International Journal of Cardiology 195 (2015) 288–289
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Revisiting annulus paradoxus in constrictive pericarditis☆ Lovely Chhabra a, Ali Ahsan Azeem a, David H. Spodick b, Aidan Flynn a,⁎ a b
Dept. of Cardiovascular Medicine, Hartford Hospital, University of Connecticut School of Medicine, Hartford, CT 06102, USA Dept. of Cardiovascular Medicine, Saint Vincent Hospital, University of Massachusetts Medical School, Worcester, MA 01608, USA
a r t i c l e
i n f o
Article history: Received 7 May 2015 Accepted 27 May 2015 Available online 29 May 2015 Keywords: Constrictive pericarditis Annulus paradoxus Echocardiography Pulmonary capillary wedge pressure
Doppler echocardiography remains an invaluable tool for the diagnostic work-up of constrictive pericarditis (CP) [1,2]. The relationship between the ratio of early transmitral flow velocity (E) to mitral annular velocity (E′) [E/E′ ratio] and directly-measured pulmonary capillary wedge pressure (PCWP) in constrictive pericarditis (CP) has been previously described. An initial eminent study found a strong inverse correlation between these two parameters in CP and called this finding as “Annulus paradoxus” [3]. A more recent study however did not find a similar correlation [4]. Other similar studies on this subject have investigated various echo-Doppler parameters in CP, however did not perform a direct comparison of E/E′ ratio and invasively measured left sided filling pressures [5,6]. Due to variable findings from the different studies, a need to re-explore this relationship was warranted [7,8]. We conducted a single center, retrospective observational study. Medical records for all patients (≥ 18 years old) at Hartford Hospital from January 2004 to June 2014 were searched using the search term ‘constrictive pericarditis’. This yielded 59 patients. Each patient's medical record was independently reviewed. Inclusion criteria were the presence of a confirmed diagnosis of CP by surgical inspection or histopathology (with additional supportive radiographic data from either cardiac computed tomogram or magnetic resonance imaging) and availability of a near-simultaneous cardiac catheterization and echocardiogram during the diagnostic work-up. After exclusion, 12 patients were finally enrolled in the study. Their echocardiograms were ☆ Funding: None. ⁎ Corresponding author at: Interventional Echocardiography, Hartford Hospital, Hartford, CT, 06102; Assistant Professor of Medicine, University of Connecticut School of Medicine, Farmington, CT,06030, USA. E-mail address: aidan.fl[email protected] (A. Flynn).
http://dx.doi.org/10.1016/j.ijcard.2015.05.154 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
independently reviewed to analyze septal E′, lateral E′, averaged E′ and the respective E/E′ ratios. Continuous variables were presented as mean ± standard deviation, and discrete variables as group percentages. Pearson correlation was used to analyze the relationship between echo parameters and PCWP. A p-value ≤0.05 was considered statistically significant. The study protocol was approved by the institutional review board at Hartford Hospital and conforms to the ethical guidelines of the 1975 Declaration of Helsinki. The major demographic, clinical and echocardiographic parameters have been presented in Table 1. Mean (±SD) age and left ventricular ejection fraction of patients (8 males and 4 females) were 63.5 (±15.7) years and 58.8% (±3.3%) respectively. 