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8 Imaging Studies andHaemodynamics inChronic Constrictive Pericarditis
a
Fig. 8.35 Four chamber T2 weighted MRI image (a) shows biatrial dilation and tubular ventricles
with thickened pericardium (white arrows). Four chamber image from a tagged cine sequence (b)
shows adherence and immobility of the myocardial-pericardial interface. (LA- Left atrium,
LV-Left ventricle, RA-Right atrium, RV-Right ventricle)
a
b
b
Fig. 8.36 Four chamber view (a) and short axis view (b) shows presence of enhancing thickened
pericardium (white arrowheads) with intrapericardial collection (*). There is presence of biatrial
dilation. Note is also made of bilateral pleural effusion (yellow arrowheads). (LA- Left atrium,
LV-Left ventricle, RA-Right atrium, RV-Right ventricle)
Cine magnetic resonance can be acquired in real time and provide data on ventricular interdependence evaluation. Free-breathing cine magnetic resonance imaging enables visual assessment of ventricular septal shift with good sensitivity and
specicity [15, 45, 46]. Ventricular interdependence can also be quantitatively evaluated by cardiac magnetic resonance derived indices. From left ventricular shortaxis view, ([cardiac area] end-inspiration/ [cardiac area] end-expiration) is
signicantly less in constrictive pericarditis as compared with patients without constrictive pericarditis (1.03±0.03 versus 1.28±0.10; p<0.0001), respectively.
The abrupt restriction of ventricular lling that is often noted with constrictive
pericarditis can be quantied with cardiac magnetic resonance by assessing
8.4 Cardiac Catheterization Haemodynamics
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ventricular volume over time. Cardiac magnetic resonance phase-encoding velocimetry can accurately assess forward ow and the rate of blood return from the
superior caval vein during ventricular systole to help in the diagnosis of constrictive
pericarditis [56, 71]. By plotting a phase-velocity map, characteristic features that
differentiate shared patterns of ventricular diastolic impairment, such as that commonly noted with restrictive cardiomyopathy, can be used. The use of velocityencoded cardiac MRI allows assessment of mitral and tricuspid velocities [215].
Detection of a dilated inferior caval vein by cardiac magnetic resonance suggests
the possibility of constrictive pericarditis in the presence of pericardial thickening
[71, 72]. Owing to high sensitivity of the dilated inferior caval vein in chronic constrictive pericarditis, its absence virtually excludes constrictive pericarditis [71, 72].
In cases of diagnostic dilemma, cardiac magnetic resonance imaging (CMR) is
the investigation of choice with its ability to dene both morphological (left atrial,
superior and inferior caval venous dilation, ventricular elongation, myocardial atrophy and brosis) and functional changes (constriction, septal bounce) unlike nongated computed tomography which demonstrates only morphological changes [44,
163–165, 167].
On cine sequences, CMR shows ventriculo-ventricular interaction with evidence
of a attened interventricular septum or its convexity towards left ventricle in enddiastole, suggesting high right ventricular pressure. During deep inspiration, there is
an increased venous return to right heart and in the presence of constrictive pericarditis, the left ventricular lling reduces and the septum attens or becomes convex
towards left ventricle. On deep expiration, there is reversal of this phenomenon [44,
163–165, 167].
It can be challenging in cases of advanced constrictive pericarditis patients, who
are unable to hold their breaths; in those with supraventricular arrhythmias who
require free breathing techniques; and in patients with calcic chronic pericarditis
(Figs.8.29, 8.30, 8.31, 8.32, 8.33, 8.34, 8.35, and 8.36) [14, 71, 98, 155].
127
8.4 Cardiac Catheterization Haemodynamics
Despite the availability of several non-imaging modalities, cardiac catheterization is
helpful when evaluating a patient with suspected constrictive pericarditis and differentiating it from restrictive cardiomyopathy, tropical endomyocardial brosis,
and other causes mimicking constrictive pericarditis [17, 33, 36, 38, 107, 134, 135,
157, 158, 215–217, 223–229]. Cardiac catheterization quanties left and right heart
pressures, conrms clinically suspected pericardial constriction, uncovers occult
constriction, diagnose effusive-constrictive disease and identies associated coronary, myocardial, and valvular disease. Finally, catheterization provides information regarding coronary artery anatomy in patients aged more than 40years prior to
pericardiectomy. External pinching or compression of a coronary artery by the constricting pericardium is rarely detected [231, 238].
Hallmark features include early rapid lling, elevation of mean left and right
atrial pressures above 10mmHg, and equalization of end-diastolic pressures in all
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8 Imaging Studies andHaemodynamics inChronic Constrictive Pericarditis
four cardiac chambers [207–212]. The difference has to be less than 5mmHg at rest.
This is more obvious after premature ventricular contraction and one beat after the
onset of inspiration [57–61, 144]. The right atrial pressure shows a preserved
descent, a prominent Y-descent, and roughly equal a and v wave heights, with a
resultant M or W conguration. Right and left ventricular pressures reveal an early
diastolic dip followed by a plateau (“dip and plateau” or “square root sign”).
As highlighted by Hurrell and associates, the tight ventricular interaction in conjunction with insulation of the cardiac chambers from variations of intrathoracic pressures during the respiratory cycle are the two key mechanisms underlying the
pathology of chronic constrictive pericarditis resulting in dissociation of intrathoracic
and intracardiac pressure. These fundamental principles explain why dynamic respiratory variation in left and right ventricular haemodynamics during catheterization is
paramount in the diagnosis of chronic constrictive pericarditis [77, 127, 128].
