Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3715_Библиотеки_им_академика_М_И_Перельмана
.pdf
46
ab
https://t.me/medicina_free
5 Clinical Challenges andDiagnostic Dilemma ofChronic Constrictive Pericarditis
are specic clinical signs found in 21% and 36% of patients with chronic constrictive pericarditis respectively [10–16, 47–50, 75, 97, 98, 108, 109].
Among laboratory parameters, erythrocyte sedimentation rate may be raised.
Plasma protein levels are reduced. Although the electrocardiographic ndings of
low voltage QRS complex, ST-T abnormalities, P-mitrale (19–37%), and atrial
brillation (30%) are non-specic, a completely normal electrocardiogram is rare in
constrictive pericarditis [7, 10, 18, 47–50, 66, 67, 97, 98].
Although chest radiography as a single non-invasive imaging modality is not
helpful in the diagnosis of chronic constrictive pericarditis, certain ndings suggest
the existence of chronic constrictive pericarditis [1, 2, 10–16]. In a typical patient
with chronic constrictive pericarditis, the cardiac silhouette is not enlarged except
with co-existing pericardial effusion or extracardiac mass. “Eggshell calcications”,
“cocoon calcications” or “amorphous calcication” in atrioventricular grooves
strongly suggest constrictive pericarditis in patients with heart failure [10–16, 68,
69, 76]. Pericardial calcication may be revealed over the right atrium and ventricle
and atrioventricular groove on lateral chest x-ray (Figs.5.1 and 5.2) [10–14, 68,
69, 76].
Although no single pathognomonic echocardiographic nding exists for chronic
constrictive pericarditis, a normal study virtually rules out the diagnosis of the same.
M-mode echocardiography reveals pericardial calcication, pericardial thickening,
rapid early diastolic lling, abnormal septal motion, attening of left ventricular
posterior wall endocardium, posterior left ventricular wall motion in mid-diastole
and premature opening of the pulmonary valve [1, 12, 13, 19, 20, 24, 33, 34, 52, 77,
78, 88–91, 134, 135, 144, 145].
Talreja etal. demonstrated that 15–20% of constrictive pericarditis patients had
a normal pericardium or mildly increased pericardial thickness [134]. Trappe and
colleagues demonstrated abruptly reduced respirophasic early diastolic posterior
motion of the interventricular septum due to underlling of the left ventricle secondary to inspiratory pulmonary vein-left atrial gradient [136].
Fig. 5.1 Frontal (a) and left lateral (b) chest radiographs reveal thick, plaque- like calcications
(arrowheads) over the diaphragmatic surface and free walls of both ventricles and along the atrioventricular groove
5 Clinical Challenges andDiagnostic Dilemma ofChronic Constrictive Pericarditis
https://t.me/medicina_free
Fig. 5.2 Lateral chest
radiograph reveals
extensive circumferential
pericardial calcication
(indicated by white arrows)
47
The role of 2D echocardiography in the introductory phase was to exclude other
causes of right heart failure secondary to valvular heart diseases, pulmonary hypertension, right ventricular infarction and pulmonary thromboembolism [35, 36, 53,
59–63, 88–91, 110–114]. Individuals with constrictive percarditis usually have pre-
served ejection fraction with normal ventricular dimensions; however, it may be
impaired in mixed constrictive restrictive disease. Annular constrictive pericarditis
secondary to a constricting calcic or non-calcic brous band may produce left
ventricular inow or right ventricular outow tract obstruction [17].
Two-dimensional echocardiographic ndings suggestive of constrictive pericarditis include: (i) dilation and non-collapsible inferior caval vein and hepatic veins,
(ii) abnormal septal motion, (iii) increased or preserved early diastolic e’ velocity of
the medial mitral annulus, and (iv) increased expiratory hepatic ow reversal reecting dissociation of intrathoracic and intracardiac pressures and ventriculo- ventricular
interaction (Fig.5.3a and 5.4h) [3–6, 24, 35, 36, 71, 77–81, 88–91].
Several investigators including ourselves have demonstrated superior resolution
of pericardial thickness using transesophageal echocardiography as compared with
transthoracic echocardiography.
A pericardial thickness of 3mm or more on transoesophageal echocardiography
was 95% sensitive and 86% specic for establishing the diagnosis of constrictive
pericarditis [69, 70]. Transesophageal echocardiographic measurements correlates
strongly with cardiac computed tomographic in evaluation of pericardial thickness
[51]. However, the role of echocardiography is limited in the evaluation of
48
a
https://t.me/medicina_free
5 Clinical Challenges andDiagnostic Dilemma ofChronic Constrictive Pericarditis
b
c
Fig. 5.3 (a) Preoperative echocardiographic images in a patient with chronic constrictive pericarditis. Apical four chamber view showing normal valvular, left and right ventricular morphology,
(b) Apical ve chamber view showing normal valvular, left and right ventricular morphology, (c)
M-mode echocardiogram showing normal left ventricle with attened interventricular septum, (d)
Colour ow Doppler echocardiogram showing normal ow across the mitral valve, (e) Colour ow
Doppler echocardiogram showing normal ow across the tricuspid valve, (f) Hepatic vein ow
Doppler showing increased respiratory variations, (g) Inferior caval venous imaging showing
dilated and non-collapsing inferior caval vein, (h) Pulse wave Doppler signals at the tricuspid
valves showing increased respiratory variations, (i) Pulse wave Doppler signals at the mitral valve
showing increased respiratory variations, (j, k) Doppler signals using tissue Doppler imaging in
apical four chamber view with sample volume placed at the medial and lateral annulus respectively
showing annulus reversus. Mitral valve inow e/a>1.5
5 Clinical Challenges andDiagnostic Dilemma ofChronic Constrictive Pericarditis
https://t.me/medicina_free
d
e
f
49
g
Fig. 5.3 (continued)
50
https://t.me/medicina_free
5 Clinical Challenges andDiagnostic Dilemma ofChronic Constrictive Pericarditis
h
i
j
k
Fig. 5.3 (continued)
5 Clinical Challenges andDiagnostic Dilemma ofChronic Constrictive Pericarditis
https://t.me/medicina_free
a
b
51
Fig. 5.4 (a) Preoperative echocardiographic images in a patient with chronic constrictive pericarditis. Apical four chamber view showing normal valvular, left and right ventricular morphology.