9 (75%) patients had a septal bounce or shudder. Mean septal E′, mean lateral E′ and mean averaged E′ were 10.9 ± 3.1 cm/s, 10.3 ± 2.69 cm/s and 10.7 ± 2.8 cm/s respectively while mean septal E/E′, mean lateral E/E′ and mean averaged E/E′ were 8.5 ± 2.2, 8.9 ± 1.9 and 8.9 ± 1.7. Mean PCWP was 20 ± 5.1 mm Hg. Septal E′ had a moderate positive correlation to PCWP (r = 0.59; p = 0.04) though lateral E′ and averaged E′ demonstrated no significant correlation to PCWP (r = 0.28; p = 0.37 and r = 0.48; p = 0.11 respectively). Septal E/E′ and averaged E/E′ had a strong inverse correlation to PCWP (r = − 0.74; p = 0.005 and r = −0.64; p = 0.02 respectively) while lateral E/E′ had no significant correlation to PCWP (r = −0.47; p = 0.12). Thus, in patients with constrictive pericarditis, septal E′ bears a direct correlation while septal E/E′ and averaged E/E′ has an inverse correlation to PCWP. E/E′ ratios (septal, lateral and averaged) were low while E′ velocities (septal, lateral and averaged) were preserved or higher despite a moderate to severe elevation in invasively measured left-sided filling pressures. Our results emphasize that the inverse correlation between invasively measured left-sided filling pressures and E/E′ does exist, though this may be significantly affected if there is a time-lag between these two tests. In the study by Ha et al., cardiac catheterizations and echocardiograms were performed within a mean timeinterval of 6 days (most patients had both studies done within 3 days interval of each other) [3], however Alaires et al.'s study included patients where these tests were performed within a period of about 2 weeks [4], which may explain the differences in the noted findings of these two studies. In our study, patients had the cardiac catheterization and echocardiogram with a time interval ranging from 0 to 5 days. Nevertheless, one may also argue that the relationship between PCWP and E/E′ may also be affected by the presence of significant co-existing myocardial disease in patients of CP. One such good example would be radiation induced pericardial disease where patients would often have co-existing myocardial involvement to some extent or patients of CP with
L. Chhabra et al. / International Journal of Cardiology 195 (2015) 288–289 Table 1 Demographic, clinical and echocardiographic variables of the study population.
filing pressures, then it should perhaps be in relation to septal E/E′ and averaged E/E′ and not for lateral E/E′ ratios.
S. no. Variable
Result
1. 2. 3. 4.
Age (in years) Sex Race Etiology of CP
Conflict of interest
5.
Mitral inflow velocity [E (cm/s)] Mitral annular velocity [E′ (cm/s)] E/E′ ratio
63.5 ± 15.7 Men: 8; women: 4 Whites: 10; African–American: 1; others: 1 Post-CABG: 2; post-cardiac transplant: 2; tuberculosis: 1; bacterial pericarditis: 1; Idiopathic, viral or unclear etiology: 4; radiation-induced: 2 91.1 ± 26.2 Septal = 10.9 ± 3.1; lateral = 10.3 ± 2.7; averaged E′ = 10.7 ± 2.8 Septal = 8.5 ± 2.2; lateral = 8.9 ± 1.9; averaged = 8.9 ± 1.7 20 ± 5 21 ± 6 Septal r = 0.59 (p = 0.04); Lateral r = 0.28 (p = 0.37) and averaged r = 0.48 (p = 0.11) Septal r = 0.64 (p = 0.02); lateral r = 0.36 (p = 0.25) and averaged r = 0.5 (p = 0.1) 9 patients (75%) 10 (83%)
References
6. 7. 8. 9. 10. 11. 12. 13. 14. 15.
PCWP (mm Hg) LVEDP (mm Hg) r (correlation coefficient between E′ and PCWP) r′ (correlation coefficient between E′ and LVEDP) Septal bounce present Patients with preserved E′ (septal or lateral E′ N 8 cm/s) % of patients with septal E′ N 9 patients (75%) Lateral E′ (annulus reversus) LVEF (%) 58.8 ± 3.3
Data are presented as Mean ± Standard deviation or n (%). p-value (2-sided) b0.05 was considered significant. PCWP represents pulmonary capillary wedge pressure. LVEDP denotes left ventricular end diastolic pressure.
significant co-existent left ventricular dysfunction. Based on the results of our study, it is suggested that if one has to reserve the term ‘annulus paradoxus’ strictly in context to the relationship of E/E′ with left-sided
289
Dr. David Spodick receives royalties from his textbook, “The Pericardium: A Comprehensive Textbook (Fundamental and Clinical Cardiology), Marcel Dekker, New York 1997”. Other authors have no disclosures, financial or otherwise.
