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Echocardiographic diagnosis of constrictive pericarditis: Mayo Clinic criteria
Terrence D Welch1, Lieng H Ling1, Raul E Espinosa1
1From the Section of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH (T.D.W.); Geisel School of Medicine at Dartmouth, Hanover, NH (T.D.W.); National University Heart Center, Singapore, Singapore (L.H.L.); Yong Loo Lin School of Medicine, Singapore, Singapore (L.H.L.); and Division of Cardiovascular Diseases (R.E.E., N.S.A., J.K.O.), Department of Health Sciences Research (H.J.W., B.D.L.), and Division of Cardiovascular Surgery (H.V.S.), Mayo Clinic, Rochester, MN.
Insights
Constrictive pericarditis can be diagnosed using echocardiography. Key indicators include ventricular septal shift, medial mitral annular e
Area of Science:
- Cardiology
- Diagnostic Imaging
- Echocardiography
Background:
- Constrictive pericarditis is a reversible cause of heart failure.
- It can be challenging to distinguish from restrictive myocardial disease and severe tricuspid regurgitation.
- Definite echocardiographic criteria are needed for accurate diagnosis.
Purpose of the Study:
- To establish definite echocardiographic criteria for diagnosing constrictive pericarditis.
- To differentiate constrictive pericarditis from restrictive myocardial disease and severe tricuspid regurgitation using echocardiography.
Main Methods:
- Retrospective comparison of 130 patients with surgically confirmed constrictive pericarditis and 36 patients with restrictive myocardial disease or severe tricuspid regurgitation.
- Blinded review of comprehensive echocardiograms.
- Analysis of five principal echocardiographic variables: ventricular septal shift, mitral inflow E velocity variation, medial mitral annular e' velocity, medial to lateral e' ratio, and hepatic vein expiratory diastolic reversal ratio.
Main Results:
- All five principal echocardiographic variables differed significantly between constrictive pericarditis and the comparison group.
- Ventricular septal shift, medial mitral annular e' velocity, and hepatic vein expiratory diastolic reversal ratio were independently associated with constrictive pericarditis.
- A combination of ventricular septal shift with medial e' ≥9 cm/s or hepatic vein expiratory diastolic reversal ratio ≥0.79 achieved 87% sensitivity and 91% specificity.
Conclusions:
- Echocardiography can effectively differentiate constrictive pericarditis from other conditions.
- Respiration-related ventricular septal shift, preserved medial mitral annular e' velocity, and prominent hepatic vein expiratory diastolic flow reversals are key diagnostic indicators.
- These echocardiographic findings aid in the accurate diagnosis of constrictive pericarditis.
Background:
Constrictive pericarditis is a potentially reversible cause of heart failure that may be difficult to differentiate from restrictive myocardial disease and severe tricuspid regurgitation. Echocardiography provides an important opportunity to evaluate for constrictive pericarditis, and definite diagnostic criteria are needed.
Methods And Results:
Patients with surgically confirmed constrictive pericarditis (n=130) at Mayo Clinic (2008-2010) were compared with patients (n=36) diagnosed with restrictive myocardial disease or severe tricuspid regurgitation after constrictive pericarditis was considered but ruled out. Comprehensive echocardiograms were reviewed in blinded fashion. Five principal echocardiographic variables were selected based on prior studies and potential for clinical use: (1) respiration-related ventricular septal shift, (2) variation in mitral inflow E velocity, (3) medial mitral annular e' velocity, (4) ratio of medial mitral annular e' to lateral e', and (5) hepatic vein expiratory diastolic reversal ratio. All 5 principal variables differed significantly between the groups. In patients with atrial fibrillation or flutter (n=29), all but mitral inflow velocity remained significantly different. Three variables were independently associated with constrictive pericarditis: (1) ventricular septal shift, (2) medial mitral e', and (3) hepatic vein expiratory diastolic reversal ratio. The presence of ventricular septal shift in combination with either medial e'≥9 cm/s or hepatic vein expiratory diastolic reversal ratio ≥0.79 corresponded to a desirable combination of sensitivity (87%) and specificity (91%). The specificity increased to 97% when all 3 factors were present, but the sensitivity decreased to 64%.
Conclusions:
Echocardiography allows differentiation of constrictive pericarditis from restrictive myocardial disease and severe tricuspid regurgitation. Respiration-related ventricular septal shift, preserved or increased medial mitral annular e' velocity, and prominent hepatic vein expiratory diastolic flow reversals are independently associated with the diagnosis of constrictive pericarditis.
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