David H. Wiener, MD Profile picture
Aug 1, 2018 12 tweets 19 min read Twitter logo Read on Twitter
#FITSurvivalGuide on Restrictive Cardiomyopathy (RCM) vs Constrictive Pericarditis (CP).

In both:

💠Diastolic RV & LV impaired; systolic function preserved
💠HFpEF phenotype, predominant “R sided” signs (­JVP, edema, ascites)

@dr_chirumamilla @Pooh_Velagapudi @bcostelloMD
🔑 to understanding different filling:
RCM = myocardial disorder
CP = pericardial disorder.

@majazayeri @fawazalenezi55 @SanChris999 @GuruKowlgi @Nidhi_Madan9 @sabeedak1 @noshreza @SaggerMawri @nsivcd @DrManiCardio @khandelwalMD @drjohnm @heartdoc45 @zainasadEP @docaward

💠Stiff myocardium➡️early diastolic ⏫­­LV and RV pressure w/small vol ∆
💠 Echo: early diastolic abnormalities
💠High initial flow (= E wave; so E/A >2); ends abruptly (⬇️E decel time)

⚠️Restrictive pattern also in stage 3 HFrEF w/abnl early diastole


💠Pericardial shell ➡️dissociation between intrathoracic pressure (PCWP) and intracardiac (ICP) ∆s
💠Inspiration: PCWP outside the sac &⬇️; ICP inside the sac and ≠ ⬇️
💠⬇️driving gradient & LV doesn’t fill as well.

@ekgpdx @chadialraies @mirvatalasnag
Echo in CP: exaggerated ventricular interdependence:

💠Inspiration (⬇️LV filling)
💠⬇️ MV flow
💠Septum shifts left (“bounce’ on echo)
💠RV fills better, ⬆️TV flow
💠Expiration = opposite; & HV late diastolic flow reversal (due to ⬇️RV filling)

Other #EchoFirst stuff in CP

💠To dx V interdependence: turn on respirometer on machine (ask a sonographer!)
💠Other D/O also have V interdependence (tamponade)
💠Annulus reversus (lateral e’ < septal – opposite of usual). Lateral not septal
myocardium bound by pericardium
Etiologies of CP vary geographically; include

💠Post radiation therapy
💠Connective tissue disease
💠TB (developing countries)

@venkmurthy @fischman_david @drtoniyasingh @drmarthagulati @vietheartPA @regadenoson
Advanced imaging helps distinguish; and helps establish etiologies (details in chart; images here!)

@cardiojaydoc02 @mark_kaeppler @mmamas1973 @CMichaelGibson @DocSavageTJU @rajivxgulati @SVRaoMD @MinnowWalsh @DrKevinCampbell @krishmd @cardiodee @DrLaxmiMehta

💠Both: early rapid filling, square root sign.
💠“Classic” criteria to distinguish (= pressures,­ ⬆️RVSP, LVEDP>RVEDP) are < specific than thought

🔑 for CP: RV vs LV filling varies with respiration. PCWP-LVP gradient varies by >5 mm with respiration

References and Summary Table:

JACC 2016;68:2329–47
JACC 2016;67:2061–76
Circ Res 2017;121:819-837
J Am Coll Cardiol 2018;71:1149–66
Am Coll Cardiol 2018;71:1130–48

Cath and multimodality colleagues: input invited! 😉

@ash71us @purviparwani @gina_lundberg

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