anatomy
Lt. Atrium is not
Completely
intrapericardial
All other cardiac chambers are
completely intrapericardial
Pulmonary Veins are
completely intrathoracic
Slide 8
Effect of Inspiration
Normal Pericardium
Intra thoracic pressure
Venous return
Constrictive Pericarditis
Intra thoracic pressure
Venous return
Transient size of RV
RV not expanded
Normal LV filling
Abnormal LV filling
Uptodate 2011
Slide 9
Mechanism
• FILLING
IMPAIREMENT
• LV-RV
INTERDEPENDANCE
Slide 10
Physiology
CP vs RCM
Constrictive Pericarditis
Myocardial compliance is NL
Pericardium not compliant
Septum compliant
Rapid early diastolic filling
cardiac volume is fixed by the
pericardium
Respiratory effect of LV
on the RV
Restrictive
Ab-Nl Myocardial compliance
Pericardium compliant
Septum not compliant
Impedence to filling increases
throughout the diastole
No Respiratory effect of
RV and the LV
Slide 11
Restrictive
Cardiomyopathy
(Myocardial Disorders)
Myocardial
disease
Endomyocardial
disease
Storage disease
Endomyocardial
fibrosis
Infiltrative
Noninfiltrative
Amyloidosis
Sarcoidosis
Idiopathic CMP
Diabetic CMP
Hemochromatosis
E William Hancok, Heart 2001, 86 343-349
Slide 12
Why is it important to make the distinction
RCM vs CP?
Associated with significant morbidity and
mortality
Restriction rarely treatable/curable
Constriction may be curable with surgery.
Slide 13
Inexplained CHF
CXray: No Cardiomegaly ( Clinically, Cxray, BNP..)
Echo: Normal LV systolic
function
Trans mitral Doppler:
Restrictive Pattern: E/A>2
TDI:
(E’>8cm/s, E/E’<15
Normal S wave)
CP
TDI:
E’<8cm/s,E/E’>15
CP
RCM
Cho YH and Schaff.Heart Fail Rev 2012
Slide 14
Inexplained CHF
CXray: No Cardiomegaly ( Clinically, Cxray, BNP..)
Echo: M-Mode, 2-D
Normal LV Systolic Function
Slide 15
M-mode and 2-D
CP
Pericardial thickening and calcification
Septal bounce
Dilated not collapsing Inferior Vena Cava
Flattening of LV post wall
Early pathological outward and inward
movement of the IVS
Color M-mode Propagation
Slide 16
18% of PC had normal thickness
Slide 17
CP
Differential Dx:
Constrictive Pericarditis
Pericardial Tamponade
Pulmonary Hypertension
LBBB
Right Ventricular Pacing
.
Paradoxal motion of the IVS
occurring in early diastole
Sensibility 62%,Specificity 93%
Journal of Thoracic Imaging. 27(1):w1, January 2012.
Slide 18
Slide 19
M-Mode CP
•
Signs reflecting increased
ventricular interdependence
Abrupt early diastolic anterior
motion of the IVS followed by a
rebound toward the LV post wall.
Mastouri et al. Expert Rev Cardiovasc 2010
.
Slide 20
M-Mode CP
Signs reflecting rapid early
•
ventricular diastolic filling:
Flattening at the LV post wall
Sensitivity 92%, Specificity 100%
Voelkel et al ,Circulation. 1978 Nov;58(5):871-5.
Slide 21
M-Mode CP
Signs reflecting
increased Right Ventr
diastolic pressure
above Pulmonary Art
pressure
• Premature opening of the
pulmonary valve
Sensibility 14%,Specificity 100%
Mastouri et al. Expert Rev Cardiovasc 2010
Slide 22
Sensibility 74%,Specificity 91%
Am J 2001,87,86-94
Slide 23
RCM 2-D
Small LV cavity with
large atria
Increased wall
thickness ( especially
in interatrial septum in
Amyloidosis)
Thickened valves and
granular sparkling
texture (amyloidosis)
Slide 24
Inexplained CHF
CXray: No Cardiomegaly ( Clinically, Cxray, BNP..)