[1] D.H. Spodick, The Pericardium: A Comprehensive Textbook, Marcel Dekker, New York, 1997. [2] A.L. Klein, S. Abbara, D.A. Agler, C.P. Appleton, C.R. Asher, B. Hoit, J. Hung, M.J. Garcia, I. Kronzon, J.K. Oh, E.R. Rodriguez, H.V. Schaff, P. Schoenhagen, C.D. Tan, R.D. White, American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease: endorsed by the Society for Cardiovascular Magnetic Resonance and Society of Cardiovascular Computed Tomography, J. Am. Soc. Echocardiogr. 26 (2013) (965e1012.e15). [3] J.W. Ha, J.K. Oh, L.H. Ling, R.A. Nishimura, J.B. Seward, A.J. Tajik, Annulus paradoxus: transmitral flow velocity to mitral annular velocity ratio is inversely proportional to pulmonary capillary wedge pressure in patients with constrictive pericarditis, Circulation 104 (2001) 976–978. [4] M.C. Alraies, K. Kusunose, K. Negishi, H. Yarmohammadi, H. Motoki, W. AlJaroudi, Z.B. Popović, A.L. Klein, Relation between echocardiographically estimated and invasively measured filling pressures in constrictive pericarditis, Am. J. Cardiol. 113 (11) (2014) 1911–1916. [5] J.P. Dal-Bianco, P.P. Sengupta, F. Mookadam, K. Chandrasekaran, A.J. Tajik, B.K. Khandheria, Role of echocardiography in the diagnosis of constrictive pericarditis, J. Am. Soc. Echocardiogr. 22 (1) (2009) 24–33. [6] T.D. Welch, L.H. Ling, R.E. Espinosa, N.S. Anavekar, H.J. Wiste, B.D. Lahr, H.V. Schaff, J.K. Oh, Echocardiographic diagnosis of constrictive pericarditis: Mayo Clinic criteria, Circ. Cardiovasc. Imaging 7 (3) (2014) 526–534. [7] L. Chhabra, D.H. Spodick, Annulus paradoxus phenomenon remains a question, Circ. Cardiovasc. Imaging (2014) (Online Publication. (Available at: http://circimaging. ahajournals.org/content/7/3/526.abstract/reply#circcvim_el_1439)). [8] L. Chhabra, D.H. Spodick, Annulus paradoxus and constrictive pericarditis: a need for revisiting the association! Am. J. Cardiol. 115 (4) (2015) 554.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Revisiting annulus paradoxus in constrictive pericarditis☆ Lovely Chhabra a, Ali Ahsan Azeem a, David H. Spodick b, Aidan Flynn a,⁎ a b
Dept. of Cardiovascular Medicine, Hartford Hospital, University of Connecticut School of Medicine, Hartford, CT 06102, USA Dept. of Cardiovascular Medicine, Saint Vincent Hospital, University of Massachusetts Medical School, Worcester, MA 01608, USA
a r t i c l e
i n f o
Article history: Received 7 May 2015 Accepted 27 May 2015 Available online 29 May 2015 Keywords: Constrictive pericarditis Annulus paradoxus Echocardiography Pulmonary capillary wedge pressure
Doppler echocardiography remains an invaluable tool for the diagnostic work-up of constrictive pericarditis (CP) [1,2]. The relationship between the ratio of early transmitral flow velocity (E) to mitral annular velocity (E′) [E/E′ ratio] and directly-measured pulmonary capillary wedge pressure (PCWP) in constrictive pericarditis (CP) has been previously described. An initial eminent study found a strong inverse correlation between these two parameters in CP and called this finding as “Annulus paradoxus” [3]. A more recent study however did not find a similar correlation [4]. Other similar studies on this subject have investigated various echo-Doppler parameters in CP, however did not perform a direct comparison of E/E′ ratio and invasively measured left sided filling pressures [5,6]. Due to variable findings from the different studies, a need to re-explore this relationship was warranted [7,8]. We conducted a single center, retrospective observational study. Medical records for all patients (≥ 18 years old) at Hartford Hospital from January 2004 to June 2014 were searched using the search term ‘constrictive pericarditis’. This yielded 59 patients. Each patient's medical record was independently reviewed. Inclusion criteria were the presence of a confirmed diagnosis of CP by surgical inspection or histopathology (with additional supportive radiographic data from either cardiac computed tomogram or magnetic resonance imaging) and availability of a near-simultaneous cardiac catheterization and echocardiogram during the diagnostic work-up. After exclusion, 12 patients were finally enrolled in the study. Their echocardiograms were ☆ Funding: None. ⁎ Corresponding author at: Interventional Echocardiography, Hartford Hospital, Hartford, CT, 06102; Assistant Professor of Medicine, University of Connecticut School of Medicine, Farmington, CT,06030, USA. E-mail address: aidan.fl[email protected] (A. Flynn).