(b) Colour ow Doppler echocardiogram showing normal ow across the mitral valve. (c) Colour
ow Doppler echocardiogram showing normal ow across the tricuspid valve. (d) Inferior caval
venous imaging showing dilated and non-collapsing inferior caval vein. (e) Pulse wave Doppler
signals at the tricuspid valves showing increased respiratory variations. (f) Pulse wave Doppler
signals at the mitral valve showing increased respiratory variations. (g, h) Doppler signals using
tissue Doppler imaging in apical four chamber view with sample volume placed at the medial and
lateral annulus respectively showing annulus reversus. Mitral valve inow e/a>1.5
52
https://t.me/medicina_free
5 Clinical Challenges andDiagnostic Dilemma ofChronic Constrictive Pericarditis
c
d
Fig. 5.4 (continued)
5 Clinical Challenges andDiagnostic Dilemma ofChronic Constrictive Pericarditis
https://t.me/medicina_free
e
53
f
Fig. 5.4 (continued)
54
https://t.me/medicina_free
5 Clinical Challenges andDiagnostic Dilemma ofChronic Constrictive Pericarditis
g
h
Fig. 5.4 (continued)
5 Clinical Challenges andDiagnostic Dilemma ofChronic Constrictive Pericarditis
https://t.me/medicina_free
55
pericardial thickening anterior to the right ventricular and the juxta right atrioventricular groove [10–16, 29–32, 36, 60–63, 80, 81, 103–106, 139].
It is noteworthy that 25–30% of patients with constrictive pericarditis do not
exhibit any respirophasic variations in blood ow velocities [88–91]. Additionally,
respirophasic variations are also observed in other confounding conditions namely,
right ventricular systolic dysfunction and chronic obstructive pulmonary disease
[9, 29–32].
Some investigators have proposed other echocardiographic tests to reduce preload to unmask respirophasic variation on trans mitral Doppler ow velocity [92].
However, the diagnosis remains equivocal in isolated instances and other diagnostic
modalities, namely multimodality imaging studies. Endomyocardial biopsy may all
be required [10–16, 21, 105, 115, 140].
Over the period of years, the diagnostic accuracy of constrictive pericarditis has
improved by taking into consideration the hemodynamic changes and mitral annular motion. In our previous investigation, Chronic constrictive pericarditis was considered to be hemodynamically signicant when there was clinical evidence of
constriction with supportive hemodynamic and echocardiographic criteria [10–16].
A constrictive pattern was dened as 25% or greater increase in mitral e’ velocity
and expiratory hepatic venous ow reversal compared with inspiration [10–16, 29–
32, 36, 60–63, 80, 81, 103–106, 139].
Tissue Doppler imaging has made possible the acquisition of myocardial wall
velocities and offers additional diagnostic information to M-mode,
2D-echocardiography and transmitral ow Doppler for detecting pericardial constriction, with a reported sensitivity and specicity of 88.8% and 94.8% respectively
(Figs.5.4g, H) [33–42, 68, 99, 116–122, 146, 147].
During systole, the mitral annulus descends towards apex, with no appreciable
apical motion in relation to the imaging transducer. Therefore, the annular displacement reects the extent or myocardial ber shortening in the longitudinal plane, and
has a strong linear correlation with global LV function [19].
Since the mechanoelastic properties of the myocardium are preserved in constrictive pericarditis, the longitudinal mitral annular velocities remain normal or can
be exaggerated lateral expansion in constrictive pericarditis is limited [99, 110–114,
119, 120].
Several investigators have demonstrated that in patients with preserved mitral e’
velocity (>8cm/s) and a low E/e’ ratio (<8cm/s) with high left ventricular lling
pressure and the recognition of “annulus reversus” should alert to the diagnosis of
constrictive pericarditis [46, 99, 100, 110–114, 119, 120].
In our previous investigation 54 patients undergoing pericardiectomy for chronic
constrictive pericarditis, we demonstrated that tissue Doppler imaging -derived
mitral and tricuspid annular velocities are non-predictors of postoperative outcome
following pericardiectomy and tissue Doppler imaging is a useful investigative
modality for diagnosis of constrictive pericarditis and not a useful indicator for
postoperative evaluation [10–16].
Whereas echo Doppler methods and tissue Doppler imaging rely mostly on longitudinal motion data, speckle tracking echocardiography can provide strain, strain
Соседние файлы в папке Библиотека им академика М.И. Перельмана