What is the management approach for discordance between left ventricle (LV) and right ventricle (RV) pressure tracings?

Management of Discordance Between LV and RV Pressure Tracings

The management approach for discordance between left ventricle (LV) and right ventricle (RV) pressure tracings should focus on diagnosing and treating constrictive pericarditis, as this is the primary condition associated with this hemodynamic finding. 1

Diagnostic Approach

• Discordance in LV/RV pressure tracings during inspiration is a key diagnostic feature of constrictive pericarditis and should prompt further evaluation with cardiac magnetic resonance (CMR) imaging 2
• Right and left heart catheterization with simultaneous pressure measurements provides the most accurate assessment when echocardiographic findings are inconclusive or conflict with clinical presentation 1
• The characteristic "dip and plateau" or "square root sign" in ventricular pressure tracings is a diagnostic hallmark of constrictive pericarditis 1
• Transthoracic echocardiography (TTE) should be the initial imaging modality to assess ventricular function, chamber size, and valvular abnormalities 2
• CMR is preferred for assessment of pericardial thickness and RV volumes when constrictive pericarditis is suspected 2

Differential Diagnosis

Constrictive Pericarditis

• Characterized by thickened, fibrotic pericardium causing restriction to diastolic filling 1
• Presents with diastolic equalization of pressures between right and left heart chambers 1
• Demonstrates ventricular interdependence with discordant pressure changes during respiration 2
• Shows preserved ventricular systolic function with restrictive filling pattern 2

Restrictive Cardiomyopathy

• Distinguished from constrictive pericarditis by absence of ventricular interdependence 1
• Typically shows elevated pulmonary vascular resistance 1
• Both ventricles demonstrate similar pressure changes during respiration (concordance) 2

Cardiac Amyloidosis

• May present with increased LV wall thickness and features mimicking heart failure with preserved ejection fraction (HFpEF) 2
• Requires specific diagnostic testing including monoclonal protein screen and technetium pyrophosphate scan 2

Management Strategy

For Constrictive Pericarditis

• Pericardiectomy is the definitive treatment for chronic constrictive pericarditis when ventricular discordance is confirmed 1
• Medical therapy with diuretics may provide symptomatic relief but does not address the underlying mechanical constraint 2
• Anti-inflammatory therapy may be beneficial in cases of transient constrictive pericarditis 1

For Other Causes of Ventricular Pressure Discordance

• High-output heart failure requires investigation and treatment of underlying causes such as anemia, arteriovenous malformations, or cirrhosis 2
• Pericardial disease following cardiac surgery, chest radiation, or pericarditis should be managed with targeted therapy for the underlying condition 2
• RV dysfunction due to pulmonary hypertension requires specific treatment of the pulmonary vascular disease 2, 3

Special Considerations

• Volume status assessment is essential before attributing hemodynamic abnormalities to cardiac dysfunction 1
• In mechanically ventilated patients, positive pressure ventilation affects the relationship between pulmonary capillary wedge pressure (PCWP) and LV end-diastolic pressure 1
• Clinical examination alone has poor agreement with invasively determined patterns of ventricular congestion, with only 44% concordance between clinical and invasive assessments 4
• RV dyssynchrony can significantly impact LV performance through ventricular interdependence in patients with pulmonary hypertension 3

Monitoring and Follow-up

• Serial echocardiographic assessment of ventricular function and hemodynamics is recommended after initiating therapy 2
• Exercise hemodynamic assessment should be considered when there is discrepancy between resting measurements and clinical symptoms 1
• Continuous monitoring of right heart pressures using implantable devices may be beneficial in selected patients with recurrent heart failure 2

Pitfalls and Caveats

• Clinical examination alone cannot reliably detect discordant RV and LV filling pressures, with poor kappa agreement (κ=0.44) between clinical and invasive assessments 4
• Jugular venous distention has excellent discrimination for elevated right atrial pressure but does not accurately predict LV filling pressures 4
• Interpretation of pressure tracings requires consideration of respiratory variation, cardiac rhythm, and conduction abnormalities 2
• Positive pressure ventilation can mask or exaggerate ventricular discordance patterns 1