Pneumopericardium and pneumothorax contralateral to venous access site after permanent pacemaker implantation.

A 77-year-old female underwent implantation of a left-sided dual chamber permanent pacemaker for symptomatic bradycardia with active fixation leads. Eight hours after the procedure, the patient complained of shortness of breath and was found to have a 30% right pneumothorax on chest X-ray. Immediately, a chest tube was inserted, promptly relieving the symptoms. A CT scan of the chest revealed extrusion of the helix of the screw-in atrial lead, through the wall of the right atrial appendage. The helix was abutting a bulla in the right lung, the likely cause for pneumothorax and pneumopericardium. The atrial lead was explanted without incident.

Color M-mode and pulsed wave tissue Doppler echocardiography: powerful predictors of cardiac events after first myocardial infarction.

To assess the association between color M-mode flow propagation velocity and the early diastolic mitral annular velocity (E(m)) obtained with tissue Doppler echocardiography and to assess the prognostic implications of the indexes, echocardiography was performed on days 1 and 5, and 1 and 3 months after a first myocardial infarction in 67 consecutive patients. Flow propagation velocity correlated well with E(m) (r = 0.72, P <.0001). The ratio of peak E-wave velocity (E) to flow propagation velocity also correlated well with E/E(m) (r = 0.87, P <.0001). The positive predictive value of E/FPV > or =1.5 to identify patients with Killip class > or =II was 90%, and the negative predictive value 92%. The corresponding values for E/E(m) > or =10 were 70% and 90%. Cox proportional hazards analysis identified E/flow propagation velocity > or =1.5 (relative risk, 12.4 [95% confidence interval, 4.1-37.3]), E/E(m) > or =10 (relative risk, 11.5 [95% confidence interval, 3.8-34.7]), and Killip class > or =II (relative risk, 7.8 [95% confidence interval, 1.6-40.4]) to be predictors of the composite end point of cardiac death and readmission because of heart failure. Thus flow propagation velocity and E(m) are closely related after myocardial infarction and appear to have similar prognostic information.

Serial Doppler echocardiographic assessment of left and right ventricular performance after a first myocardial infarction.

We sought to investigate the relation between left ventricular (LV) and right ventricular (RV) function assessed with the Doppler-derived myocardial performance index (MPI), to assess serial changes, and to investigate the prognostic value of biventricular assessment of cardiac function after a first myocardial infarction (MI). To do so, serial Doppler echocardiography was performed in 77 consecutive patients with a first MI. Right ventricular MPI correlated significantly with LV MPI (r = 0.51, P <.0001). In patients with echocardiographic signs of RV MI, the RV MPI was significantly higher (0.59 +/- 0.18 versus 0.44 +/- 0.19, P =.001), whereas no difference in LV MPI was seen (0.55 +/- 0.19 versus 0.56 +/- 0.13, P = not significant). Right ventricular MPI showed a rapid normalization during follow-up, whereas LV MPI did not decrease. During follow-up, 23 patients died of cardiac causes or were readmitted because of worsening heart failure. Multivariate Cox analysis indicated LV MPI (relative risk 4.9 [95% CI 1.8-13.5], P =.002) and RV MPI (relative risk 3.8 [1.3-17.0], P =.01) to be predictors of cardiac events. Thus the RV MPI is frequently abnormal after a first MI but normalizes rapidly on follow-up, and biventricular assessment of cardiac function may improve the prognostic accuracy compared with LV assessment alone.

Clinical utility of Doppler echocardiography and tissue Doppler imaging in the estimation of left ventricular filling pressures: A comparative simultaneous Doppler-catheterization study.

