Pericardial constriction cardiac catheterization


 * Associate Editor-In-Chief: Atif Mohammad, M.D.

Cardiac Catheterization
Typically, there is equalization of diastolic pressures in all four chambers. These filling pressures are typically elevated. RVSP is usually moderately elevated but rarely exceeds 60 mmHg.

If RVSP is >60 mmHg, restriction is suggested. The RVEDP is usually at least 1/3 of the RVSP. Again, if it is lower, restriction is suggested. Some say that the LVEDP may be slightly higher than the RVEDP in restriction, especially after volume load or exercise.

The RV and LV waveforms exhibit a “dip and Plateau or square root” sign, which is another manifestation of the early rapid diastolic filling, followed by abrupt cessation of flow. Discordance between the RVS and LVS pressures can also be seen during inspiration.

Diuresis can obscure the hemodynamic findings in the catheterization laboratory, and diuretics should be held and careful IVF rehydration given if the diagnosis is entertained.

Pericardial constriction should be differentiated from restriction (which involves the left ventricle more selectively). The clinical features and hemodynamic findings of the two syndromes have significant overlap. One useful test in the cardiac catheterization laboratory to distinguish the two is a volume challenge. On simultaneous LV and RV diastolic pressure tracings, constriction compromises both ventricles equally (the LV and RV diastolic pressures will rise equally). Restriction on the other hand, will affect the LV more than the RV, and the LV diastolic pressure will rise out of proportion to the RV diastolic pressure. If restriction is suspected, one should screen for hemochromatosis, sarcoid, the hypereosinophillic syndrome, amyloid and radiation induced-myopathy.

Constrictive Pericarditis can also be differentiated from Restrictive Cardiomyopathy during cardiac catheterization using "Systolic Area Index" as a reliable hemodynamic criterion. Systolic Area Index is the ratio of right ventricular to left ventricular systolic area pressure -time (mm Hg X s) area during inspiration and expiration .It is increased (>1.1) in Constrictive Pericarditis as compared to Restrictive Cardiomyopathy which confirms the "ventricular interdependence" phenomenon present in Constrictive Pericarditis. |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(07)03432-8}} A new criteria to diagnosis pericardial constriction is respiratory discordance in the simultaneous LV and RV systolic pressures.