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Pericardial DiseasesConstriction vs RestrictionJae K. Oh, MDASE Board Review 2017 2012 MFMER 3200268v3(2010)-1
Echo Evaluation of Pericardial Diseases Constriction vs Restriction Typical Constriction Effusive CP Transient CP CP and Tricuspid Regurgitation Multi-modality Imaging Cases Tamponade 2016 MFMER slide-2
Restriction vs ConstrictionParadoxical DHF or HFpEFNo paradoxicalPulseParadoxicalNo variationDiastolic Filling VariationDecreasedRelaxation (e’)ParadoxicalInspirationHV reversalExpirationConcordantLV/RV SPDiscordantDiagnosis should be based on their characteristicHEMODYNAMICSCP983059-3 2011 2016 MFMER slide-3
Mayo Echo Diagnostic CriteriaSeptal motion abnormalityMV Flow VelocityRestrictive (E/A 1)Medial e’ 8 cm/sHepatic Vein Diastolicreversal with expirationSensitivitySpecificity87 %91 %Welch et al Circ Imaging 2014 2016 MFMER slide-4
Hemodynamics of Myocardial DiseaseConcordant change in PCWP and e et al. Circ 1989 2011MFMER slide-5 2016 MFMER slide-5CP1105201-1
Constrictive PericarditisEEMitral Inflow vs Cath1. Dissociation between intrathoracic andintracardiac pressures2. Interventricular DependenceCP992397-39 2016 MFMER slide-6
Hemodynamics in ConstrictionIntracardiac pressure Δ intrathoracic pressure ΔInterventricular dependenceCP1051850-19 2016 MFMER slide-7
ConstrictionAbnormal septal motionInterventricular Dependence“Consider constriction if there isseptal motion abnormality in patientswith HF and preserved EF (HFpEF)”InspirExpir 2016 MFMER slide-8
Mitral Annulus Tissue VelocityConstriction vs Myocardial DiseaseMedialSaAaEaLateralNormal“ Mitral medial annulus velocity 8 cm/ssuggests CP in pts with HF and normal EF” 2016 MFMER slide-9
Normal vs RCM vs CPMedial Mitral e’ velocityNormalMedial e’ 13 cm/sRCMMedial e’ 3 cm/sCPMedial e’ 14 cm/s 2011 2016 MFMER slide-10
Illustrative Cases 2016 MFMER slide-11
27 yo man with fatigue and dyspnea Sep. 2015 Flu-like symptoms, treated withinhaler Oct. 2015 Pre-syncopy and palpitation Pericardial rub Pericardial effusion on Echo Treated with Ibuprofen 2400 mg/d,Colchicine 0.6 mg BID Not feeling better and CRP 60 Underwent pericardial window 2016 MFMER slide-12
27 year old man underwent a windowReferred to Mayo Pericardial fluid studies were negative Not feeling better RUQ abdominal pain and fatigue U/S Enlarged gallbladder and liver 2016 MFMER slide-13
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27 yo man after pericardial windowMitral InflowHepatic VeinExpiratory DiastolicFlow ReversalMitral e’ 15 cm/sec1 CT 2 MRI 3 Cath 4 Pericardiectomy 2016 MFMER slide-15
71 yo man with RUQ discomfort anddyspnea 2 years after CABG Physical Examination JVP elevation Prominent S3 Peripheral edema CT was obtained: Calcified Pericardium 2016 MFMER slide-16
71 yo man with calcified pericardiumReferred for Pericardiectomy Cardiac Cath Normal Coronaries Elevated RAP, RVEDP, LVEDPEqualized LV/RV EDP 2016 MFMER slide-17
71 year old man with calcified pericardiumReferred for PericardiectomyMitral inflowE 0.8 A 0.2What would you do next?1 Pericardiectomy2 HF Medical Rx3 Myocardial Biopsy4 MRIMedial e’ 3 cm/sLateralLateral e’ 4 cm/s 2016 MFMER slide-18
71 year old man with calcified pericardiumMRI : Patchy myocardial delayedenhancement and increased wall thicknessCardiac Amyloidosis 2016 MFMER slide-19
Constriction vs Restriction3020100-10RMD1.0PASP (mm Hg)RVEDP/PASP(mm Hg)CPLV RFW (mm Hg)LVEDP-RVEDP(mm Hg)Traditional Hemodynamic Diagnostic MD80604020Talreja et al: J Am Coll Cardiol 51:315, 2008 2016 MFMER slide-20
Constrictive Pericarditis in the Modern EraNovel Criteria for Diagnosis in the Cardiac Cath Laboratory(Talreja, Nishimura, Oh, Holmes. Jan. 2008 JACC)Discordant changeConstrictionRestriction(RMC)Concordant change 2016 MFMER slide-21
An e-mail from a junior staff at a major MC52 year old man waiting for heart transplantation(Had Echo, MRI, and cardiac cath performed)Dx RCMDiastolic ReversalFlow with ExpirationMedial e’ 20 cm/sec 2016 MFMER slide-22
.What would you recommend?1. Being a junior staff, keep quiet2. Believing in Echo-Doppler, un-listhim and further evaluation3. Proceed with transplantation 2016 MFMER slide-23
Explanted Heart 2016 MFMER slide-24
77 yo man with severe aortic stenosisTAVR and PM implantation 2016 MFMER slide-25
77 yo man with severe aortic stenosisTAVR and PM implantation & RV PerforationPericardiocentesis yielded 125 cc ofbloody fluid 2016 MFMER slide-26