BACKGROUND: Noninvasive assessment of diastolic filling by Doppler echocardiography provides important information about left ventricular (LV) status in selected subsets of patients. This study was designed to assess whether mitral annular velocities as assessed by tissue Doppler imaging are associated with invasive measures of diastolic LV performance and whether additional information is gained over traditional Doppler variables. METHODS AND RESULTS: One hundred consecutive patients referred for cardiac catheterization underwent simultaneous Doppler interrogation. Invasive measurements of LV pressures were obtained with micromanometer-tipped catheters, and the mean LV diastolic pressure (M-LVDP) was used as a surrogate for mean left atrial pressure. Doppler signals from the mitral inflow, pulmonary venous inflow, and TDI of the mitral annulus were obtained. Isolated parameters of transmitral flow correlated with M-LVDP only when ejection fraction <50%. The ratio of mitral velocity to early diastolic velocity of the mitral annulus (E/E') showed a better correlation with M-LVDP than did other Doppler variables for all levels of systolic function. E/E' <8 accurately predicted normal M-LVDP, and E/E' >15 identified increased M-LVDP. Wide variability was present in those with E/E' of 8 to 15. A subset of those patients with E/E' 8 to 15 could be further defined by use of other Doppler data. CONCLUSIONS: The combination of tissue Doppler imaging of the mitral annulus and mitral inflow velocity curves provides better estimates of LV filling pressures than other methods (pulmonary vein, preload reduction). However, accurate prediction of filling pressures for an individual patient requires a stepwise approach incorporating all available data.

The echo-Doppler evaluation of left ventricular diastolic function. A current perspective.

The role of left ventricular (LV) diastolic function in health and disease is still incompletely understood and under appreciated by most primary care physicians and many cardiologists. Physical examination, electrocardiogram, and chest radiographs are unreliable in making the diagnosis of LV diastolic dysfunction in most individuals, and invasive measurements of cardiac pressures, rates of LV relaxation, and LV compliance are costly, clinically impracticable as they carry increased risk, and require special catheters and software analysis programs. The authors address the definition of LV diastolic dysfunction, history of diastole, LV filling patterns, pulmonary venous flow velocity variables, additional ancillary data, practical echo-Doppler evaluation of LV diastolic function, and limitations.

Ratio of left ventricular peak E-wave velocity to flow propagation velocity assessed by color M-mode Doppler echocardiography in first myocardial infarction: prognostic and clinical implications.

OBJECTIVES: To determine the ability of the ratio of peak E-wave velocity to flow propagation velocity (E/Vp) measured with color M-mode Doppler echocardiography to predict in-hospital heart failure and cardiac mortality in an unselected consecutive population with first myocardial infarction (MI). BACKGROUND: Several experimental studies indicate color M-mode echocardiography to be a valuable tool in the evaluation of diastolic function, but data regarding the clinical value are lacking. METHODS: Echocardiography was performed within 24 h of arrival at the coronary care unit in 110 consecutive patients with first MI. Highest Killip class was determined during hospitalization. Patients were divided into groups according to E/Vp <1.5 and > or =1.5. RESULTS: During hospitalization 53 patients were in Killip class > or =II. In patients with E/Vp > or =1.5, Killip class was significantly higher compared with patients with E/Vp <1.5 (p < 0.0001). Multivariate logistic regression analysis identified E/Vp > or =1.5 to be the single best predictor of in-hospital clinical heart failure when compared with age, heart rate, E-wave deceleration time (Dt), left ventricular (LV) ejection fraction, wall motion index, enzymatic infarct size and Q-wave MI. At day 35 survival in patients with E/Vp <1.5 was 98%, while for patients with E/Vp > or =1.5, it was 58% (p < 0.0001). Cox proportional hazards model identified Dt <140 ms, E/Vp > or =1.5 and age to be independent predictors of cardiac death, with Dt < 140 ms being superior to age and E/Vp. CONCLUSIONS: In the acute phase of MI, E/Vp > or =1.5 measured with color M-mode echocardiography is a strong predictor of in-hospital heart failure. Furthermore, E/Vp is superior to systolic measurements in predicting 35 day survival although Dt <140 ms is the most powerful predictor of cardiac death.

Comparison of mitral inflow and superior vena cava Doppler velocities in chronic obstructive pulmonary disease and constrictive pericarditis.

