J AM COLL CARDIOL 9071983,1(3}'907-12

DIAGNOSTIC TECHNIQUES

Atrial Systolic Notch on the Interventricular Septal Echogram: AnEchocardiographic Sign of Constrictive Pericarditis

CHUWA TEl, MD, FACC , JOHN S. CHILD, MD, FACC, HIROMITSU TANAKA , MD*,

PRAVIN M. SHAH, MD, FACC

Los Angeles, California and Kagoshtma , Japan

Interventricularseptal motionduringventricular dias­tole was analyzed using M-modeechocardiography in13patientswithconstrictivepericarditisand 12 patientswithrestrictivecardiomyopathy. In seven of eight pa­tients with constrictivepericarditis in sinus rhythm , anabnormal" atrial systolic"notch was observed consist­ing ofabruptinitialposteriormotion toward the leftventricleapproximatelyat tlie middle of the P wave andsubsequentanteriormotion at the end of the P waveandterminationbefore theR wave. This notch was ab­sentduringatrialprematurebeatsthatwererecordedin twopatients.The atrialsystolic notch was not ob-

The clinicalandhemodynamicdiffe rentiationbetweencon­strictive pericarditis and restrictive card iomyopathy is oftendifficultand at times impossible todetermine. Echocar­diography has beenof use in this regard(1-7). Severalechocardiographicfindings in constrictive pericarditissuchas abnormaldiastolicflatteningof the left ventricularpos­tcriorwall endocardium ( 1,2,8,9), and pericardial thick­ening (2,8,10), premature pulmonary valve opening(II)abnormalventricularseptal motion durin g systole(1,12)andearlydiastole(3) havebeenreported .However. these find­ings are notuniformlynoted nor are they specific,

In a preliminarystudy of constrictive pericarditis,weobservedan abnormal"atrial systolic notch " on the inter­ventricularseptalechogram that had not beendescribedpreviously,Therefore,we undert ook a systematicevaluation

FromtheDepartmentofMedicine.University ofCaliformaSchoolofMedicme, WadsworthVeterans Administration Medical Center. Los An­geles,California,and Kagoshima University". Kagoshima,Japan Dr.Chuwa Tei is aSenrorInvestigator ofthe American HeartAssociationGreaterLosAngelesAffiliate. supportedIn partbyGrouplnvestigatorshrpAward. theArthurDodd Fuller Foundation forCardro-VascularResearchandVeteransAdministrationMedicalResearchFunds. LosAngeles. Cal­ifornia. Manuscriptreceived August10. 1982,accepted September24,1982.

Address forreprints. Pravm M. Shah,MD , CardiologyDivision (6911l l lli),WadsworthVeteransAdministrationMedicalCenter,WillshireandSawtelleBoulevards,Los Angeles, California90073.

©1983 by theAmencanCollege of Cardiology

served in anypatientwithrestrictivecardiomyopathy.The septal notch in earlyventriculardiastole previouslydescribed inconstrictivepericarditiswas seen in 62%ofpatientswithconstrictivepericarditisand 25% of pa­tients withrestrictivecardiomyopathy.Thus , anabnor­malatrialsystolic notch may be anadditionaluseful signtodifferentiateconstrictivepericarditisfromrestrictivecardiomyopathy.The mechanism may berelatedtotran­sient late diastolicpressuregradientsbetween both ven­triclesresultingfromasynchronyof left and rightatrialcontractions.

ofthe interventricular septal echogram inpatientswith con­stricti ve pericarditis and restrictivecardiomyopathyinorderto: I) characterizethe abnormal atrial systolic notch , 2)attemptto understand the mechani smof the notch , and 3)assess the utilityofthe finding in the diagnosisofconstric­tivepericarditis.

