Ling, Lieng Hsi

Background: Assessment of coexisting pericardial and myocardial disease in constrictive pericarditis (CP) remains a diagnostic challenge and decision for pericardiectomy depends on the degree of pericardial versus myocardial restraint limiting left ventricular (LV) filling. Early diastolic longitudinal mitral annulus velocity (Ea) can help to differentiate CP from restrictive cardiomyopathy. Recently, acceleration rate of Ea has been shown to be an index of LV myocardial relaxation. We therefore assessed acceleration (Ea-AR) and deceleration (Ea-DR) rate of Ea in patients with CP before and after pericardiectomy. Methods: We retrospectively studied patients (n=42) with surgically confirmed CP who underwent radical pericardiectomy between 2003–2006 at Mayo Clinic Rochester. Ea-AR and Ea-DR slopes were measured before (pre-Echo) and after (post-Echo) pericardiectomy. Patients were divided into primary CP (idiopathic & acute pericarditis with presumed normal myocardial function) and secondary CP (cardiac surgery & chest irradiation with presumed abnormal myocardial function). Results: Ea-AR and Ea-DR changed significantly after pericardiectomy in primary CP patients, however remained similar in secondary CP patients. Diagnostic accuracy of Ea-AR, Ea-DR and Ea to discriminate primary versus secondary CP by ROC analysis was 0.88, 0.80 and 0.81 respectively. Conclusion: Assessment of Ea-AR and Ea-DR in patients with CP is useful to discriminate primary from secondary CP and may help to predict coexistence of myocardial disease: Prepericardiectomy Ea-AR and Ea-DR appear to reflect the interaction of intrinsic myocardial relaxation with enhanced early LV filling. The lack of decrease of Ea-AR and Ea-DR in patients with secondary CP seems to indicate a primarily restrictive component. The significant decrease of Ea-DR in patients with primary CP after pericardiectomy could reflect abolition of a predominant pericardial limitation to LV filling. Early Diastolic Longitudinal Mitral Annulus Motion before and after Pericardiectomy

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.

Background The optimal timing for surgery in patients with mitral regurgitation is disputed. Because of the frequency of left ventricular dysfunction, which is difficult to predict, early surgery has been recommended, but its potential benefits have not been demonstrated. Methods and Results The outcomes of 221 patients (mean age, 65±13 years; 71% males) with flail leaflets diagnosed with two-dimensional echocardiography between 1980 and 1989 who were eligible for operation were analyzed. Group I comprised 63 patients who had early mitral valve surgery (within 1 month after diagnosis). Group II comprised 158 patients initially treated conservatively (80 of whom were operated on later). Group I patients were younger ( P =.009), had more symptoms ( P <.0001), and were more frequently in atrial fibrillation ( P =.023) than group II patients. There was no difference in ejection fraction between the groups. The early surgery strategy was followed by an improved overall survival rate ( P= .028) and a lower incidence of cardiovascular deaths ( P =.025), congestive heart failure ( P =.046), and new chronic atrial fibrillation ( P =.032), as confirmed by multivariate analysis (adjusted risk ratios of 0.31, 0.18, 0.38, and 0.05, respectively; all P< .02). Conclusions In patients with mitral regurgitation due to flail leaflets, the strategy of early surgery versus conservative management is associated with an improved long-term survival rate, decreased cardiac mortality, and decreased morbidity after diagnosis. This outcome advantage suggests that early surgery is a reasonable treatment option to be considered in low-risk candidates with repairable valves and severe mitral regurgitation.

