Left and right ventricular filling in heart failure: The role of pericardial restraint

Abstract

ObjectiveThe aim of this study was to assess the existence and potential influence of pericardial restraint in patients with heart failure (HF) by evaluating the respiratory change of pulsed Doppler mitral inflow, tricuspid inflow, left ventricular outflow and hepatic vein flow velocities that determine left ventricular and right ventricular filling pattern. BackgroundPericardial restraint contributes to the diastolic filling abnormality in heart failure. The presence or magnitude of respirophasic change in Doppler flow velocity curves may be helpful in demonstrating the existence of pericardial restraint. MethodsWe prospectively studied 113 patients with HF, left ventricular ejection fraction (LVEF) <50%, no clinical or 2D echocardiographic evidence for constrictive pericarditis (CP), and no history of chronic lung disease. Pulsed-wave Doppler interrogation of the mitral, tricuspid inflow, left ventricular outflow and hepatic vein flow was performed with simultaneous respiratory recording and compared with that of 35 normal subjects. The presence or absence of a third heart sound (S3) was determined by auscultation and confirmed by phonocardiography. Significant respiratory variation was defined as a >25% increase (during the first cardiac cycle coincident with the onset of expiration compared to the inspiratory cycle) for mitral E, >40% increase for tricuspid E and >25% increase for left ventricular outflow velocities. Augmented hepatic vein expiratory diastolic/atrial reversals were defined as >25% of forward diastolic velocity, significant increase of inspiratory diastolic/atrial reversals (a?Y50% increase and a?Y100% increase).ResultsSignificant mitral E velocity variation (MEVV)was present in 35 patients (31%). It was more frequently observed in patients with an audible S3 than in those without a S3 [13/28 (50%) vs. 21/82 (25%), P = 0.027], and in pts with LVEF <30% compared to those with LVEF >30% [29/45 (39%) vs. 6/33 (17%), P = 0.0093]. MEVV tended to be more common in patients with any degree of RV systolic dysfunction on 2D echocardiography [19/46 (41%) vs. 16/66 (24%), P = 0.055). Significant tricuspid E velocity variation (TEVV) was present in 75 (67%) patients and also more common in patients with a S3 than in those without a S3 [22/28 (78.65) vs 53/81 (65.4%), P = 0.02]. Both MEVV and TEVV were not associated with respiratory rate, heart rate, body mass index, the degree of mitral regurgitation & tricuspid regurgitation. Increased expiratory diastolic/atrial reversals of hepatic vein flow were obvious in 60 HF patients (72.3%). Among them, there was an a?Y50% increase in diastolic/atrial reversals from inspiration to expiration in 39 (47%) patients and a?Y100% increase in 19 (23%) respectively. ConclusionAssociation with a S3 suggests a common basis in pericardial restraint. Doppler features resembled those observed in CP. Isolated MEVV, TEVV and significant increased expiratory diastolic/atrial HV reversals are not reliable criterion for diagnosing CP in patients with HF and reduced EF.