Caso completísimo presentado por Enrique Garcia-Sayan, MD, FACC, FASE (@EGarciaSayan).
What do we have here? A nice case, poll (below) in thread, and explanation to follow for all the #EchoFirst enthusiasts. #FellowsFirst #ACCFIT #cardiotwitter #ASE360 pic.twitter.com/Z4lfWSfEFm
— Enrique Garcia-Sayan, MD, FACC, FASE (@EGarciaSayan) June 20, 2020
1/ ?There is constriction, but specifically effusive-constrictive pericarditis.
— Enrique Garcia-Sayan, MD, FACC, FASE (@EGarciaSayan) June 21, 2020
?#tweetorial here:
?To understand #EchoFirst findings in pericardial disease, must go back to basics
?Remember that superior portion of LA and pulmonary veins are extra-pericardial structures. pic.twitter.com/2SiVYnYe9y
2/ In constrictive pericarditis (CP) or cardiac tamponade (CT), inspiratory⬇️of intra-thoracic pressure & in PVeins is not transmitted to LA or LV. This dissociation leads to⬇️PVein-LA gradient and ⬇️LV filling, demonstrated by an inspiratory ⬇️in mitral inflow velocity by >25%. pic.twitter.com/SkxYPy6qZR
— Enrique Garcia-Sayan, MD, FACC, FASE (@EGarciaSayan) June 21, 2020
3/ In CP. early diastolic septal "bounce" is noted in 2D and M-mode. M-mode also reveals rapid relaxation of posterior wall followed by "flattening" of motion throughout diastole. Ventricular interdependence seen in CP and CT, septum shifts L in inspiration and R in expiration. pic.twitter.com/mhu1jVuaHL
— Enrique Garcia-Sayan, MD, FACC, FASE (@EGarciaSayan) June 21, 2020
4/ In restriction, tissue Doppler is abnormal (⬇️e' and ⬆️ E/e') but in constriction e' is preserved and often higher in the septal annulus rather than lateral which can be tethered by the thickened pericardium ("annulus reversus" or "annulus paradoxus") as seen in our case. pic.twitter.com/GTvqXvw9pe
— Enrique Garcia-Sayan, MD, FACC, FASE (@EGarciaSayan) June 21, 2020
5/ PWD of the hepatic veins (HV) reveals expiratory diastolic flow reversal in both CP and CT. This is due to LV interdependence and septum shifting to the R in expiration, not allowing RV to fully expand in diastole. Demonstrated here (respirometer tracing not great, sorry...). pic.twitter.com/2vqbQAqcEq
— Enrique Garcia-Sayan, MD, FACC, FASE (@EGarciaSayan) June 21, 2020
6/ So how do we differentiate CP from CT? First thing is of course the presence of significant pericardial effusion, clinical picture (pulsus paradoxus vs Kussmaul's sign), and R chamber collapse (for RA >30% of cardiac cycle). This case has an effusion but no definite collapse. pic.twitter.com/LzomUG9O4q
— Enrique Garcia-Sayan, MD, FACC, FASE (@EGarciaSayan) June 21, 2020
8/ So though CT, CP and ECP all display inspiratory decrease in mitral inflow and diastolic flow reversal in hepatic veins, PWD patterns in mitral inflow and HV are not the same!
— Enrique Garcia-Sayan, MD, FACC, FASE (@EGarciaSayan) June 21, 2020
?See excellent paper by @JaeKOh2 et al on this subject: https://t.co/x9rnnIHndM pic.twitter.com/4ZQgETmkEg
9/ End of "#tweetorial. Subtle cases of constrictive pericarditis can often be missed if not paying attention to these details. And differentiation of cardiac tamponade and constrictive physiology in patients with pericardial effusion is not always easy! I hope this was helpful.
— Enrique Garcia-Sayan, MD, FACC, FASE (@EGarciaSayan) June 21, 2020