Background —The clinical spectrum of constrictive pericarditis (CP) has been affected by a change in incidence of etiological factors. We sought to determine the impact of these changes on the outcome of pericardiectomy. Methods and Results —The contemporary spectrum of CP in 135 patients (76% male) evaluated at the Mayo Clinic from 1985 to 1995 was compared with that of a historic cohort. Notable trends were an increasing frequency of CP due to cardiac surgery and mediastinal radiation and presentation in older patients (median age, 61 versus 45 years). Perioperative mortality decreased (6% versus 14%, P =0.011), but late survival was inferior to that of an age- and sex-matched US population (57±8% at 10 years). The long-term outcome was predicted independently by 3 variables in stepwise logistic regression analyses: (1) age, (2) NYHA class, and most powerfully, (3) a postradiation cause. Of 90 late survivors in whom functional class could be determined, functional status had improved markedly (2.6±0.7 at baseline versus 1.5±0.8 at latest follow-up [ P <0.0001]), with 83% being free of clinical symptoms. Conclusions —The evolving profile of CP, with increasingly older patients and those with radiation-induced disease in the past decade, significantly affects postoperative prognosis. Long-term results of pericardiectomy are disappointing for some patient groups, especially those with radiation-induced CP. By contrast, surgery alleviates or improves symptoms in the majority of late survivors.

Background— Previous studies have demonstrated that mitral annulus early diastolic (e′) velocity is increased in constrictive pericarditis (CP) and reduced in restrictive cardiomyopathy. However, those studies did not comprehensively evaluate mitral and tricuspid annular velocities before and after pericardiectomy. Methods and Results— We performed comprehensive echocardiography before and after pericardiectomy in 99 patients with CP, 52 with primary (idiopathic or postpericarditis etiology) and 47 with secondary CP (due to surgery or radiation). Overall, mean±SD mitral medial, mitral lateral, and tricuspid lateral e′ velocities were 12.2±4.2, 10.0±5.4, and 11.6±3.5 cm/s, respectively; annular late diastolic velocities were 10.3±4.3, 12.2±4.9, and 11.7±5.4 cm/s, respectively; and annular systolic (s′) velocities were 7.8±2.8, 8.2±2.1, and 11.2±3.8 cm/s, respectively. Medial e′ was equal to or greater than mitral lateral e′ in 74% of analyzable cases. With the exception of tricuspid s′, there were significant differences in all s′ and e′velocities between primary and secondary CP before pericardiectomy. After pericardiectomy, all annular velocities decreased significantly ( P <0.02 for all comparisons). The reduction in medial e′ velocity was greater than that of mitral lateral e′ velocity ( P <0.0001 and P =0.0004, respectively), and the mitral lateral/medial e′ ratio normalized ( P =0.0002). Conclusions— The mitral lateral/medial e′ ratio is reversed in three fourths of patients with CP. All annular velocities are lower in secondary compared to primary CP before pericardiectomy. After pericardiectomy, there is reduction of all annular velocities and normalization of the mitral lateral/medial e′ ratio.

Background The early diastolic velocity of the mitral annulus (E′) is reduced in patients with diastolic dysfunction and increased filling pressures. Because transmitral inflow early velocity (E) increases progressively with higher filling pressures, E/E′ has been shown to have a strong positive relationship with pulmonary capillary wedge pressure (PCWP) and left ventricular end-diastolic pressure. However, previous studies have primarily involved patients without a pericardial abnormality. In constrictive pericarditis (CP), E′ is not reduced, despite increased filling pressures. This study evaluated the relationship between E/E′ and PCWP in patients with CP. Methods and Results We studied 10 patients (8 men; mean age, 64±7 years) with surgically confirmed CP. Doppler echocardiography was performed to measure early and late diastolic transmitral flow velocities. Tissue Doppler echocardiography was performed to measure E′. PCWP was measured with right heart catheterization. All patients were in sinus rhythm. Mean E and E′ were 91±15 cm/s and 11±4 cm/s, respectively. Mean PCWP was 25±6 mm Hg. E′ was positively correlated with PCWP ( r =0.69, P =0.027). There was a significant inverse correlation between E/E′ and PCWP ( r =−0.74, P =0.014). Despite high left ventricular filling pressures, E/E′ (mean, 9±4) was <15 in all but 1 patient. Conclusions Paradoxical to the positive correlation between E/E′ and PCWP in patients with myocardial disease, an inverse relationship was found in patients with CP.