OBJECTIVE: This study was conducted to determine whether Doppler recording of superior vena cava flow velocities can differentiate chronic obstructive pulmonary disease from constrictive pericarditis in patients with a respiratory variation of > or = 25% in mitral inflow E velocity. BACKGROUND: Although respiratory variation (> or = 25%) in mitral E velocity is the main diagnostic criterion for constrictive pericarditis by Doppler echocardiography, it can also be present in chronic obstructive pulmonary disease. Because the respiratory variation is due to increased change in intrathoracic pressure with respiration in chronic obstructive pulmonary disease, and to dissociation of intrathoracic-intracardiac pressure changes in constriction, it was hypothesized that the Doppler flow velocity pattern in the superior vena cava (affected by intrathoracic pressure) would be different in these two conditions. METHODS: Pulsed-wave Doppler recording of mitral and superior vena cava flow velocities in 20 patients with chronic obstructive pulmonary disease who had > or = 25% respiratory variation in mitral E-wave velocity were compared with those of 20 patients who had surgically proved constrictive pericarditis. RESULTS: Constrictive pericarditis and chronic obstructive pulmonary disease had similar respiratory variation in mitral E velocity (41% versus 46%). In the latter, the E/A ratio was lower (inspiration, 0.8+/-0.3 versus 1.5+/-0.7 [p < 0.0001]; expiration, 1.0+/-0.3 vs. 1.9+/-0.7 [p < 0.0001]) and deceleration time longer (inspiration, 198+/-53 ms versus 137+/-32 ms; expiration, 225+/-43 ms vs. 161+/-33 ms [p < 0.0001]). Inspiratory superior vena cava systolic forward flow velocity was significantly higher in chronic obstructive pulmonary disease (72.9+/-22.6 cm/s versus 36.2+/-9.3 cm/s, p < 0.0001), while expiratory systolic forward flow velocity was similar. Hence, there was a significantly greater respiratory variation in superior vena cava systolic forward flow velocity in chronic obstructive pulmonary disease without an overlap with constrictive pericarditis (39.5+/-18.8 cm/s vs. 4.2+/-3.4 cm/s, p < 0.0001). CONCLUSIONS: Despite a similar respiratory variation in mitral E wave velocities, mitral inflow variables in chronic obstructive pulmonary disease are less restrictive compared with those in constrictive pericarditis. More importantly, patients with chronic obstructive pulmonary disease show a marked increase in inspiratory superior vena cava systolic forward flow velocity, which is not seen in patients with constrictive pericarditis.

Age independence of the difference in duration of pulmonary venous atrial reversal flow and transmitral A-wave flow in normal subjects.

Aging influences pulmonary venous flow and mitral inflow velocities. The duration of pulmonary venous atrial reversal flow exceeds that of the mitral inflow A wave in patients with left ventricular end-diastolic pressures greater than 15 mm Hg. The objective of this study was to investigate the effect of age on the difference between the duration of pulmonary venous atrial reversal flow and that of the mitral inflow A wave in a large number of normal individuals. Pulsed wave Doppler transthoracic echocardiograms of the pulmonary venous flow and the transmitral inflow with respiratory monitoring were made of 72 normal volunteers (40 women) ranging in age between 23 and 84 years. The differences in the durations of pulmonary venous atrial reversal flow and mitral inflow A wave were measured and their correlation with age assessed. Age was not highly correlated with the duration of pulmonary venous atrial reversal flow (r = 0.25) nor the duration of the mitral inflow A wave (r = 0.33). The duration of pulmonary venous atrial reversal flow exceeded the duration of the mitral inflow A-wave flow only in three (4%) of 72 subjects, and age was not related to the index in this group (r = -0.16; p = 0.19). The difference in durations was not significantly affected by the phase of respiration. Men had higher values on all measurements than women. The difference between the pulmonary venous atrial reversal duration and the mitral inflow A-wave duration is independent of age and thus may be used as a reliable index of left ventricular end-diastolic pressure, even in elderly patients.

Determination of left ventricular filling pressure by Doppler echocardiography in patients with coronary artery disease: critical role of left ventricular systolic function.

