Final The Echo Manual DIGITAL

Chapter 12 Pericardial Diseases

CHAPTER 12 PERICARDIAL DISEASES

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LV

FIGURE 12-29 A significant overlap of traditional hemodynamic parameters for constriction, between restrictive myocardial disease ( RMD ) and constric- tive pericarditis ( CP ).

(e.g., RV systolic pressure and equalization of ventricular end-diastolic pressures), which show marked overlap in both conditions (Table 12-1) (29). Ventricular Interdependence due to Increased Respiratory Effort Patients with chronic obstructive lung disease or other conditions (sleep apnea, asthma, obesity), which increase respiratory effort, may demonstrate increased ventricular interdependence similar to that of constrictive pericardi- tis. In those conditions, respirophasic abnormal ventricu- lar septal motion occurs, and mitral inflow E velocities vary with respiration, but the mitral inflow profile may TABLE 12-1 Traditional Hemodynamic Criteria for Constriction versus Restriction Criterion Constriction Restriction LVEDP-RVEDP, mm Hg ≤5 >5 RV systolic pressure, mm Hg ≤50 >50 RVEDP/RVSP ≥0.33 <0.3 LVEDP, left ventricular end-diastolic pressure; RVEDP, right ventricular end-diastolic pressure; RVSP, right ventricular systolic pressure.

sociation between intrathoracic and intracardiac pressure with respiration can be demonstrated by simultaneously recording LV and pulmonary capillary wedge pres- sures (Fig. 12-19A). In constrictive pericarditis, the dis- sociation of intrathoracic and intrapericardial pressure manifests as more marked fluctuation in pulmonary cap- illary wedge pressure than LA and LV diastolic pressures. Likewise, exaggerated ventricular interdependence can be observed with simultaneous recordings of LV and RV pressures (Fig. 12-29). With inspiration, which induces less filling of the LV, LV peak systolic pressure decreases. Simultaneous enhanced RV filling increases RV peak sys- tolic pressure (34). LV and RV ejection times also vary in opposite directions with respiration. This discordance between RV and LV pressures during inspiration should be sought as a sign of exaggerated interdependence of ventricular filling and, therefore, pericardial constric- tion. These changes do not occur in restrictive cardio- myopathy. Pressure and time descriptors of enhanced ventricular interaction are readily quantified as an area under the curve parameter, i.e., the systolic area index, defined as the ratio of RV to LV area in inspiration versus expiration (34). A systolic area index of greater than 1.1 identifies constrictive pericarditis with 97% sensitivity and 100% specificity (34). Hence, the invasive diagnosis of constriction should be based on respiration-mediated hemodynamic changes instead of traditional criteria &RS\ULJKW ‹

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