In patients with endomyocardial brosis, restrictive cardiomyopathy, and in
patients with a normal pericardium, there is a concordance of left and right ventricular pressures [127, 128]. As a manifestation of exaggerated ventricular interdependence, there is increased respiratory variation in left and right ventricular
systolic and diastolic pressure. During peak inspiration, there is decrease in left
ventricular pressure and a concomitant increase in right ventricular pressure, indicating discordance of ventricular pressures. This has been quantied by using the
“systolic area index”, the ratio of right ventricle to left ventricle systolic pressure
times area in inspiration versus expiration. A ratio greater than 1: 1 strongly suggests constriction [219].
Hancock stated that “a comparison of end-diastolic pressure in the two ventricles
is the most critical way, and a comparison of the mean pressures in the right and left
atrium (or the pulmonary capillary wedge pressure) may be the most reliable way,
to evaluate diastolic equalization of pressures” [57–61].
If the diastolic pressures are low in a suspected case of chronic constrictive pericarditis (occult constrictive pericarditis), a one litre intravenous bolus can enhance
the diastolic pressure and will separate the right and left diastolic pressure by more
than 5mmHg in normal dehydrated patients without constrictive pericarditis. In a
case of constrictive pericarditis, despite pressure rise, the right and left sided pressures will not disperse after bolus uid administration [16].
Other causes of diastolic equalization of pressure such as atrial septal defect with
hyperinated lungs, pericardial tamponade, endomyocardial brosis, restrictive cardiomyopathy, end-stage cardiomyopathy, and cardiac amyloidosis need to be
excluded before diagnosing constrictive pericarditis [72, 144, 185].
Vaitkus and Kussmaul demonstrated overall predictive accuracy of three major
haemodynamic criteria obtained by cardiac catheterisation in the diagnosis of
chronic constrictive pericarditis. A difference between right and left ventricular
pressures of 5mmHg or less, a ratio of right ventricular end-diastolic pressure to
right ventricular systolic pressure of >1.3, and a right ventricular systolic pressure
of 50mmHg or less have 85%, 76% and 70% sensitivity respectively for diagnosing
chronic constrictive pericarditis [230]. The sensitivity increases to 97% and the predictive accuracy reaches 100% when all three criteria are present [57–64, 72, 77,
127, 128, 144, 191, 192, 214].
8.5 Radionuclide Ventriculography
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The pulmonary capillary wedge pressure declines more than the left ventricular
end-diastolic pressure during inspiration; the reduction in transmitral ow translates
into the observed reduction in left ventricular systolic pressure. In restrictive cardiomyopathy, both right and left ventricular systolic pressures decrease concordantly
with inspiration [77]. Ventricular interdependence has 100% sensitivity and 95%
specicity for distinguishing chronic constrictive pericarditis from restrictive cardiomyopathy [77]. Other ndings on cardiac catheterization which can assist in the
diagnosis are increased distance between the coronary arteries and the cardiac silhouette, which suggest the presence of thickened pericardium, and tethering of
coronary arteries to the diaphragm.
In the Mayo Clinic, as well as in All India Institute of Medical Sciences (AIIMS),
New Delhi, cardiac catheterization was not deemed necessary for patients in whom
the diagnosis of typical chronic constrictive pericarditis could be made on the basis
of the clinical presentation and typical features on non-invasive testing which
include a restrictive mitral inow velocity, typical respiratory changes in transmitral
and hepatic vein Doppler velocities, and a normal to increased early diastolic mitral
annular tissue velocity along with ndings suggestive of constrictive physiology in
computed tomography and magnetic resonance imaging [18–25, 112, 134, 135, 214].
Ratio of right ventricular diastolic pressure to systolic pressure of greater than
one-third, as well as right ventricular or pulmonary systolic pressures of less than
55mmHg, are commonly found in constrictive pericarditis, but not in restrictive
cardiomyopathy [57–64, 77, 127, 128, 144, 181, 191–202, 229]. Another character-
istic sign of constrictive pericarditis during right heart catheterisation are the ‘diastolic dip and plateau’ (square root sign) and a prominent rapid lling wave. Further
characteristic ndings are Kussmaul’s sign and pulsus paradoxus which are discussed in the pathophysiological ndings section of this manuscript (Chap. 6). Of
143 patients with constrictive pericarditis operated in Mayo Clinic, 78 patients
underwent cardiac catheterization. Among these patients, diastolic equalization of
pressures and dip and plateau were seen in 81% and 77% respectively. Respiratory
variation in left-right ventricular gradient was seen in 44%. The mean atrial pressure
was around 21mmHg [219].
129
8.5 Radionuclide Ventriculography
In recent times, several investigators have suggested myocardial tagging as an alternative method of diagnosing mitral and/or tricuspid involvement in the setting of
chronic constrictive pericarditis. Normally with ventricular contraction there is a
slippage between the pericardium and myocardium. However, with pericardial
adhesions, this slippage is absent and the tag lines passing through the myocardium
and pericardium are not deformed during the cardiac cycle [99]. The presence of
abnormal diastolic motion of the septum on cine magnetic resonance imaging may
also be a useful nding to diagnose chronic constrictive pericarditis, and distinguishes it from restrictive cardiomyopathy [55, 56].
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8 Imaging Studies andHaemodynamics inChronic Constrictive Pericarditis
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