A Constrictive Pericarditis Pulmonary Regurgitant Doppler Flow Pattern – Why Not?

Oct 28, 2015   |  ; Rana Marie Costa

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Editor's Note: Commentary based on Kaga S, Mikami T, Takamatsu Y et al. Quantitative and Pattern Analyses of Continuous-Wave Doppler-Derived Pulmonary Regurgitant Flow Velocity for the Diagnosis of Constrictive Pericarditis. J Am Soc Echocardiogr 2014; 27;1223-9.

Constrictive pericarditis (CP) is known to be somewhat elusive to diagnose on transthoracic echocardiography. Several studies have explored different echocardiographic and Doppler variables, all in an attempt to make the diagnosis of constriction easier and more reliable. Echocardiographic findings of pericardial thickening, ventricular septal shift in relation to respiration, plethora of the inferior vena cava, preserved or relatively increased medial mitral annular e' velocity and prominent hepatic vein diastolic flow reversal with expiration, among others, remain the mainstay of diagnosing constriction despite variable sensitivities and specificities.1-5 Prior to this study, only once was the pulmonary valve regurgitant flow pattern – but not its velocities per se – addressed as a possible indicator of constriction in a small cohort of patients.6

The frequency of detecting pulmonary regurgitation (PR) on transthoracic echocardiography is approximately 92%7, making it safe to assume that most patients with constriction will actually have a PR jet. On invasive hemodynamics, it has also been well-established that the dip and plateau sign is present in around 75% of patients with CP.8 It may be assumed, due to the prevalence of PR, that those with the dip and plateau pattern invasively will actually have a PR jet but that has not yet been validated objectively.

A PR jet, as with all valvular regurgitant jets, has several components: a maximal initial velocity (VMAX) that decreases at a specific slope (deceleration time) and ultimately reaches a minimum velocity (VMIN). Upon encountering an elevated right ventricular end diastolic pressure (RVEDP), the flow slows down, making the slope of the deceleration less steep and causing the appearance of an inflection point (VIFL). Physiologically, constriction causes elevation of RVEDP. This would explain the steep initial deceleration time of a PR jet followed by an early and elevated inflection point making the ratio of VIFL/VMAX<0.5, as shown in figure 1 below.

Figure 1
Figure 1 – Illustration of a pulmonary valve regurgitation wave form with VMAX representing peak maximal diastolic velocity, VIFL representing inflection velocity and VMIN representing minimal diastolic velocity (VIFL/VMAX <0.5, VMIN/VMAX <0.33).
By Ms. Marion Tomasko, Graphics Department, Cleveland Clinic

Much like aortic insufficiency in patients with elevated left ventricular end diastolic pressure (LVEDP), the regurgitant jet is abruptly slowed upon encountering high pressures in the ventricle. In this study, however, the authors prove relatively high sensitivities and specificities of the early mid-diastolic inflection, VIFL/VMAX<0.5, VMIN<50 cm/sec and VMIN/VMAX<0.33 for diagnosing patients with constrictive pericarditis. To elaborate further on the reliability of these parameters, we took the liberty of calculating the discriminatory power (DP) of these variables based on their sensitivities and specificities, using the following formula:

    DP= [(square root of 3)/π]* (ln [Sens/ 1 -Spec] +ln [Spec/ 1- Sens])9,10

Statistically, an estimated DP value is helpful in assessing how powerful a test is in discriminating between patients who have or do not have a certain disease. A calculated DP value of 1.0 is not considered effective, in contrast to a value of 3.0 which is considered highly effective. In reality, a DP value of 3.0 reflects a three standard deviation difference between patients with and without the disease.10 For the four parameters mentioned above, the respective DP's are: 2, 3.08, 2.47 and 2.77, further confirming the accuracy that the authors show in their receiver operating characteristic (ROC) curve analyses. However, the study by Gilman et al. and the current study both assess small cohorts retrospectively.6

Furthermore, as seen in the study at Mayo Clinic by Welch et al., many variables can be correlated with the diagnosis of CP, but only a few remain to be independently predictive.11 Similarly, it remains to be seen in further and larger studies if these interesting PR parameters will be consistently found reliable in diagnosing constriction independent of other well established parameters.

References

  1. Popp RL. Echocardiographic assessment of cardiac disease. Circulation 1976;54(4):538-52.
  2. Himelman RB, Lee E, Schiller NB. Septal bounce, vena cava plethora, and pericardial adhesion: informative two-dimensional echocardiographic signs in the diagnosis of pericardial constriction. J Am Soc Echocardiogr 1988;1(5):333-40.
  3. Candell-Riera J, Garcia del Castillo H, Permanyer-Miralda G, Soler-Soler J. Echocardiographic features of the interventricular septum in chronic constrictive pericarditis. Circulation 1978;57(6):1154-8.
  4. Hatle LK, Appleton CP, Popp RL. Differentiation of constrictive pericarditis and restrictive cardiomyopathy by Doppler echocardiography. Circulation 1989;79(2):357-70.
  5. Oh JK, Hatle LK, Seward JB, Danielson GK, Schaff HV, Reeder GS, et al. Diagnostic role of Doppler echocardiography in constrictive pericarditis. J Am Coll Cardiol 1994;23(1):154-62.
  6. Gilman G, Ommen SR, Hansen WH, Higano ST. Doppler echocardiographic evaluation of pulmonary regurgitation facilitates the diagnosis of constrictive pericarditis. J Am Soc Echocardiogr 2005;18(9):892-5.
  7. Kostucki W, Vandenbossche JL, Friart A, Englert M. Pulsed Doppler regurgitant flow patterns of normal valves. Am J Cardiol 1986;58(3):309-13.
  8. Talreja DR, Edwards WD, Danielson GK, Schaff HV, Tajik AJ, Tazelaar HD et al. Constrictive pericarditis in 26 patients with histologically normal pericardial thickness. Circulation 2003;108(15):1852-7.
  9. Hasselblad V, Hedges LV. Meta-analysis of screening and diagnostic tests. Psychol Bull 1995;117(1):167-78.
  10. Blakeley DD, Oddone EZ, Hasselblad V, Simel DL, Matchar DB. Noninvasive carotid artery testing: a meta-analytic review. Ann Intern Med 1995;122(5):360-7.
  11. Welch TD, Ling LH, Espinosa RE, Anavekar NS, Wiste HJ, Lahr BD et al. Echocardiographic diagnosis of constrictive pericarditis: Mayo Clinic criteria. Circ Cardiovasc Imaging 2014;7(3):526-34.

Keywords: Abnormalities, Multiple, Blood Pressure, Constriction, Deceleration, Diastole, Ear, External, Echocardiography, Freedom, Hepatic Veins, Hypospadias, Muscle Hypotonia, Pericarditis, Constrictive, Prevalence, Pulmonary Valve, Pulmonary Valve Insufficiency, ROC Curve, Reproducibility of Results, Retrospective Studies, Vena Cava, Inferior, Pericarditis


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