Cath Lab: Pressure Traces in Constrictive Pericarditis

From The Catheterization Handbook by Morton J. Kern
3rd ed. 1999. p. 201-202

Constrictive Pericarditis:
(From Boston Cath Manual)
1) Increase or equalization of pressures in RA, LA and EDPs (all within 5 mmHg from each other)...Isn't this normal?!
2) Kussmaul Sign: Loss of inspiratory decline in RA pressure (shown in trace above - lower panel)
3) Equalization of a and v waves, preserved x decent and prominent y decent. Thus creating "M" pattern. (shown in trace above)
4) Square root sign in ventricular pressure trace (both RV and LV). Shown in trace above. Also called "Dip and Plateau" sign.
Masked by tachycardia due to short diastole. So, inducing a PVC shows a long diastole - to visualize this pattern.
5) Record ventricular pressure during an induced ectopy for reason stated above.
6) Important: Most senstive and specific signs.
Ventricular discordance or Ventricular interdependence: Normally, RVSP and LVSP are supposed to raise and fall together with different phases of breathing. In Constrictive pericarditis, RVSP raises during inspiration while LVSP falls.
Also, Early transmitral gradient (LA - LVEDP or PAWp - LVEDP) decreases during inspiration. Normally, there is no such variation with respiration.

Echo: Abnormal Ventricular Diastolic Function

Extract from Snider's Echo book (Restrictive Cardiomyopathy):

Restrictive cardiomyopathy is characterized by

1) abrupt cessation of diastolic filling in the first 1/3rd of diastole

2) Associated with large atria, normal-sized ventricles and variable systolic function.

Normal LV dimensions, normal or low fractional shortening %.

M-mode:

Abrupt increase in LV dimension in early diastole (Abrupt posterior motion of LVPW and anterior motion of IVS) followed by no further increase in dimensions (i.e. flat LVPW & IVS throughout the rest of diastole)

2D:

Abrupt cessation of filling creates a jerky, spasmodic wall motion.

Doppler fl0w pattern:

MV Doppler:

Peak E and % of E area - Normal

Peak A & % of A area - Decreased

Therefore, E/A ratio is increased.

Mitral Deceleration Time:

Decreased less than 150 ms

LV. IVRT (Isovolumic relaxation time) - shorter

Mechnism of short deceleration time (MV): Rapid equalization of LVEDP and Atrial pressure(corresponds to "Rapid filling wave" in LV trace in cath lab).

Further shortening of TV deceleration occurs with inspiration (Increased filling -> septum bows to left -> Decreases LV diastolic function.

Mid-diastolic MR or TR (correspond to peak of rapid filling wave)

Systemic venous flow pattern:

1) Decreased forward flow during systole

2) Increased or prolong flow reversal during atrial contraction (worse during inspiration)...Reflects decreased RV compliance.

Diastolic forward flow in MPA (during inspiration)