OBJECTIVES: This study was designed to determine the usefulness of transthoracic Doppler measurements in detecting increased left ventricular (LV) end-diastolic pressure in patients with coronary artery disease, specifically examining the influence of systolic function on the accuracy of these methods. BACKGROUND: Studies that have correlated Doppler indexes with LV filling pressures primarily involved patients with LV systolic dysfunction. The reliability of Doppler indexes in estimating filling pressures in patients with coronary artery disease and preserved systolic function is unclear. METHODS: Pulsed wave Doppler transmitral and pulmonary venous flow velocity curves and LV pressure were recorded in 83 patients with coronary artery disease. RESULTS: Conventional Doppler indexes (deceleration time of mitral E wave velocity, ratio of peak mitral E to A wave velocities and pulmonary venous systolic fraction) correlated with LV filling pressure in patients with an ejection fraction (EF) < or = 50% but not in those with an EF > 50%. Previously published regression analysis for prediction of LV filling pressure was accurate in patients with an EF < or = 50% but not in those with an EF > 50%. The difference between flow duration with atrial contraction in the pulmonary veins and transmitral flow duration with atrial contraction correlated with LV filling pressure in both groups. CONCLUSIONS: Analysis of the early diastolic portion of the transmitral or pulmonary venous flow velocity curves can be used to predict LV filling pressures in patients with systolic dysfunction, but are inaccurate in patients with preserved systolic function. The combined analysis of both flow velocity curves at atrial contraction is a reliable, feasible predictor of increased LV filling pressure, irrespective of systolic function.

Hemodynamic determinants of Doppler pulmonary venous flow velocity components: new insights from studies in lightly sedated normal dogs.

OBJECTIVES: We sought to define the hemodynamic determinants of pulmonary venous (PV) flow velocities to assess how these are affected by respiration, heart rate and loading conditions. BACKGROUND: Pulmonary venous flow velocity (PVFV) recorded with pulsed wave Doppler technique is currently used in the noninvasive evaluation of left ventricular (LV) diastolic function and filling pressures. Although previous studies in both animals and humans have shown that PV flow is pulsatile, the hemodynamic determinants of the individual components of this flow remain controversial. Understanding the physiologic mechanisms should help to better define the clinical utility of these Doppler techniques. METHODS: PV flow velocities obtained with transesophageal pulsed wave Doppler imaging were recorded together with PV, left atrial (LA) and LV pressures in 10 sedated, spontaneously breathing normal dogs. PVFV and hemodynamic data were analyzed during apnea, inspiration and expiration, at atrial paced heart rates of 60, 80, 100 and 120 beats/min and mean LA pressures of 6, 12, 18 and 24 mm Hg. RESULTS: The data showed that 1) PV pressure varied depending on recording site, resembling pulmonary artery pressure closer to the pulmonary capillary bed and LA pressure closer to the venoatrial junction; 2) PVFV qualitatively followed changes in the PV-LA pressure gradient; 3) four PVFV components exist under normal conditions-three of which follow phasic changes in LA pressure and one of which (the late systolic component) is more influenced by RV stroke volume and the compliance of the pulmonary veins and left atrium; 4) normal respiration and changes in heart rate significantly alter PVFV variables--in particular, reverse flow velocity at atrial contraction; and 5) increasing LA pressure results in larger PV A wave and PV early systolic flow velocities, as well as an earlier peak in PV late systolic flow velocity and a more prominent velocity minimum before PV diastolic flow. CONCLUSIONS: Using transesophageal pulsed wave Doppler technique, four PVFV components are identifiable and determined by PV-LA hemodynamic pressure gradients. These gradients appear to be influenced by a combination of physiologic events that include RV stroke volume, the compliance of the pulmonary vasculature and left atrium and phasic changes in LA pressure. PV flow velocity components are significantly influenced by heart rate, respiration and LA pressure. These findings have implications for the interpretation of LV diastolic function and filling pressures by current Doppler echocardiographic techniques but require further clinical investigation.

Utility of preload alteration in assessment of left ventricular filling pressure by Doppler echocardiography: a simultaneous catheterization and Doppler echocardiographic study.

