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Constrictive pericarditis versus restrictive cardiomyopathy: a reappraisal and update of diagnostic criteria
1Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia 19104.
Insights
Differentiating constrictive pericarditis from restrictive cardiomyopathy is challenging. Hemodynamic criteria can aid diagnosis, but new imaging and biopsy techniques offer complementary insights for accurate patient selection.
Area of Science:
- Cardiology
- Cardiovascular Imaging
- Diagnostic Medicine
Background:
- Distinguishing constrictive pericarditis from restrictive cardiomyopathy presents a significant clinical challenge.
- Accurate differentiation is crucial as constrictive pericarditis is surgically curable, while restrictive cardiomyopathy is not.
Purpose of the Study:
- To review and evaluate existing methods for differentiating constrictive pericarditis from restrictive cardiomyopathy.
- To propose an algorithm integrating various diagnostic data for improved patient selection.
Main Methods:
- Systematic review of published reports utilizing hemodynamic criteria.
- Analysis of data from left ventriculography, Doppler echocardiography, radionuclide angiography, CT, MRI, and endomyocardial biopsy.
- Evaluation of diagnostic accuracy and limitations of each method.
Main Results:
- Hemodynamic criteria (RVEDP/LVEDP difference, RV systolic pressure, RVEDP/RV systolic pressure ratio) showed varying predictive accuracies (85%, 70%, 76%).
- Concordant hemodynamic criteria achieved >90% accuracy, but 25% of patients remained unclassified.
- Imaging modalities like CT and MRI show promise for detecting pericardial abnormalities; endomyocardial biopsy is useful for infiltrative cardiomyopathies.
Conclusions:
- Hemodynamic criteria are valuable but insufficient alone for diagnosing constrictive pericarditis versus restrictive cardiomyopathy.
- Newer imaging and biopsy techniques offer complementary diagnostic information.
- An integrated algorithm considering hemodynamic, imaging, and biopsy data is proposed for optimal patient selection, particularly for pericardial biopsy and stripping.
Abstract:
Distinguishing constrictive pericarditis from restrictive cardiomyopathy is a difficult clinical challenge. We review published reports in which hemodynamic criteria were used to differentiate these two diagnoses. There were 82 cases of constriction and 37 cases of restriction. The overall predictive accuracy of the difference between right and left ventricular end-diastolic pressures (RVEDP and LVEDP), RV systolic pressure, and the ratio of RVEDP to RV systolic pressure were 85%, 70%, and 76%, respectively. If all three criteria were concordant, the probability of having correctly classified the patient was greater than 90%. However, one fourth of patients could not be classified by hemodynamic criteria. There are few data to support the use of hemodynamic measurements after exercise or volume infusion to separate these two groups. Numerous recent studies have reported on the ability of left ventriculography, Doppler echocardiography, or radionuclide angiography to distinguish constriction from restriction. Many of the proposed indices appear promising, but these studies suffer from small sample size, potential selection bias, and complexity of the proposed criteria, which have limited their widespread application. New imaging technologies, such as CT scanning or MRI have been applied in a limited number of cases, but appear to be a sensitive means of detecting abnormal pericardium. Endomyocardial biopsy has proven useful in establishing the diagnosis of infiltrative cardiomyopathies, eliminating in those cases the need for surgical intervention. The finding of myocarditis must be considered a nonspecific finding that does not preclude thoracotomy. Since constrictive pericarditis is a surgically curable condition, the distinction between constrictive and restrictive disease is of critical importance. Taking into account the relative contribution of data derived from hemodynamic, imaging,and biopsy studies, we propose an algorithm for the selection of appropriate candidates for pericardial biopsy and stripping.