Final The Echo Manual DIGITAL

Chapter 12 Pericardial Diseases

CHAPTER 12 PERICARDIAL DISEASES

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FIGURE 12-27 ( Continued ) B: Strain imaging in this patient shows typical reduction of longitudinal strain value in the inferior and lateral walls. C: After cardioversion, mitral inflow continues to show mild respiratory variation in E velocity, and hepatic vein Doppler has prominent diastolic flow reversal with expiration ( right ).

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Differentiation from Restrictive Cardiomyopathy and Other Mimickers There are several clinical conditions, which can mimic clinical presentations and hemodynamic abnormalities of constrictive pericarditis, most notably, restrictive car- diomyopathy and tricuspid regurgitation. Patients with constrictive pericarditis can also present with abdominal or pulmonary symptoms. Careful clinical examination with findings of increased jugular venous pressure, peri- cardial knock, and hepatomegaly can steer them to a car- diac evaluation, usually an echocardiogram. Restrictive Cardiomyopathy With the advent of tissue Doppler evaluation of the mitral annulus, it has become easier to recognize and distinguish restrictive myocardial disease from constric- tive pericarditis. Since myocardial relaxation is reduced in all forms of myocardial diseases, mitral annulus early diastolic velocity (e ′ ) is reduced to less than 7 cm/s, while it is preserved or even increased in constrictive pericarditis. &RS\ULJKW ‹

Although the mitral inflow pattern in restrictive car- diomyopathy appears similar to that of constriction (increased E velocity, E/A ratio >0.8 and sometimes >2.0, and deceleration time usually <160 milliseconds) and may show respiratory variation, although not often, hepatic vein diastolic flow reversals are more prominent with inspiration in restrictive cardiomyopathy and expi- ration with constriction (Fig. 12-24B). Despite the distinct differences in pathophysiologic mechanisms of restriction and constriction, the tradi- tional invasive hemodynamic variables of these two conditions overlap considerably (Fig. 12-28). Increased atrial pressures, equalization of end-diastolic pressures, and dip-and-plateau (or square root sign) of the ven- tricular diastolic pressure recording are hemodynamic features typical of constrictive pericarditis. However, similar pressure tracings can be obtained in patients with restrictive cardiomyopathy (Fig. 12-30) (29). Thus, in addition to these hemodynamic features, respiratory variation in ventricular filling must be demonstrated to confirm the diagnosis of constriction. Invasively, the dis-

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