Echo: M-Mode, 2-D
Normal LV Systolic Function
Echo-Doppler:
Restrictive Pattern:
E/A>2,DT<150ms,IVRT<60ms
AV Inflow
Slide 25
Echo-Doppler
Mitral and Tricuspid Inflow
IVRT
TR
Hepatic Veins
Pulmonary Regurgitation
Pulmonary Veins
Superior Vena Cava
Slide 26
CP
Specificity
67%,
Sensibility
86%
JACC,1994 Jan;23(1):154-62
J Am Coll Cardio 1994 jan.23,154-
Slide 27
Constriction: Non-respirophasic
Mixed Restriction and Constriction
Marked increase in Preload
• Provocation test with head-up tilting or
sitting position with decrease of the
preload may unmask the CP.
Maisch, Seferovic, Ristic et al.ESC guidelines on pericardial
disease, E J 2004
Slide 28
Slide 29
AF and CP
Slide 30
AF and CP
J Am Coll Cardio 2001;37:1936-42
Slide 31
CP
JACC 1994 Jan;23(1):154-62
Slide 32
Diagrammatic representation of the transmitral early (E-wave) and late (A-wave) velocities
during diastole throughout the respiratory cycle.
Nihoyannopoulos P , Dawson D Eur J Echocardiogr
2009;10:iii23-iii33
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author
2009. For permissions please email: [email protected]
Slide 33
CP
Slide 34
CP
Slide 35
Normal
CP
Specificity79%,
Sensitivity 86%
Circulation 2002, Rajagopalan et al. AJC 2001
Slide 36
CP
Slide 37
Normal
CP
RCM
PV is Respirophasic
PV is not Respirophasic
Slide 38
CP
Slide 39
CP vs COPD
CP
Slide 40
Inexplained CHF
CXray: No Cardiomegaly ( Clinically, Cxray, BNP..)
Echo: Normal LV systolic
function
Echo-Doppler:
Restrictive Pattern:
E/A>2,DT<150ms,IVRT<60ms
AV Inflow
Tissue Doppler:
Annular TDI
Slide 41
Specificity 89%,Sensibility100%
Rajagopalan et al
.Am.J.Cardio 2001
Slide 42
E/e’=6
Am J Cardiol 2004;93:886-890
Slide 43
MITRAL “ANNULUS REVERSUS”
Normal
E’ Lateral > E’ Septal
CP
E’ Lateral< E’Septal
RCM
E’ Lateral =E’ Septal
Reuss et al.Eur J Echocardiography 2009
Slide 44
Slide 45
Inexplained CHF
CXray: No Cardiomegaly ( Clinically, Cxray, BNP..)
Echo: Normal LV systolic
function
Echo-Doppler:
Restrictive Pattern:
E/A>2,DT<150ms,IVRT<60ms
AV inflow
Tissue Doppler:
Annular TDI
Strain Imaging
Slide 46
Myocardial Mechanics in RCM and CP
Deformation
Parameter
Longitudinal
Strain
Circumferential
Strain
CP
Normal
Decreased
JACC Cardiovasc Imaging. 2008 Jan;1(1):29-38
RCM
Decreased
Normal
Slide 47
Slide 48
CP
RCM
J Am Soc Echocardiogr 2009:22:24-33
2-D Speckle-tracking
Slide 49
CP
RCM
Em: Longitudinal early diastolic
lengthening velocity
J Am Soc Echocardiogr 2009:22:24-33
Slide 50
Slide 51
Slide 52
Too much for Diastology
Slide 53
Conclusions
Dx has important therapeutic implications
Clinical Presentaion similar
Echocardiography (Doppler,TDI, Strain/Strain
rate) have increased yield.
Cardiac catheterisation still considered
mandatory.
Slide 54
End
Slide 55
Inexplained CHF
CXray: No Cardiomegaly ( Clinically, Cxray, BNP..)
Echo: Normal LV systolic
function
Echo-Doppler:
Restrictive Pattern:
E/A>2,DT<150ms,IVRT<60ms
AV inflow
Tissue Doppler
Annular TDI
Hemodynamic
Strain
Slide 56
QTDI
CP
Normal
International J of Cardio
137(2009)22-39
Slide 57
RCM
International J of Cardio 137(2009)22-39
Slide 58
Major historical events in CP
Korean Circ J 2012;42:143-150