MethodsPatients.Thirteenpatients( 10 men and3 women)withchronic

constrictivepericarditis and12 patients (8 men and 4 women) withrestrictivecardiomyopathy were studied. Patients with these di­agnoseswere included in thestudy if they hadgood interventricularseptal echograms with a continuous endocardial outline from thestandardleft parasternal "window," The diagnosisof constrictivepericarditiswas confirmed by operation in nine patients and wasestabhshed in four by typical pressure pulses at cardiac catheter­ization and presence of pericardial calcification on chest X-rayfilm. The diagnosis of restrictive cardiomyopathy was establishedat autopsy in five patients, and in six patients by tissue biopsy.One patient was diagnosed at thoracotomy. In11 of 12 patientswith restrictive cardiomyopathy, amyloidosis was the underlyingcause. The cause in the other patient diagnosed by thoracotomyIS unknown. The mean age was 47 years (range 29 to 67)10 thepatients with constrictive pericarditis and 49 years (range15 to74) in the patients with restrictive cardiomyopathy. Eight of13

0735-1097/83/030907-6$03 00

Figure1. M-mode echocardiogramof theinterventricularseptum from apatient withconstrictive pericarditisin sinus rhythm.Blackarrowsshowthe atrial systolic notch on theinterventricularseptum. The onset of theposten or motion occurs at the middle of the P wave (solid line) and thenadir of the notch is at the end of the P wave. The anterior motion endsJust before the QRScomplex.No abnormal atnal systolic motion is ob­served on thepostenorwall

patients with constrictive pericarditis and all patients with restric­tive cardiomyopathy had sinus rhythm. Five patients with con­strictive pericarditis had atrial fibrillation. In six (three with sinusrhythm, three with atrialfibrillation)of nine patients undergoingpericardiectomy, echocardiograms were repeated I to 6 monthsafter pericardiectomy.

Echocardiograms.Subjects were studied in the left lateralde­cubitusposition. Two-dimensionalechocardiogramswereobtainedusing a commercially available phased array system(Varian 3000,ToshibaSSH-IIA or Toshiba SSL-53M). M-mode echocardi­ogramsusing standardtechnique wereperformedeitheron a Smith­Kline Instruments Ekoline 20A system interfaced with a Honey­well 1856 fiberoptic strip chart recorder using a 2.25 MHz trans­ducer, a Toshiba SSL-53M system using an electroniccursor from

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a 2.25 MHz wide-angle electronically phased array transducerinterfacedwith a HoneywellLSR-I8A line scan stripchart recorderor a ToshibaSSH-IIA system interfaced with aHoneywellItAstrip chart recorder. M-mode echocardiograms were recordeddur­ing sustained expiration at a paper speed of 50 or 100mmls si­multaneously with electrocardiograms or phonocardiograms, orboth. The ventricular septal motion during diastole was analyzedat the level of the chordae tendineae below the mitral leaflets.

ResultsAn abnormal atrial systolic notch of the interventricular

septal echocardiogram (Fig. I) consistingofabruptinitialposteriormotiontowardthe leftventriclewith subsequentanteriormotionwasobservedin sevenofeightpatientswithconstrictive pericarditisandsinusrhythm(TableI). In con­trast,this abnormalabruptmovementwas notobservedinanypatientwithrestrictivecardiomyopathy(Fig. 2) despitethepresenceofsinusrhythm.Patientswithconstrictiveperi­carditisand atrialfibrillationdid notdemonstratethis notch(Fig. 3). The onsetof initialposteriorventricularseptalmotionbeginsin themiddleof the P wave on theelectro­cardiogram.The nadirofthe notch is at theendofP wave.The anteriormotionof the septumends beforethe QRScomplex.In two cases with constrictivepericarditisandatrialprematurebeatsduringthe echographicrecordings,theatrialsystolicnotch wasabsentduringtheectopicatrialcontraction(Fig. 4). In threepostoperativepatientswithsinus rhythm(Fig. 5), theabnormalatrialsystolicnotchdisappearedI, 2 and 6 months, respectively,afterpericardiectomy.

The early diastolic notch reported in constrictive peri­carditis was seen ineight(62%) of the patientswith con­strictivepericarditisand inthree(25%) ofthepatientswithrestrictivecardiomyopathy.It disappearedin fourpatientsand decreasedin two patientsI to 6 monthsafterperi­cardiectomy.