OBJECTIVES: The aim of this study was to demonstrate the usefulness of preload alterations in assessing left ventricular filling pressures with transmitral Doppler velocity curves. BACKGROUND: Doppler mitral inflow velocities, used to estimate left ventricular filling pressures noninvasively, are limited in predicting left ventricular filling pressures, especially in patients with normal systolic function and a "pseudonormal" mitral filling pattern. METHODS: Forty-nine patients were studied in the cardiac catheterization laboratory with simultaneous Doppler echocardiography using high fidelity catheters to compare left ventricular diastolic filling pressures (pre-A wave left ventricular pressure) and Doppler mitral inflow at baseline and during reduction of preload during the strain phase of the Valsalva maneuver (n = 27) or sublingual nitroglycerin (n = 36), or both (n = 14). Doppler measurements consisted of E (initial peak velocity), A (velocity at atrial contraction), deceleration time (time from E velocity to deceleration of flow extrapolated to baseline) and absolute A wave velocity (A' [peak A wave velocity minus velocity at onset of atrial contraction]). RESULTS: In patients with high pre-A wave pressure (> or 15 mm Hg), there was a greater change in the E/A' ratio during the Valsalva maneuver than in patients with a normal pre-A wave pressure (-1.22 +/- 1.1 vs. -0.35 +/- 0.17; p = 0.02). A similar change was seen when comparing the change in the E/A' ratio after administration of nitroglycerin in patients with a high versus a normal pre-A wave pressure (0.81 +/- 0.49 vs. 0.18 +/- 0.17; p < 0.001). These differences were present in patients with a normal E/A ratio at baseline. CONCLUSIONS: Alterations in preload during assessment of Doppler echocardiographic indexes may be useful in noninvasively assessing left ventricular filling pressures.

The noninvasive assessment of left ventricular diastolic function with two-dimensional and Doppler echocardiography.

Left ventricular diastolic filling can be determined reliably by Doppler-derived mitral and pulmonary venous flow velocities. Diastolic filling abnormalities are broadly classified at their extremes to impaired relaxation and restrictive physiology with many patterns in between. An impaired relaxation pattern identifies patients with early stages of heart disease, and appropriate therapy may avert progression and functional disability. Pseudonormalization is a transitional phase between abnormal relaxation and restrictive physiology and signifies increased filling pressure and decreased compliance. In this phase, reducing preload, optimizing afterload, and treating the underlying disease are clinically helpful. A restrictive physiology pattern identifies advanced, usually symptomatic disease with a poor prognosis. Therapeutic intervention is directed toward normalizing loading conditions and improving the restrictive filling pattern, although this may not be feasible in certain heart diseases. Finally, many patients have left ventricular filling patterns that appear indeterminate or mixed. In these cases, clinical information, left atrial and left ventricular size, pulmonary venous flow velocity, and alteration of preload help assess diastolic function and estimate diastolic filling pressures.

Doppler evaluation of left and right ventricular diastolic function: a technical guide for obtaining optimal flow velocity recordings.

Doppler mitral flow velocities and related variables are used to assess left (LV) and right ventricular filling and, indirectly, ventricular diastolic function. Three abnormal ventricular filling patterns (impaired relaxation and pseudonormal and restrictive physiology) are recognized in patients with various heart diseases and have been related to alterations in LV diastolic properties and filling pressures. More recently, these variables have been used to assess the hemodynamic effects of drug therapy or heart surgery and prognosis in patients with restrictive and dilated cardiomyopathies. Despite these encouraging results, widespread clinical use of these Doppler techniques has been hampered by difficulties in obtaining accurate and reproducible measurements from Doppler flow velocity recordings. This is due, in part, to an underappreciation of factors such as cardiac filling mechanics, Doppler examination principles, and ultrasound machine settings, which can markedly affect the quality of the flow velocity recordings. The purpose of this article is to provide the technical information for performing a systematic and comprehensive Doppler evaluation of LV diastolic function that can be used on a routine basis. This information includes discussing the different flow velocity recordings required for a Doppler assessment of LV diastolic function, their proper recording technique, and the common technical pitfalls.

Preload reduction to unmask the characteristic Doppler features of constrictive pericarditis. A new observation.

