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The Echo Manual

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CHAPTER 12 PERICARDIAL DISEASES

FIGURE 12-30 Simultaneous left ventricular ( LV ) and right ventricular ( RV ) pres- sure tracings in restrictive cardiomyopathy ( RCM ) and constriction. (See text for details.) The concordant changes in peak LV and RV systolic pressures with respiration in RCM are opposite to those discordant changes in constriction. Arrows , Concordant ( left ) and discordant ( right ) LV and RV systolic pressures in RCM ( left ) and constriction ( right ).

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(see Fig. 4-14B). Noninfrequently, constrictive pericarditis can coexist with severe tricuspid regurgitation (see below). Coexisting Cardiac Abnormalities with Constrictive Pericarditis Several cardiac conditions can coexist with constrictive pericarditis including valvular heart disease and myocar- dial disease. Tricuspid regurgitation is relatively common in patients with constrictive pericarditis and moderate to severe in 20% (45). When tricuspid regurgitation and con- strictive pericarditis coexist, constrictive pericarditis may be missed. In this situation, hepatic vein Doppler can be help- ful. In patients with severe tricuspid regurgitation alone, hepatic vein Doppler shows distinct systolic flow reversals. If constriction and severe tricuspid regurgitation are pres- ent together, there are prominent diastolic flow reversals, especially with expiration (Fig. 12-31). The expiratory hepatic vein diastolic flow reversal pattern is highly specific for constriction and can help diagnose constriction when it coexists with other structurally more obvious condi- tions. In patients with a history of radiation therapy to the chest, 10 to 30 years prior may present with aortic valve, mitral valve, and/or coronary artery disease. Figure 12-32 demonstrates echocardiography data in a patient who was referred to us for aortic valve replacement, with an aortic valve area of 0.6 cm 2 and a mean gradient of 30 mm Hg. Hepatic vein Doppler demonstrated diastolic flow reversal with expiration consistent with constrictive hemodynam- ics, and tissue Doppler showed increased mitral annulus e ′ velocity along with the annulus reversus. The patient had a history of radiation treatment and ultimately underwent pericardiectomy as well as aortic valve replacement for constrictive pericarditis and low flow low gradient severe aortic stenosis (46).

not be restrictive because the LV filling pressure is rela- tively low (Fig. 12-30A). The Doppler finding that most reliably distinguishes chronic obstructive lung disease from constrictive pericarditis is the superior vena cava flow profile. Superior vena cava flow markedly increases with inspiration (Fig. 12-30B) because intrathoracic pres- sure decreases to a greater degree in chronic obstructive lung disease and RA pressure is typically normal. In con- trast, with constrictive pericarditis, superior vena cava systolic flow velocities do not change significantly with respiration (Fig. 12-30B); the difference in systolic for- ward flow velocity between inspiration and expiration is rarely more than 20 cm/s in constrictive pericarditis (44). It should be emphasized that systolic, not diastolic, flow velocities in the superior vena cava should be compared during respiration. Acute Dilatation of the Right Heart Acute dilatation of the right heart from pulmonary embo- lism or RV infarction can cause changes in increased ventricular interdependence. In these cases, the pericar- dium is intrinsically normal but becomes noncompliant because it has no time to stretch in response to sudden RV dilatation. Tricuspid Regurgitation Patients with severe tricuspid regurgitation present with right heart failure and similar clinical manifestations as constrictive pericarditis. However, echocardiography should be able to detect severe TR by 2-D, Doppler, and color flow imaging. Sometimes, torrential TR may show laminar flow, which may escape our visual detection. Hepatic vein Doppler should also show characteristic systolic flow reversals, which increases with inspiration

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