DiscussionTable1. Incidence of Abnormal Interventricular SeptalDiastolic Motion

EarlyPatients Atnal Diastolic

(no.) Notch Notch

Constrictivepencarditis

Sinus rhythm 8 7/8 (88%) 5/8 (63%)Atnal fibrillation 5 0/5 (0% ) 3/5 (60%)

Restrictivecardiomyopathy

Smus rhythm 12 0112 (0% ) 3/12 (25%)

Our studyreportsa new echocardiographicfinding inconstrictive pericarditisin the formof a notch on the in­terventricularseptalechogramduringatrialsystole(atrialsystolicnotch). In patientswith sinus rhythm,this signaccuratelydiscriminatedconstrictivepericarditisfrom re­strictivecardiomyopathy.Althoughwe did notsystemati­cally examinethe mechanismof this notch,indirectevi­dencefrom pressuretracingssuggeststhatasynchronousfilling of the right and leftventriclesresultingfrom thenormalasynchronyofthe twoatriaplaysan importantrole.Thus atrialprematurebeatswith alteredconfigurationand

ECHOCARDIOGRAM IN CONSTRICTIVE PERICARDITIS J AM cou,CARDlOl1983.1(3)907-12

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Figure2. M-modeechocardiogramof theinterventricularseptum from apatient with restrictivecardiomyopathy.No atrial systolic notch (whitearrows)is observed on theinterventricularseptum, although a slight earlydiastolic notch(blackarrows)is seen. LV= left ventricle; RV= rightventricle.

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one patientwith constrictivepericarditisand atrial fibril­lation in whom wemeasuredpressuresin the two ventriclessimultaneously,beforeand afterpericardiectomy(Fig. 6).The pattern and timing of an instantaneous left to right ven­tricularpressuregradientclosely resemblethe diastolicnotchingof theinterventricularseptalechogram.This ob­servation supports the hypothesis that the atrial systolic notchmay besimilarlyinfluencedby instantaneousinterventric­ularpressuregradients(Fig. 7). Thus,the normalearlieractivationandcontractionof the right atrium may result in

Figure4. M-modeechocardiogramof theinterventricularseptum from apatient withconstrictive pericarditisassociated with an atrial prematuredepolarization(whitearrow).Blackarrowsshow the atnal systolic notchassociated with a sinus bifid P wave. An atrial systolic notchIS not seenwith the atrial prematuredepolarizallon.

presumedalterationin thesequenceof atrialactivationfailedto show thisnotch,althoughthe normal sinus beats did.

Atrialsystolicversusearlydiastolicseptalnotchinconstrictivepericarditis.The diastolicmotion of the in­terventricularseptum inconstrictivepericarditisis probablygreatlyinfluencedby instantaneouspressuregradientsbe­tween the twoventricles.Thus, the previouslydescribedearlydiastolicnotch may be related to temporalasynchronyof right and leftventricularfilling in early diastolesecondarytoasynchronousopeningof thetricuspidand mitral valves.This should hold true inconstrictivepericarditiswhen thefree walls of bothventriclesareencasedin a thickened,rigid pericardialsac. Wesubstantiatedthis hypothesisin

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Figure3. M-modeechocardrograrnof theinterventricularseptum from a patient with constnctive pericarditis in atrialfibrillation. An early diastolic notch(blackarrow)on theinterventricularseptum is shownsimultaneouswith theknock sound; however, no atnal systolic notchI:> seen.LV = left ventricle; RV= right ventricle.

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Figure5. M-mode echocardiograms before(upperpanel) and I monthafter (lowerpanel)pericardiectomy from a patient with constrictive peri­carditis. The atrialsystolicnotch(blackarrows)on theupperpanel isno longer observed after pericardiectomy.

