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The Echo Manual

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CHAPTER 12 PERICARDIAL DISEASES

FIGURE 12-21 A figure of apical long axis view showing early diastolic motion of the medial mitral annulus ( downward arrows with dotted box ) in normal individual, patient with impaired relaxation in myocardial disease, and constrictive peri- carditis. Early diastolic mitral annulus velocity ( downward arrow ) is decreased in myocardial diseases and preserved or increased in contrictive pericarditis (Video 12-8). LV , left ventricle; RV , right ventricle. XWKRUL]HG UHSURGXFWLRQ RI WKH FRQWHQW LV SURKLELWHG GXFW

also been shown that the thickness of the pericardium at the atrioventricular groove is inversely proportional to the respective lateral e ′ velocity (42). Both septal and lateral LV e ′ velocity decrease after pericardiectomy (41). The reduc- tion in septal e ′ is proportionately greater, thus normaliz- ing the ratio between septal and lateral e ′ and abolishing annulus reversus. Myocardial tethering to the pericardium is also appar- ent with strain imaging of regional LV systolic function in patients with constrictive pericarditis. The inferior and lateral walls, which are tethered to the pericardium, show reduced longitudinal strain, while the ventricular septum maintains normal strain values (Fig. 12-23).

constriction versus restrictive myocardial disease (7,26,32) (Fig. 12-21). In almost all, if not all, myocardial disease, LV relaxation is impaired, so mitral annulus e ′ velocity, which reflects the rate of longitudinal myocardial relaxation, is decreased (medial e ′ < 7 cm/s and lateral e ′ < 10 cm/s in). In constrictive pericarditis, e ′ velocity is relatively normal or even increased (Figs. 12-21 and 12-22), as increased lon- gitudinal motion of the heart, particularly medially, com- pensates for the loss of ventricular filling from constricted radial expansion of the heart. This longitudinal motion increases further as constriction worsens, with associated higher filling pressure, opposite to the change in e ′ with myocardial disease. This phenomenon has been termed annulus paradoxus (38), wherein E/e ′ is inversely propor- tional to pulmonary capillary wedge pressure, in contrast to myocardial disease, where E/e ′ increases with pulmonary capillary wedge pressure. However, in case of concomi- tant myocardial disease as in radiation injury or coronary artery disease, medial e ′ velocity may be less than 7 cm/s and annulus paradoxus may not apply (39). Furthermore, septal e ′ usually exceeds lateral mitral annulus e ′ , which is the reverse of the normal situation. This so-called “annulus reversus” (40) is observed in about 80% of patients with constriction (Fig. 12-22) (26,41) and occurs because the lateral annulus is tethered by adherent pericardium. It has

MAYO CLINIC DIAGNOSTIC CRITERIA FOR CONSTRICTION

Since there are several echocardiographic findings with constrictive pericarditis, we established a simple set of diagnostic criteria that can be used to identify constric- tion patients with high sensitivity and specificity (26). Five principal echocardiography parameters were tested in 166 patients (130) with surgically confirmed con- strictive and 36 with restrictive myocardial disease or severe tricuspid regurgitation who had a comprehensive

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