BACKGROUND: Respiratory variation of > or = 25% in mitral E velocity is a characteristic Doppler echocardiographic feature in constrictive pericarditis. However, a subset of patients with constriction do not exhibit the typical respiratory change, most likely because of marked increase in the left atrial pressure, and preload reduction may unmask the respiratory variation. METHODS AND RESULTS: In 12 patients with surgically confirmed constrictive pericarditis who had < 25% respiratory variation in mitral E velocity during an initial preoperative examination, the Doppler study was repeated after an attempt to decrease left ventricular filling pressure. At baseline, mean mitral E velocity was similar after inspiration and expiration (0.81 +/- 0.24 and 0.84 +/- 0.21 m/s, respectively). On repeat Doppler examination, with the patient in a head-up tilt or sitting position the decrease in mitral E velocity with inspiration (0.61 +/- 0.13 m/s) was significant (P < .004), whereas it did not change significantly with expiration. The mean percent respiratory change in E velocity was 5 +/- 7% at baseline and 32 +/- 28% with preload reduction. Eight (75%) of the 12 patients developed respiratory variation of > or = 25%. CONCLUSIONS: When the respiratory variation in Doppler mitral E velocity is blunted or absent during the evaluation of suspected constrictive pericarditis, repeat Doppler recording of mitral flow velocities after maneuvers to decrease preload is recommended to unmask the characteristic respiratory variation in mitral E velocity.

Feasibility of obtaining pulmonary venous flow velocity in cardiac patients using transthoracic pulsed wave Doppler technique.

The purpose of this study was to determine, in an adult population, the percentage of patients in whom high quality pulmonary venous flow velocity recordings can be obtained using current transthoracic pulsed wave Doppler techniques. Pulmonary venous and mitral flow velocity variables obtained with a pulsed wave Doppler method were used for the indirect assessment of left ventricular (LV) diastolic function and LV filling pressures. The general clinical use of these methods, however, remains uncertain because the transthoracic success rate of obtaining all components of pulmonary venous flow velocity has been variable, and sometimes reported to be as low as 30% to 60%. Mitral and pulmonary venous flow velocity variables were obtained using pulsed wave Doppler signals in 200 consecutive adult patients (mean age 68.2 +/- 11.4 years) in normal sinus rhythm who were referred for echocardiographic study. Six cardiac sonographers and five ultrasound systems were used. The success rate for obtaining pulmonary venous systolic and diastolic flow velocity was 95%, reverse flow velocity at atrial contraction was 90%, and the duration of reverse flow at atrial contraction was 89%. In the 5% to 11% of patients in whom pulmonary flow velocities could not be adequately recorded, the most common reasons were depth limitations of the pulsed wave Doppler machine, marked cardiac enlargement, or left atrial wall motion artifact. The success rate also was influenced by the ultrasound equipment used, individual variation among sonographers, and even the type (impaired, pseudonormal, restricted) of associated mitral filling pattern. Given current machine technology, sonographer education, and daily practice, high quality, complete recordings of pulmonary venous flow velocity can be obtained in approximately 90% of adult patients using the precordial transthoracic Doppler technique. These results suggest that using these variables as an aid for evaluating LV diastolic function and filling pressures may have broader clinical applicability than previously appreciated.

Noninvasive doppler echocardiographic evaluation of left ventricular filling pressures in patients with cardiomyopathies: a simultaneous Doppler echocardiographic and cardiac catheterization study.