Figure6. M-mode echocardiogram and ventricular pressures and pressuregradient between both ventricles before (A) and I month after (8) peri­cardiectomy in a patient with constrictive pericarditis and atnal fibrillanon.The early diastolic notch(blackarrow)is seen preoperatively on theinterventricular septal echogram and in the left and right ventricular (LV­RV) pressure gradient (Pre. Ora) tracing. The notch disappeared on bothtracings after operation. Diastolic motion patterns on the interventricularseptal echogram and left and right ventricular pressure gradient are similarbefore and after operation.

LV Pre. 1\/"- =!JRV P e .J

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ECHOCARDIOGRAM IN CONSTRICTIVE PERICARDITIS J AM COLL CARDIOL1983;1(3)'907-12

911

Figure7. Schematic of a proposed mechanism for the abnormal atrialsystolic notch inconstnctivepericarditis. The right ventricular (RY) pres­sure may be higher than the left ventricular (LY) pressure from the middleof the P wave owing to earlier activation and contraction of the right atrium.Subsequently, as a result of left atrialcontraction,the leftventncularpressure may become higher than the right. Thus, the atrial systolic notchmay result from the transient negative left and right ventricular pressuregradient during atrial systole. A similar explanation may also underlie theearly diastolic notch asschematicallyshown. IYS = interventricular sep­tum; PW = posterior wall.

displacementof theinterventricularseptum toward the leftventricle,andsubsequentcontractionof the left atrium withan increase in leftventricularpressure would result in arapid anterior movement toward the right ventricle. Thispattern ofmovementaccuratelydescribes the atrial systolicnotchobservedin this study.

Comparison with restrictive cardiomyopathy. Re­strictivecardiomyopathyis characterizedby diastolic re­striction of filling of the ventricles, similar to that noted inconstrictive pericarditis(13-15). However, the underlyingpathologic process involves the ventricular walls diffusely, inthe form of either infiltrativeor fibroticlesions(16).Generally,the interventricular septum is equally as affected as the freewalls(16),and thus its ability to move abruptly with instan­taneous interventricular pressure gradients is not maintained.Hence, the early diastolic notch and the atrial systolic notchcommon in constrictive pericarditis are likely tobe rare inrestrictive myopathy. Infiltrative involvement of the atria withresulting impairment in atrial contraction may also contributeto the absence of the atrial systolic notch in the present seriesof patients with restrictive cardiomyopathy.

Mechanisms of septal motion. The diastolic shape andmotion of theinterventricularseptum have been studied byothers(17-20).Weyman et al.(17) reported abnormal early

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diastolic motion of theinterventricularseptum in mitralstenosis and postulated that unequal rates of filling of thetwo ventricles were responsible for thisobservation.Workby Tei(18) and Tanaka (19) and associatesdemonstratedthat the abnormal shape and motion of theinterventricularseptum in severepulmonaryhypertensionare related to theinstantaneous pressure gradients between the two ventricles.A more recent study by Little et al.(20) examined theinterventricularseptal motion in left bundle branch blockand related the abnormal septal motion during delayed leftventricularactivation to transient changes ininterventricularpressure gradient.Theirstudyemphasizeda close correla­tion of diastolic motion of theinterventricularseptum withthe instantaneous pressure gradients between the two ven­tricles. Thus, what is true of a structurally normal heart, asin theseexperimentalstudies, is likely to be more relevantin constrictivepericarditis.The interventricularseptum inthis latterconditionis structurally normal and the constrict­ingpericardiumimpairs motion of the free walls, renderingthe ventricles noncompliant. A small increase in volume mayresult in substantial increase in pressure, especially in latediastole when the ventricle is on the steeper end of thepressure-volumerelation.Therefore,the normally asyn­chronous atrialcontractionis likely to result in marked andsudden increases incorrespondinginterventricularpressureswhich would influence theinterventricularseptal motion.

We conclude that an abnormal atrial systolic notch maybe an additional useful sign todifferentiateconstrictive peri­carditis from restrictivecardiomyopathy.Its mechanismmay be related to transient late diastolic pressure gradientsbetween the right and left ventricles secondary to asyn­chrony of left and right atrialcontraction.

EarlyDiastolicNotch

AtrialSystolicNotch

PW

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