Pericardial Disease
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Co-Authors: Ron Jacob; Kanae Mukai

Date: 3/1/2018

description

  • A typical CMR for the evaluation of the pericardium includes a variety of pulse sequences. Cine-CMR can be used to quantify chamber size and function; black blood T1 with and without fat saturation is often used to measure pericardial thickness; T2-STIR images can help determine if the pericardium is actively inflamed; myocardial tagging is used to determine if the pericardium is tethered to the myocardium as a sign of constriction; late gadolinium enhancement can provide insight into whether there is pericardial and/ or myocardial inflammation or fibrosis present, and real time cine images and phase contrast imaging can be used to determine if there is evidence of constrictive physiology.

Indications and Purpose of the Scan:

  • To evaluate the pericardium for constriction and for masses/cysts.

Why CMR (Specific Advantages):

  • CMR has the unique ability to look for the presence of pericardial inflammation and can in addition identify myocardial involvement in myopericarditis. This can be useful to make the diagnosis as a first test and can reduce additional testing with appropriate treatment initiated earlier(3)

Evidence:

  • Thavendiranathan P, Verhaert D, Walls MC et al. Simultaneous right and left heart real-time, free-breathing CMR flow quantification identifies constrictive physiology. JACC Cardiovascular imaging 2012;5:15-24.
  • CMR provides anatomic, functional and hemodynamic information that can be very helpful in making the diagnosis of constriction.
  • Zurick AO, Bolen MA, Kwon DH et al. Pericardial delayed hyperenhancement with CMR imaging in patients with constrictive pericarditis undergoing surgical pericardiectomy: a case series with histopathological correlation. JACC Cardiovascular imaging 2011;4:1180-91.
  • Delayed enhancement imaging by CMR identifies neovascularization of the pericardium.
  • Beroukhim RS, Prakash A, Buechel ER et al. Characterization of cardiac tumors in children by cardiovascular magnetic resonance imaging: a multicenter experience. Journal of the American College of Cardiology 2011;58:1044-54.
  • CMR provides an unobstructed view of the pericardium, which can be difficult to visualize on echocardiography due to limited acousti windows.  Evaluation of the CMR features using various sequences allows tissue characterization and can often help in understanding the etiology of pericardiac masses/cysts, evaluate for the need for further intervention, and assist in surgical planning when indicated.

Contraindications:

  • Any implanted device that is not MRI conditional

  •  Inability to lie flat

  •  Inability to tolerate the scan

  •  Altered mental status/ inability to follow verbal commands in scanner

  •  Severe arrhythmias

Appropriateness:(Appropriate. Class I.  Level of Evidence C.)

  • Adler, Y, Charron, P, Imazio, M, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases. The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC). European Heart Journal (2015) 36, 2921–2964.
  • Hendel, R, Patel, M, Kramer, C, et al. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging: a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology, North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology. J Am Coll Cardiol. 2006 Oct 3;48(7):1475-97.

More Information:

Figure 1

Patient is a 48 year old female with SLE who presented with  chest discomfort and shortness of breath. The patient’s physical exam and ECG were unrevealing.  The Cardiac MRI reveals a thickened pericardium with significant delayed enhancement with gadolinium (red arrows). The patient was treated with steroids with complete resolution of her symptoms.

References:

  1. Khandaker MH, Espinosa RE, Nishimura RA et al. Pericardial disease: diagnosis and management. Mayo Clin Proc 2010;85:572-93.
  2. Salisbury AC, Olalla-Gomez C, Rihal CS et al. Frequency and predictors of urgent coronary angiography in patients with acute pericarditis. Mayo Clin Proc 2009;84:11-5.
  3. Imazio M, Bobbio M, Cecchi E et al. Colchicine in addition to conventional therapy for acute pericarditis: results of the COlchicine for acute PEricarditis (COPE) trial. Circulation 2005;112:2012-6.
  4. Talreja DR, Edwards WD, Danielson GK et al. Constrictive pericarditis in 26 patients with histologically normal pericardial thickness. Circulation 2003;108:1852-7.
  5. Thavendiranathan P, Verhaert D, Walls MC et al. Simultaneous right and left heart real-time, free-breathing CMR flow quantification identifies constrictive physiology. JACC Cardiovascular imaging 2012;5:15-24.
  6. Zurick AO, Bolen MA, Kwon DH et al. Pericardial delayed hyperenhancement with CMR imaging in patients with constrictive pericarditis undergoing surgical pericardiectomy: a case series with histopathological correlation. JACC Cardiovascular imaging 2011;4:1180-91.
  7. Feng D, Glockner J, Kim K et al. Cardiac magnetic resonance imaging pericardial late gadolinium enhancement and elevated inflammatory markers can predict the reversibility of constrictive pericarditis after antiinflammatory medical therapy: a pilot study. Circulation 2011;124:1830-7.
  8. Bertog SC, Thambidorai SK, Parakh K et al. Constrictive pericarditis: etiology and cause-specific survival after pericardiectomy. Journal of the American College of Cardiology 2004;43:1445-52.
  9. Cosyns B, Plein S, Nihoyanopoulos P et al. European Association of Cardiovascular Imaging (EACVI) position paper: Multimodality imaging in pericardial disease. Eur Heart J Cardiovasc Imaging 2015;16:12-31.
  10. Beroukhim RS, Prakash A, Buechel ER et al. Characterization of cardiac tumors in children by cardiovascular magnetic resonance imaging: a multicenter experience. Journal of the American College of Cardiology 2011;58:1044-54.
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