http://dx.doi.org/10.1016/j.ijcard.2015.05.154 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
independently reviewed to analyze septal E′, lateral E′, averaged E′ and the respective E/E′ ratios. Continuous variables were presented as mean ± standard deviation, and discrete variables as group percentages. Pearson correlation was used to analyze the relationship between echo parameters and PCWP. A p-value ≤0.05 was considered statistically significant. The study protocol was approved by the institutional review board at Hartford Hospital and conforms to the ethical guidelines of the 1975 Declaration of Helsinki. The major demographic, clinical and echocardiographic parameters have been presented in Table 1. Mean (±SD) age and left ventricular ejection fraction of patients (8 males and 4 females) were 63.5 (±15.7) years and 58.8% (±3.3%) respectively. 9 (75%) patients had a septal bounce or shudder. Mean septal E′, mean lateral E′ and mean averaged E′ were 10.9 ± 3.1 cm/s, 10.3 ± 2.69 cm/s and 10.7 ± 2.8 cm/s respectively while mean septal E/E′, mean lateral E/E′ and mean averaged E/E′ were 8.5 ± 2.2, 8.9 ± 1.9 and 8.9 ± 1.7. Mean PCWP was 20 ± 5.1 mm Hg. Septal E′ had a moderate positive correlation to PCWP (r = 0.59; p = 0.04) though lateral E′ and averaged E′ demonstrated no significant correlation to PCWP (r = 0.28; p = 0.37 and r = 0.48; p = 0.11 respectively). Septal E/E′ and averaged E/E′ had a strong inverse correlation to PCWP (r = − 0.74; p = 0.005 and r = −0.64; p = 0.02 respectively) while lateral E/E′ had no significant correlation to PCWP (r = −0.47; p = 0.12). Thus, in patients with constrictive pericarditis, septal E′ bears a direct correlation while septal E/E′ and averaged E/E′ has an inverse correlation to PCWP. E/E′ ratios (septal, lateral and averaged) were low while E′ velocities (septal, lateral and averaged) were preserved or higher despite a moderate to severe elevation in invasively measured left-sided filling pressures. Our results emphasize that the inverse correlation between invasively measured left-sided filling pressures and E/E′ does exist, though this may be significantly affected if there is a time-lag between these two tests. In the study by Ha et al., cardiac catheterizations and echocardiograms were performed within a mean timeinterval of 6 days (most patients had both studies done within 3 days interval of each other) [3], however Alaires et al.'s study included patients where these tests were performed within a period of about 2 weeks [4], which may explain the differences in the noted findings of these two studies. In our study, patients had the cardiac catheterization and echocardiogram with a time interval ranging from 0 to 5 days. Nevertheless, one may also argue that the relationship between PCWP and E/E′ may also be affected by the presence of significant co-existing myocardial disease in patients of CP. One such good example would be radiation induced pericardial disease where patients would often have co-existing myocardial involvement to some extent or patients of CP with
L. Chhabra et al. / International Journal of Cardiology 195 (2015) 288–289 Table 1 Demographic, clinical and echocardiographic variables of the study population.
filing pressures, then it should perhaps be in relation to septal E/E′ and averaged E/E′ and not for lateral E/E′ ratios.
S. no. Variable
Result
1. 2. 3. 4.
Age (in years) Sex Race Etiology of CP
Conflict of interest
5.
