Constrictive Pericarditis

Question 1

3 effects of CP on the left and right cardiac chambers

1. Early during diastolic filling, the pressure of all 4 cardiac chambers _____________ enough to equalize
2. The shell prevents the transmission of intrathoracic pressure to the cardiac chambers _____________
3. Both LV and RV are constricted within this shell, so that a change in volume of one chamber reflects upon the other _________________

Answer 1

1. Early during diastolic filling, the pressure of all 4 cardiac chambers increases enough to equalize with the pressure exerted by the stretched shell, that is, a high pressure of 15 to 25 mmHg.
2. The shell prevents the transmission of intrathoracic pressure to the cardiac chambers (dissociation between intracardiac and intrathoracic pressures).
3. Both LV and RV are constricted within this shell, so that a change in volume of one chamber reflects upon the other (ventricular interdependence).

Question 2

Hemodynamic findings/pathophy in CP:

1. Diastolic pressures?
2. RA and RV tracing
3. RA pressure

Answer 2

1. Mean RA pressure ~ mean PCWP and RVEDP = diastolic PA pressure = LVEDP.
   -Diastolic pressure of all 4 cardiac chambers, diastolic PA pressure, and diastolic PCWP (~mean PCWP) all become equal to the pressure of the stretched pericardium (equalization of diastolic pressures).
2. Deep X and Y descent
   -In early systole, upon downward movement of the valvular annulus, RA and LA pressures sharply decrease before they again promptly equalize with the pericardial pressure (Deep and rapid X descent)
   -In early diastole, upon ventricular relaxation, there is a sharp decrease of ventricular pressure with subsequent “sucking” from the atria. However, because of constriction, the pressure in the ventricles quickly rises and equalizes with the pericardial pressure (Deep and rapid Y descent)
3. Ventricular Dip and Plateau
   -In early diastole, upon ventricular relaxation, there is a sharp decrease of ventricular pressure with subsequent “sucking” from the atria. However, because of constriction, the pressure in the ventricles quickly rises and equalizes with the pericardial pressure.
4. High mean RA pressure

Question 3

Normal physiology:

On INSPIRATION:
______________ intrathoracic and intracardiac pressure (RV and LV)
______________ venous return through the SVC and IVC (extrathoracic)
Increase flow to the ________ and RV

______________ pulmonary venous pressure (PV are intrathoracic and extracardiac)
______________ LA-LV gradient
______________ LV filling/flow

Answer 3

1. Decrease intrathoracic and intracardiac pressure (RV and LV)
2. Increase venous return through the SVC and IVC
3. Increase flow to the RA and RV
4. Decrease pulmonary venous pressure (PV are intrathoracic and extracardiac)
5. Unchanged/minimal change in LA-LV gradient (since there is a decrease pressure in PV and LA/LV)
6. Minimal or no change LV filling/flow

Reverse in expiration

Question 4

Constrictive physiology:

On INSPIRATION:
______________ intrathoracic pressure
______________ intracardiac pressure (RA, LA, RV and LV)
______________ SVC pressure, __________ IVC pressure
______________ SVC flow, __________ IVC flow
Increase flow to the ________ and __________ for a short period due to the flow from IVC in early diastole

______________ pulmonary venous pressure and PCWP (PV are intrathoracic and extracardiac)
______________ LA-LV gradient
______________ LV filling/preload and stroke volume

Answer 4

1. Decrease intrathoracic pressure
2. No change in intracardiac pressure (RA, LA, RV and LV)
3. Decrease in SVC pressure, no change IVC pressure (extrathoracic)
4. Decrease SVC flow, increase IVC flow (partly because of the positive intra-abdominal pressure)
5. Increase flow to the RA and RV for a short period due to the flow from IVC in early diastole
6. Decrease pulmonary venous pressure and PCWP (PV are intrathoracic and extracardiac)
7. Decrease LA-LV gradient (PV/PCWP decreased pressure, but LA/LV unchanged)
8. Decrease LV filling/preload and stroke volume

Decrease in PCWP and pulmonary venous pressure, but the LA and LV pressures are unchanged, so that the driving gradient between the pulmonary veins and the LV is reduced. This reduces flow toward the LV (manifested as reduced transmitral E velocity on echocardiography).

