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Novel marker "Ejection Times" may distinguish CCP from RCMP, finds JAMA study
While enhanced ventricular interaction is a foundational parameter to distinguish chronic constrictive pericarditis (CCP) from restrictive cardiomyopathy (RCMP), it is an enhancement of a normal phenomenon and the boundary between normal and abnormal values is not absolute.
Pseudo ventricular interaction can occur in the settings of respiratory distress or other circumstances of increased work of breathing. Atrial fibrillation, with variable diastolic intervals, will alter beat to beat ventricular stroke volumes, making respirophasic assessment more complex. Hence, even with the available ECHO and catheterization based distinguishing parameters, the distinction of these two closely mimicking but therapeutically different disease process remains challenging.
Ejection times (ETs) correlate with stroke volumes and can be easily measured from arterial pressure tracings. Jain et al aimed to assess respirophasic changes in pulmonary artery (PA) ETs and aorta (Ao) ETs as a marker for enhanced ventricular interdependence. This study evaluated patients undergoing left-side and right-side heart catheterization for assessment of CCP after noninvasive evaluation was inconclusive.
Measurements of the PA and Ao ETs were made during inspiration and expiration. Ventricular interaction was mainly assessed by evaluating the difference of ETs from expiration to inspiration as well as the difference in Ao minus the difference in PA.
A total of 10 patients with surgically proven CCP and 10 patients without CCP (restrictive cardiomyopathy or severe tricuspid regurgitation) were identified. There were no significant differences in demographic characteristics or baseline hemodynamic measurements. In patients with CCP compared with those without CCP, there was a significantly greater decrease in PA ET and a nonsignificantly greater increase in Ao during expiration vs inspiration.
Thus, the difference in Ao ET minus the difference in PA ET during expiration vs inspiration was significantly greater in those with CCP compared with those without CCP. In individuals with CP, the noncompliant pericardium impairs ventricular filling, preferentially increasing RV stroke volume with inspiration at the expense of LV stroke volume, and the inverse applying during expiration.
Evaluation of ejection times can thus simplify the invasive assessment for constriction, particularly when high-fidelity micromanometers are not available and frequent catheter-induced ventricular ectopy or mechanical aortic prostheses are present. Using PA and Ao parameters to evaluate ventricular interdependence offers several advantages. These tracings can be obtained efficiently, without the need to access both ventricles, and confront ventricular ectopy or fluid-filled catheter whip artifact.
Source: JAMA Cardiology: doi:10.1001/jamacardio.2021.3478
MBBS, MD , DM Cardiology
Dr Abhimanyu Uppal completed his M. B. B. S and M. D. in internal medicine from the SMS Medical College in Jaipur. He got selected for D. M. Cardiology course in the prestigious G. B. Pant Institute, New Delhi in 2017. After completing his D. M. Degree he continues to work as Post DM senior resident in G. B. pant hospital. He is actively involved in various research activities of the department and has assisted and performed a multitude of cardiac procedures under the guidance of esteemed faculty of this Institute. He can be contacted at editorial@medicaldialogues.in.
Dr Kamal Kant Kohli-MBBS, DTCD- a chest specialist with more than 30 years of practice and a flair for writing clinical articles, Dr Kamal Kant Kohli joined Medical Dialogues as a Chief Editor of Medical News. Besides writing articles, as an editor, he proofreads and verifies all the medical content published on Medical Dialogues including those coming from journals, studies,medical conferences,guidelines etc. Email: drkohli@medicaldialogues.in. Contact no. 011-43720751