Mitral inflow velocity [E (cm/s)] Mitral annular velocity [E′ (cm/s)] E/E′ ratio
63.5 ± 15.7 Men: 8; women: 4 Whites: 10; African–American: 1; others: 1 Post-CABG: 2; post-cardiac transplant: 2; tuberculosis: 1; bacterial pericarditis: 1; Idiopathic, viral or unclear etiology: 4; radiation-induced: 2 91.1 ± 26.2 Septal = 10.9 ± 3.1; lateral = 10.3 ± 2.7; averaged E′ = 10.7 ± 2.8 Septal = 8.5 ± 2.2; lateral = 8.9 ± 1.9; averaged = 8.9 ± 1.7 20 ± 5 21 ± 6 Septal r = 0.59 (p = 0.04); Lateral r = 0.28 (p = 0.37) and averaged r = 0.48 (p = 0.11) Septal r = 0.64 (p = 0.02); lateral r = 0.36 (p = 0.25) and averaged r = 0.5 (p = 0.1) 9 patients (75%) 10 (83%)
References
6. 7. 8. 9. 10. 11. 12. 13. 14. 15.
PCWP (mm Hg) LVEDP (mm Hg) r (correlation coefficient between E′ and PCWP) r′ (correlation coefficient between E′ and LVEDP) Septal bounce present Patients with preserved E′ (septal or lateral E′ N 8 cm/s) % of patients with septal E′ N 9 patients (75%) Lateral E′ (annulus reversus) LVEF (%) 58.8 ± 3.3
Data are presented as Mean ± Standard deviation or n (%). p-value (2-sided) b0.05 was considered significant. PCWP represents pulmonary capillary wedge pressure. LVEDP denotes left ventricular end diastolic pressure.
significant co-existent left ventricular dysfunction. Based on the results of our study, it is suggested that if one has to reserve the term ‘annulus paradoxus’ strictly in context to the relationship of E/E′ with left-sided
289
Dr. David Spodick receives royalties from his textbook, “The Pericardium: A Comprehensive Textbook (Fundamental and Clinical Cardiology), Marcel Dekker, New York 1997”. Other authors have no disclosures, financial or otherwise.
[1] D.H. Spodick, The Pericardium: A Comprehensive Textbook, Marcel Dekker, New York, 1997. [2] A.L. Klein, S. Abbara, D.A. Agler, C.P. Appleton, C.R. Asher, B. Hoit, J. Hung, M.J. Garcia, I. Kronzon, J.K. Oh, E.R. Rodriguez, H.V. Schaff, P. Schoenhagen, C.D. Tan, R.D. White, American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease: endorsed by the Society for Cardiovascular Magnetic Resonance and Society of Cardiovascular Computed Tomography, J. Am. Soc. Echocardiogr. 26 (2013) (965e1012.e15). [3] J.W. Ha, J.K. Oh, L.H. Ling, R.A. Nishimura, J.B. Seward, A.J. Tajik, Annulus paradoxus: transmitral flow velocity to mitral annular velocity ratio is inversely proportional to pulmonary capillary wedge pressure in patients with constrictive pericarditis, Circulation 104 (2001) 976–978. [4] M.C. Alraies, K. Kusunose, K. Negishi, H. Yarmohammadi, H. Motoki, W. AlJaroudi, Z.B. Popović, A.L. Klein, Relation between echocardiographically estimated and invasively measured filling pressures in constrictive pericarditis, Am. J. Cardiol. 113 (11) (2014) 1911–1916. [5] J.P. Dal-Bianco, P.P. Sengupta, F. Mookadam, K. Chandrasekaran, A.J. Tajik, B.K. Khandheria, Role of echocardiography in the diagnosis of constrictive pericarditis, J. Am. Soc. Echocardiogr. 22 (1) (2009) 24–33. [6] T.D. Welch, L.H. Ling, R.E. Espinosa, N.S. Anavekar, H.J. Wiste, B.D. Lahr, H.V. Schaff, J.K. Oh, Echocardiographic diagnosis of constrictive pericarditis: Mayo Clinic criteria, Circ. Cardiovasc. Imaging 7 (3) (2014) 526–534. [7] L. Chhabra, D.H. Spodick, Annulus paradoxus phenomenon remains a question, Circ. Cardiovasc. Imaging (2014) (Online Publication. (Available at: http://circimaging. ahajournals.org/content/7/3/526.abstract/reply#circcvim_el_1439)). [8] L. Chhabra, D.H. Spodick, Annulus paradoxus and constrictive pericarditis: a need for revisiting the association! Am. J. Cardiol. 115 (4) (2015) 554.