Because of ventricular interdependence, the reduced LV volume “sucks” the RV during inspiration; thus, the RV sucks flow from the RA, and the flow between the RA and RV increases

The flow between RA and RV is mainly increased for a short period that corresponds to the deep Y and X descents

Question 5

Constrictive physiology:

On EXPIRATION:
______________ intrathoracic pressure
______________ intracardiac pressure (RA, LA, RV and LV)
______________ SVC pressure, __________ IVC pressure
______________ SVC flow, __________ IVC flow
Increase flow to the ________ and __________ for a short period due to the flow from IVC in early diastole

______________ pulmonary venous pressure and PCWP (PV are intrathoracic and extracardiac)
______________ LA-LV gradient
______________ LV filling/preload and stroke volume

Answer 5

1. Increase intrathoracic pressure
2. No change in intracardiac pressure (RA, LA, RV and LV)
3. Increase in SVC pressure, no change IVC pressure (extrathoracic)
4. Increase SVC flow, decrease IVC flow
5. Increase flow between PV and LA, LA to LV, shifts IVS to the right
6. Decrease in RV volume, dec flow from RA and IVC; but flow between SVC and RA is increased
7. Increase pulmonary venous pressure and PCWP (PV are intrathoracic and extracardiac)
8. Increase LA-LV gradient (PV/PCWP increase pressure, but LA/LV unchanged)
9. Increase LV filling/preload and stroke volume

Question 6

Restrictive CMP vs Constrictive Pericarditis

Restrictive CMP
Decreased ventricular chamber ________________ due to increased myocardial ____________.
The steep compliance curve results in an abnormal increase in impedance throughout the ________________ and a reduced atrial filling component at end-diastole

Constrictive Pericarditis
The ventricular chamber compliance is __________ in ______ diastole, allowing for normal or rapid early filling.
In _____________, ventricular filling is abruptly decelerated as the intracardiac volume approaches the fixed limit of the constricting pericardium.

Answer 6

1. Compliance
2. Stiffness
3. Entire diastolic period
4. Normal, early diastole
5. Mid-diastole

Question 7

________________ heard on physical examination corresponds to the sudden cessation of ventricular filling at the end of the dip, when the ventricles hit the pericardium

Answer 7

Pericardial knock

Question 8

Lack of inspiratory fall or increase in in JVP on inspiration

Answer 8

Kussmaul’s sign

SVC pressure decreases but RA pressure does not decrease because of constriction. Thus, the flow between SVC and RA decreases with inspiration, which ultimately leads to increased SVC pressure and reduced flow within the SVC, hence the increased jugular venous pressure with inspiration

Question 9

Features shared by constrictive pericarditis, restrictive cardiomyopathy, and decompensated ventricular failure

Answer 9

1-Elevated right- and left-sided filling pressures (elevated RA pressure and PCWP)

2-Ventricular dip-plateau pattern

3-Deep atrial X and Y descents with an atrial M morphology

Question 10

5 traditional criteria of CP

Answer 10

1. End-diastolic pressure equalization (LV end-diastolic pressure minus RV end-diastolic pressure <5 mm Hg)
2. PAP <55 mm Hg
3. RV end-diastolic pressure divided by RV systolic pressure >1/3
4. Dip and plateau diastolic pressure morphology as reflected by the height of the LV rapid filling wave (>7 mm Hg)
5. Kussmaul’s sign (No or minimal inspiratory decrease of mean RA pressure (<3-5 mmHg) (X and Y become deeper and RA pressure may increase with inspiration))

Neither sensitive or specific for CP

Question 11

____________________________ (correspondence of LV-RV systolic pressures) exhibited during respiration is the most sensitive and specific hemodynamic finding differentiating constrictive pericarditis from restrictive physiology.

Answer 11

Dynamic ventricular interdependence (100% sensitive, 95% specific)

During peak inspiration, there was discordance between RV and LV function with an increase in RV systolic pressure and simultaneous decrease in LV systolic pressure.

Question 12

Hemodynamic findings in Severe RV Failure or Severe TR (acute/subacute RV dilatation, acute PE)

Answer 12

1. The ventricular interdependence is not markedly affected by respiration because the RV is already markedly distended and may not distend further and increase its output with inspiration
2. The X descent is usually shallow in TR or RV failure. A large V wave is more common in TR than in CP but may be present in both.
3. Patients with severe RV failure or TR have an inspiratory increase in RA pressure and V wave and may have mean RA pressure > mean PCWP. In RV failure or TR, the right-sided flow and TR volume increase with inspiration. All right-sided pressures (RA, SVC [Kussmaul], IVC, V wave/Y descent, and RV end-diastolic pressure) significantly increase during inspiration despite the transmission of the negative inspiratory pressure to the cardiac chambers

RVEDP > LVEDP
Mean RA pressure or RVEDP > mean PCWP

Only in RV failure can RVEDP or RA pressure be higher than LVEDP.

Question 13

Difference of COPD from CP

Answer 13

1. Inspiratory decrease of RA pressure
2. Inspiratory increase of SVC to RA flow.
3. Lack of equalization of diastolic pressures
4. Lack of deep X/deep Y on the RA tracing
5. Lack of the dip-plateau pattern on the ventricular tracings.