77 yo man with severe aortic stenosisIncreasing dyspnea 2 months afterpericardiocentesis 2016 MFMER slide-27
Effusive-Constrictive PericarditisInterventricular DependenceExpiratory diastolic flow reversal 2016 MFMER slide-28
MRI DE in 2 patients with ConstrictionMedicalRXBaseline3 MonthsCirculation Oct 2011MFMER slide-29 2016 MFMER slide-293rd2011
Transient Constrictive PericarditisOne week of Steroid Rx 2011MFMER slide-30 2016 MFMER slide-30
Transient ConstrictionReversible (N 14)Persistent (N 15)Age54 1759 16LVEF57 360 3E’ (cm/sec)12 111 1Steroid Rx71 %53 %Pericardium3.8 0.6 mm4.0 0.6 mmDE Pericardium 4.4 0.4 mm2.1 0.4mmGrade 3-4/4 DE93 %33 %Sed rate45 to 425 to 20CRP75 to 214 to 15 2011MFMER slide-31 2016 MFMER slide-31
35 yo man presents with dyspnea and feverBP 80/40 mmHg 2016 MFMER slide-32
Echo guided PericardiocentesisWelles-04-07.movChest wall79%3%18%SubcostalLocation 2016 MFMER slide-33
35 yo man with tamponade and feverTEE after pericardiocentesis 2016 MFMER slide-34
Heart failure with ascites and leg edema1 Severe TR2 Constriction3 TR CP4 TR and RV dysfunction 2011MFMER slide-35 2016 MFMER slide-35
Annulus ReversusSevere TR and CPMedial e’ 12 cm/secLateral e’ 9 c/sec 2011MFMER slide-36 2016 MFMER slide-36
Constriction or Myocardial Disease ?Diagnostic AlgorithmMedial e’ 12 cm/sMedial e’ 5 cm/sSyed, Schaff, Oh Nature Review Sep 2014 2016 MFMER slide-37
47 pagesJASE 2013In the modern era, multimodality imaging is essentialin the diagnosis and management of pericardialsyndromes. Echocardiography is the initial test formost pericardial syndromes, including acutepericarditis,recurrent pericarditis, and CP. CMR andCT can usually be added when there is complexity nothandled by echocardiography or technicallylimited windows or when tissue characterization isneeded, such as with edema and inflammation. 2016 MFMER slide-38
Echocardiography for Pericardial DiseasesCystTamponadeConstriction 2016 MFMER slide-39
Cardiac CT for Pericardial DiseasesAbsent Pericardium 2016 MFMER slide-40
Cardiac MRI for Pericardial DiseasesInterventricularDependence withtypical septal motionExtensive pericardialenhancement &adjacent left pleural 2016 MFMER slide-41
Illustrative Cases 2016 MFMER slide-42
47 year old man Chest pain Not exertional Normal Examination 2016 MFMER slide-43
47 year old man with chest painAbsent pericardium Usually left side Heart shifted to left Mostly asymptomatic Strangulation can happen 2016 MFMER slide-44
Congenital Absence of thePericardiumSnoopy Sign 2016 MFMER slide-45
Pericardial Cyst 2016 MFMER slide-46
A large pericardial cyst 2011MFMER slide-47 2016 MFMER slide-47
46 year old male smoker presents withchest pain to a local ED Chest pain for 5 hours Stable and unremarkable examination ECG shows ST elevation STEMI was activatedPR depression 2016 MFMER slide-48
46 year old man with ? STEMIMRI withDelayedEnhancementPericardialInflammation 2016 MFMER slide-49
Acute PericarditisManagement Recommendation Nonsteroidal anti-inflammatory (NSAID) agent for 1month : ASA (1.5-2 Gr/d), Ibuprofen (2.5-3 Gr/d),Indocin (25-50 mg tid or qid) Colchicine for 3 months0.6 mg twice a day17 % vs 38 % Recurrence rate Avoid steroid if possible Avoid vigorous exercise for 1-2 months 2011MFMER slide-50 2016 MFMER slide-50
American J. Cardiology 1996;78: 251Baseline10 minutes ofBruce protocol63 yo man with chest pain, normal coronary angiogram, no cardiacenzyme elevation, elevated ESR, and small pericardial effusion 2016 MFMER slide-51
51 year old with SLE and BP 150/115 2016 MFMER slide-52
57 year old male with STEMIThrombolysis and StentHypotensive and tachycardic1. Dopamine2. IABP3. Fluid4. Surgery 2016 MFMER slide-53
57 year old man with STEMIHepatic vein diastolicreversal with expirationRV Diastolic Collapse 2016 MFMER slide-54
Tamponade PhysiologyCriticaltamponadePressureLimit ofpericardialstretchRapid effusionSlow effusionVolume over timeNEJM 349: 684, 2003CP1299236-6 2016 MFMER slide-55
66 year old woman with dyspneaGastro-pericardial fistulaPneumo-pericardium 2016 MFMER slide-56
Thank you for listening!Oh.jae@mayo.edu 2016 MFMER slide-57
ASE Board Review 2017 2016 MFMER slide-2 Echo Evaluation of Pericardial Diseases Constriction vs Restriction Typical Constriction Effusive CP Transient CP CP and Tricuspid Regurgitation Multi-modality Imaging Cases Tamponade 2016 MFMER slide 2011 -3 MFME R slide-3 Restriction vs Constriction Paradoxical DHF or HFpEF CP983059-3 No paradoxical Pulse .