OBJECTIVES: The purpose of this study was to examine the relation of the mitral flow velocity curves to left ventricular filling pressures in patients with two different types of myocardial problems: hypertrophic cardiomyopathy and severe left ventricular systolic dysfunction. BACKGROUND: Previous studies have suggested that assessment of Doppler-derived mitral flow velocity curves can be used to predict left ventricular filling pressures in specific disease entities. However, it is unclear whether information derived from specific mitral flow velocity curves obtained from one disease entity can be valid in other disease states. METHODS: The study group consisted of 42 patients with left ventricular systolic dysfunction (group A) and 55 patients with hypertrophic cardiomyopathy (group B); both groups underwent simultaneous cardiac catheterization and were studied by Doppler echocardiography. High fidelity measures of left atrial and left ventricular pressures were obtained simultaneously with mitral flow velocity curves. RESULTS: There was a significant relation between the Doppler echocardiographic variables and mean left atrial pressure in group A patients. The left atrial pressure was directly related to the E/A ratio (r = 0.49, p = 0.004) and inversely related to the deceleration time (r = 0.73, p < 0.001). The sensitivity and specificity of the deceleration time, < 180 m/s, which indicated a mean left atrial pressure > or = 20 mm Hg, were both 100%. In group B patients, there was no significant relation between mean left atrial pressure and deceleration time. CONCLUSIONS: Doppler echocardiographic mitral flow velocity curves are useful in predicting and estimating left ventricular filling pressures in patients with left ventricular dysfunction. However, because of the complexity of the multiple interrelated factors that determine diastolic filling of the left ventricle, these flow velocity curves cannot be used in patients with other disease entities, such as hypertrophic cardiomyopathy. Future studies of different disease states are necessary to fully understand the role of Doppler echocardiography in the assessment of diastolic filling.

Doppler evaluation of patients with constrictive pericarditis: use of tricuspid regurgitation velocity curves to determine enhanced ventricular interaction.

OBJECTIVES: This study sought to examine the value of analyzing Doppler echocardiographically derived tricuspid regurgitation signals during respiration in relation to the diagnosis of constrictive pericarditis. BACKGROUND: A physiologic hallmark of constrictive pericarditis is enhanced ventricular interdependence, which produces reciprocal changes in right and left ventricular filling and ejection dynamics during the respiratory cycle. It was hypothesized that these changes could be detected noninvasively by analyzing Doppler echocardiographically derived tricuspid regurgitation signals and that this information could assist in noninvasively diagnosing constrictive pericarditis. METHODS: Simultaneous Doppler echocardiography and catheterization studies of the right and left sides of the heart with high fidelity pressure manometers were performed in 5 patients with surgically confirmed constrictive pericarditis and 12 patients (control subjects) with heart failure due to other causes. RESULTS: Changes observed in tricuspid regurgitation Doppler echocardiographic variables from onset to peak inspiration in patients with constrictive pericarditis were significantly different from those in control subjects. Mean (+/- SD) percent change in maximal tricuspid regurgitation velocity was 13% +/- 6% and -8% +/- 7% in the constrictive pericarditis and control groups, respectively (p < 0.0001); mean percent change in tricuspid regurgitation signal duration was 18% +/- 2% and -2% +/- 7%, respectively (p < 0.0001); mean percent change in tricuspid regurgitation time velocity integral was 27% +/- 15% and -10% +/- 12%, respectively (p < 0.0001). CONCLUSIONS: Respiratory changes in Doppler echocardiographically derived tricuspid regurgitation peak velocity and velocity duration are increased in patients with constrictive pericarditis and may be helpful in diagnosing this condition noninvasively.

Value of dynamic respiratory changes in left and right ventricular pressures for the diagnosis of constrictive pericarditis.

BACKGROUND: Conventional cardiac catheterization criteria for the diagnosis of constrictive pericarditis (CP) rely on equalization of intracardiac pressures and have many recognized limitations. Recently, Doppler echocardiographic methods have been used to examine dynamic respiratory changes of increased ventricular interdependence and dissociation of intrathoracic and intracardiac pressures for the diagnosis of CP. These pathophysiological features may be best delineated by cardiac catheterization. Therefore, we studied the accuracy of these dynamic respiratory changes in left ventricular and right ventricular pressure for the diagnosis of CP at cardiac catheterization. METHODS AND RESULTS: High-fidelity manometric catheters and respirometry were used to study 36 patients: 15 patients with surgically proven CP (group 1) and 21 patients with other causes of heart failure (group 2). Conventional cardiac catheterization variables used to establish the diagnosis of CP lacked sensitivity and specificity and failed to distinguish between these groups. However, the finding of discordance between right ventricular and left ventricular pressures during inspiration, a sign of increased ventricular interdependence, accurately distinguished patients in group 1 from those in group 2 (P < .05). CONCLUSIONS: Examination of dynamic respiratory changes indicating increased ventricular interdependence may be helpful in the diagnosis of CP in the cardiac catheterization laboratory.