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S4 W3 Constrictive Pericarditis and Restrictive CM > Constrictive Pericarditis > Flashcards

Constrictive Pericarditis Flashcards

1
Q

What is constrictive pericarditis?

A
  • Inflammation, thickening, scarring and/or calcification of the pericardium
  • Results in fusion of visceral and parietal pericardial layers
  • Encasement of heart within a solid, non-compliant sac
  • Impaired diastolic filing (due to fixed total intra-pericardial volume)
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2
Q

Restricted diastolic filling in CP?

A
  • Early diastole: rapid ventricular filling as normal
  • Mid diastole: rapid termination of diastolic flow occurs when the limits of pericardial compliance reached (i.e. pericardium can stretch no further)
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3
Q

Haemodynamic hallmark of CP?

A
  • Equalisation of diastolic pressures in all 4 chambers
  • “Square root sign” seen in cardiac catheterisation
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4
Q

Right and left heart filling with respiration in CP?

A
  • Exaggerated
  • Dissociation between ITP and ICP = haemodynamic effects similar to tamponade
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5
Q

Ventricular interdependence in CP?

A
  • Enhanced
  • Dissociation between ITP and ICP = haemodynamic effects similar to tamponade
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6
Q

What are the clinical signs of CP?

A
  • Kussmaul’s sign
  • Pericardial knock
  • Not specific for CP, also seen when right heart failure
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7
Q

What is Kussmaul’s sign?

A

Paradoxical rise in JVP on inspiration (normally falls)

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8
Q

What is a pericardial knock?

A
  • High pitch heart sounds in early diastole
  • Occurs when rapid ventricular filling is abruptly halted by the constricting pericardium
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9
Q

Anatomic features of CP?

A
  • Thickened and calcified pericardium
  • Fibrosis and adhesion of pericardial layers
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10
Q

CP vs Tamponade: Low CO state

A
  • CP: Yes
  • Tamponade: Yes
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11
Q

CP vs Tamponade: JVD

A
  • CP: Present
  • Tamponade: Present
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12
Q

CP vs Tamponade: Restricted Diastolic Filling

A
  • CP: Mid-late diastole
  • Tamponade: Entire diastolic period
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13
Q

CP vs Tamponade: Dissociation between ITP and ICP

A
  • CP: Isolation of heart by constrictive pericardial shell
  • Tamponade: Increased IPP (impedes transmission of ITP to pericardial sac and heart)
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14
Q

CP vs Tamponade: Kussmaul’s Sign

A
  • CP: Present
  • Tamponade: Absent
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15
Q

CP vs Tamponade: Pulsus Paradoxus

A
  • CP: Absent
  • Tamponade: Present
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16
Q

CP vs Tamponade: Heart Sounds

A
  • CP: Pericardial knock
  • Tamponade: Decreased
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17
Q

Echo signs of CP?

A
  • Notching of IVS (as seen on m-mode)
  • Pericardial thickening (increased echo-genicity of pericardium)
  • Absence of pericardial slippage (thickened pericardium tethered to the heart)
  • Septal bounce (exaggerated ventricular interdependence)
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18
Q

Enhanced Ventricular Interdependence in CP?

A
  • Inspiration: septum moves left = increased RV cavity size = decreased LV cavity size
  • Expiration: septum moves right = increased LV cavity size = decreased RV cavity size
19
Q

Mitral inflow variation in CP?

A
  • Decreased E velocity on 1st beat of inspiration
  • Same as tamponade
20
Q

IVRT in CP?

A

Prolonged IVRT 1st beat of inspiration

21
Q

Tricuspid inflow variation in CP?

A

Increased E velocity on 1st beat inspiration

22
Q

Hepatic venous variation in CP?

A
  • Increased peak D velocity on 1st beat inspiration
  • Marked increase AR velocity with expiration
23
Q

Formula to calculate respiratory change?

A

(Expiration - inspiration) / expiration x 100

24
Q

Transmitral significance of respiratory change in CP?

A

Inspiratory decrease in E velocity ≥ 25%

25
Q

Tricuspid significance of respiratory change in CP?

A

Inspiratory increase in E velocity > 40%

26
Q

Hepatic venous significance of respirator change in CP?

A
  • Expiratory increase in AR velocity ≥ 25% of forward flow
27
Q

Transmitral and tricuspid inflow in CP?

A
  • May show restrictive filling
  • E:A is high, > 2, and deceleration time is very short
28
Q

What is the normal relationship between lateral and septal e’?

A

Medial/septal e’ < lateral e’

29
Q

What is the relationship between lateral and septal e’ in CP?

A
  • Annulus reverses
  • Lateral e’ < septal e’
30
Q

What is the normal relationship between E/e’ ratio and LVFP?

A

The higher the E/e’ ratio, the higher the LV filling pressure

31
Q

What is the relationship between E/e’ ratio and LVFP in CP?

A
  • Annulus paradoxus
  • E/e’ ratio decreases as LV filling pressures increase
32
Q

Why does annulus reversus occur in CP?

A

Tethering of adjacent fibrotic and scarred pericardium which impedes diastolic lateral longitudinal motion (lateral e’ < medial e’)

33
Q

Why does annulus paradoxus occur in CP?

A

Compensatory increase in diastolic medial longitudinal motion (e’ preserved or accentuated despite increased LVFP)

34
Q

Calculating E/e’ in CP?

A
  • Use medial e’
  • Lateral e’ affected by calcification or adhesions of the pericardium
35
Q

Challenging cases in CP?

A
  • Chronic obstructive airways disease (COAD)
  • Ventilated patients
  • CP without respiratory variation
36
Q

What is COAD?

A
  • Exaggerated changes due to exaggerated respiratory changes in ITP
  • In COAD patients with pericardial thickening; may be difficult to determine cause for respiratory variation in MV/TV inflow
37
Q

How to distinguish COAD from CP?

A

Look at SVC flow profile

38
Q

COAD vs CP SVC Flow Profile?

A
  • COAD: marked augmentation of SD forward flow with inspiration
  • CP: minimal variation in S forward flow with respiration
39
Q

CP in ventilated patients?

A
  • Respiratory changes are opposite to spontaneously breathing patients
  • ITP increases (rather than decreases) with inspiration
40
Q

What can cause reduced respiratory variation?

A
  • Localised construction
  • Combined restrictive CM and CP
  • Markedly raised atrial pressure
41
Q

What to do when you suspect CP but no respiratory variations?

A

Sit or stand patient up and repeat mitral inflow to unmask characteristic respiratory variation

42
Q

What is effusive-constrictive pericarditis?

A

Pericardial effusion + constrictive physiology

43
Q

Echo features of effusive-constrictive pericarditis?

A
  1. Small-moderate PE
  2. Fibrous strands within PE
  3. Classic 2D/Doppler features of CP
44
Q

What is the gold standard for effusive-constrictive pericarditis?

A
  • Cardiac MRI
  • Can identify pericardial thickening and location of thickening (characterised by white rim around the heart)

S4 W3 Constrictive Pericarditis and Restrictive CM (2 decks)

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