Pericardial diseases are relatively uncommon but are difficult to diagnose because their clinical presentation may mimic more prevalent conditions like coronary artery disease and heart failure.¹ Due to limited evidence-based data, diagnostic and therapeutic strategies have been mostly based on expert opinions and consensus statements. The European Association of Cardiovascular Imaging (EACVI) recently released a position paper about the complementary use of different imaging modalities in the diagnosis and management of pericardial diseases². This position paper is an attempt to standardize diagnostic criteria and to incorporate the use of different imaging modalities to diagnose pericardial pathologies, and extends earlier efforts by the European Society of Cardiology (ESC)³ and the American Society of Echocardiography (ASE)⁴.

The EACVI report starts by introducing findings that can be appreciated using each imaging modality, and their advantages and disadvantages in normal as well as different pericardial pathologies. The report highlights the important role of trans-thoracic echocardiography in the diagnosis and management of pericardial tamponade and constriction (CP), and the emerging role of speckle tracking echocardiography in addition to Doppler in differentiating CP from restrictive cardiomyopathy (RCM). While the report is more of a contemporary overview of the field, perhaps its merits lie in the specific in-depth discussions of CT and CMR and the different methodologies that can be applied using both techniques in the context of various clinical scenarios. More importantly, the EACVI report proposes an algorithm that can be effectively used to initially guide the need for different diagnostic imaging tools in acute pericarditis and its possible complications².

The EACVI report specifically points out that an initial echocardiogram is sufficient to identify the presence of pericardial effusion and to assess the presence of hemodynamic criteria of tamponade or CP. Three main possible scenarios have been listed; first, the presence of pericardial effusion complicated by tamponade; second, the presence of moderate to large pericardial effusion that may or may not be complicated with CP (effusive CP), which might require conservative treatment or percutaneous drainage according to the clinical setting; and finally, the presence of minimal or no effusion, with or without the presence of CP features which might resolve by medical treatment (transient pericarditis) or persist despite medical treatment requiring surgical intervention. If the initial echocardiogram shows signs of tamponade, echocardiography guided pericardiocentesis is immediately indicated with no need for additional imaging except follow-up echocardiography for post procedural recollection of fluid⁵. Similarly, no other imaging modality is required to exclude tamponade if the initial echocardiography suggests small or no effusion, unless loculated effusion is suspected, where CT and CMR can be helpful.

For patients with suspected CP on echocardiography, anti-inflammatory medications can be first tried in the hope of resolving the CP as a part of transient pericarditis. Late Gadolinium enhancement (LGE) on CMR can be of special use in this case, being able to predict reversibility of CP with anti-inflammatory medications. If the CP features persist despite medication or were initially severe, the decision can be made to proceed with pericardiotomy, where CT can be helpful to accurately assess pericardial thickness and calcification.

Patients with acute pericarditis may be associated with moderate to large effusion, which can be further complicated by the development of effusive constrictive pericarditis. In those patients, CT and CMR are very helpful in identification of the nature of the pericardial fluid and differentiating serous fluid from exudate and hemorrhagic fluid accumulation. Because faster accumulation of large volumes in those patients may impede right sided diastolic filling even in the absence of tamponade, percutaneous drainage may be required with further imaging and laboratory work to identify the etiology. In this sense, CT and CMR can be used for extra-cardiac structure assessment particularly in a traumatic and neoplastic etiology.

The report also reviews the ability of different imaging techniques to diagnose and differentiate rare pericardial pathologies such as congenital absence of the pericardium, pericardial cysts and diverticula, and primary pericardial tumors. Although echocardiography remains the first imaging modality of choice, the high spatial resolution and the ability of tissue characterization and extra-cardiac structural assessment give CT and CMR advantages in assessment of these rare conditions.

The use of multiple imaging modalities thus seems complimentary in pericardial diseases; however, the cost-effectiveness of different strategies remains to be defined. The EACVI report, in agreement with the previous guidelines thus correctly points towards the use of additional imaging modalities only if transthoracic echocardiogram is suboptimal or, for specific needs like planning for pericardiotomy, the need for tissue characterization, and assessment of response to anti-inflammatory medications^1,3,4,6. Readers should be cautioned however that most of the current criteria used for diagnosis and management of patients with pericardial diseases are derived from small single center clinical studies. The lack of evidence warrants continued use of clinical judgment and rationale on a case-by-case basis while keeping the expert consensus-based reports as a background guide for assessment of pericardial diseases.

References

1. Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK. Pericardial disease: Diagnosis and management. Mayo Clinic proceedings. 2010;85:572-593
2. Cosyns B, Plein S, Nihoyanopoulos P, Smiseth O, Achenbach S, Andrade MJ, Pepi M, Ristic A, Imazio M, Paelinck B, Lancellotti P, European Association of Cardiovascular I, European Society of Cardiology Working Group on M, Pericardial d. European association of cardiovascular imaging (eacvi) position paper: Multimodality imaging in pericardial disease. European heart journal cardiovascular Imaging. 2015;16:12-31
3. Maisch B, Seferovic PM, Ristic AD, Erbel R, Rienmuller R, Adler Y, Tomkowski WZ, Thiene G, Yacoub MH, Task Force on the D, Management of Pricardial Diseases of the European Society of C. Guidelines on the diagnosis and management of pericardial diseases executive summary; the task force on the diagnosis and management of pericardial diseases of the european society of cardiology. European heart journal. 2004;25:587-610
4. Klein AL, Abbara S, Agler DA, Appleton CP, Asher CR, Hoit B, Hung J, Garcia MJ, Kronzon I, Oh JK, Rodriguez ER, Schaff HV, Schoenhagen P, Tan CD, White RD. American society of echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease: Endorsed by the society for cardiovascular magnetic resonance and society of cardiovascular computed tomography. Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography. 2013;26:965-1012 e1015
5. Pepi M. [ultrasound-guided pericardiocentesis]. Cardiologia. 1995;40:783-785
6. Yared K, Baggish AL, Picard MH, Hoffmann U, Hung J. Multimodality imaging of pericardial diseases. JACC. Cardiovascular imaging. 2010;3:650-660

Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Pericardial Disease, Atherosclerotic Disease (CAD/PAD), Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and Coronary Artery Disease, Interventions and Imaging, Echocardiography/Ultrasound

Keywords: Algorithms, Cardiac Tamponade, Cardiomyopathy, Restrictive, Consensus, Constriction, Coronary Artery Disease, Diverticulum, Drainage, Echocardiography, Expert Testimony, Exudates and Transudates, Follow-Up Studies, Gadolinium, Heart, Heart Failure, Hemodynamics, Humans, Judgment, Mediastinal Cyst, Pericardial Effusion, Pericardiectomy, Pericardiocentesis, Pericarditis, Pericarditis, Constrictive, Pericardium, United States

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