What Are the Indications for Cardiac Magnetic Resonance Imaging in Pericardial Disease?

The recent increased interest in the diagnosis and management of pericardial disease has paralleled innovations in echocardiography, cardiac computed tomography, and cardiac magnetic resonance imaging (CMR).1,2 However, in the current era where efficient and cost-effective health care is appropriately emphasized, an integral question is, "what patient with suspected or known pericardial disease needs a CMR after a comprehensive clinical and echocardiographic assessment?" In general, further testing is pursued if a diagnosis remains uncertain or if additional testing is needed to direct patient management. With CMR and pericardial diseases, these general categories can be distilled to two specific scenarios. First, is constrictive physiology still suspected, but not yet confirmed, after an echocardiogram? Second, could pericardial inflammation be contributing to a patient's symptoms and thus warrant initiation or intensification of anti-inflammatory therapy?

How does CMR add to the evaluation for constrictive physiology?

To address the first question, an echocardiogram with a respirometer is the initial diagnostic test. Due to pericardial tethering, constrictive pericarditis is characterized by non-compliant cardiac chambers, prominent respiratory variation in cardiac flow, and accentuated early diastolic filling. Echocardiographic features of this pathophysiology include a diastolic septal bounce, respirophasic ventricular septal shift, a plethoric inferior vena cava (IVC), significant respiratory variation in mitral (25%)and tricuspid inflow (40%), a preserved or increased septal e' velocity( ≥ 0.8 cm/s), and hepatic vein expiratory end-diastolic reversal velocity/ forward diastolic flow ≥ 0.8. The combination of respirophasic ventricular septal shift with either of the latter two features appears sensitive and specific when "surgically confirmed constriction" is used as the gold standard.3 In addition, overall global longitudinal strain may be preserved in constrictive pericarditis,4,5 but longitudinal strain may be regionally decreased in the left ventricular anterolateral and right ventricular free walls, presumably due to impaired deformation of these segments related to tethering.6

In a patient with prominent heart failure symptoms, respirophasic ventricular septal shift, an increased septal e' velocity, decreased anterolateral global longitudinal strain, and a dilated IVC, the diagnosis of constrictive pericarditis is secure. After echocardiography, however, many patients will have features both in favor and against the diagnosis of constrictive pericarditis, especially in patients with radiation heart disease. For these patients, CMR can be useful. With CMR, further evidence of interventricular dependence is possible with real time cine imaging of septal motion during respiration.7 CMR also provides further anatomic information supporting constrictive pericarditis including increased pericardial thickness, conical deformity of the right ventricle, and tubular deformity of the left ventricle. In a recent study,8 the hierarchical relationship among various CMR variables was assessed (Figure 1), again using "surgically confirmed constriction" as the reference standard. Relative interventricular septal excursion with respiration provided the best discrimination. When septal excursion was combined with increased pericardial thickness, using patients with pericardial disease but no constriction and patients without pericardial disease as controls, sensitivity was 100% and specificity was 90%. Therefore, if the diagnosis of constrictive pericarditis is uncertain, CMR can provide important corroborating information.

Figure 1: CMR Findings in Constrictive Pericarditis

Figure 1
Double-inversion dark-blood four chamber view shows a thickened pericardium, most prominent anterior to the right ventricle (A, orange diamond). Bright-blood cine steady-state free procession images with four chamber view shows a conical deformity of the right ventricle (yellow triangle) and a tubular deformity of the left ventricle (yellow oval)(B). Real-time bright-blood cine steady-state free procession images with short axis views obtained during expiration (C) and early inspiration (D) shows septal excursion. Relative septal excursion is calculated by dividing the right ventricle free wall to septum distance (white line) by the overall biventricular distance (yellow line). The septal position was 49% during inspiration and 35% during expiration. The relative septal excursion is 14%. A septal excursion >12% is a specific finding for constrictive pericarditis.

How does CMR assess for pericardial inflammation in acute/recurrent pericarditis and constrictive pericarditis?

In distinction to the hemodynamic assessment where echocardiography and CMR are complementary, echocardiography provides little insight into pericardial inflammation except for pericardial effusion and increased pericardial brightness. Conversely, CMR can assess the tissue characterization and inform both the acuity and intensity of pericardial inflammation. Current assessments for pericardial inflammation with CMR include edema-weighted short-tau inversion-recovery fast spin-echo images (T2 STIR) and pericardial delayed hyperenhancement (DHE) after gadolinium administration. Increased pericardial signal on T2 STIR sequences is consistent with pericardial edema9 and usually indicates acute inflammation. Unlike myocardial DHE that indicates fibrosis, the histological correlate of pericardial DHE is neovascularization and fibroblast proliferation10. This organizing pericarditis represents ongoing inflammation whereas a patient with constrictive pericarditis and no DHE signal is more likely to have fibrosis and decreased vascularity. Therefore, a patient with increased pericardial T2STIR and DHE signal is likely acutely inflamed, and a patient without increased T2STIR but with increased DHE is likely in a sub-acute stage of the disease or resolving on anti-inflammatory therapy. A patient with constrictive pericarditis who has neither increased T2STIR nor DHE is likely in a chronic or "burnt-out"phase of the disease (Figure 2). Finally, in a patient with recurrent chest pain where pericarditis is in the differential, the absence of pericardial DHE supports the pursuit of other diagnoses.

Figure 2: CMR Staging of Pericardial Inflammation

Figure 2
In a patient with acute pericardial inflammation (A and B), short axis images show significant pericardial delayed hyperenhancement (DHE) after gadolinium administration (A) and increased pericardial signal on edema-weighted short-tau inversion-recovery fast spin-echo images (T2 STIR).
In a patient with sub-acute pericardial inflammation (C and D), short axis images show increased pericardial DHE but no increase in pericardial T2 STIR signal.
In a patient with "burnt-out" pericarditis (E and F), there is neither increased pericardial DHE nor T2 STIR signal. These images (E and F) are from the patient with constrictive pericarditis shown in Figure 1.

How can pericardial inflammation on CMR guide treatment?

In contrast to using CMR as an adjunct to assess for constrictive physiology or to diagnose pericarditis, the role of CMR to guide anti-inflammatory therapy in patients with pericardial inflammation is less well established. In patients with constrictive pericarditis, pericardial DHE identifies patients that are likely to respond to anti-inflammatory therapy11, an entity referred to as transient or reversible constrictive pericarditis. More recently, in a retrospective study of patients with recurrent pericarditis, CMR-guided therapy reduced glucocorticoid use and the number of recurrences12. Still, while these results are encouraging, more research, including clinical trials, are needed to define how CMR results can best guide anti-inflammatory regimens and treatment durations for patients with pericardial inflammation.


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Clinical Topics: Heart Failure and Cardiomyopathies, Noninvasive Imaging, Pericardial Disease, Acute Heart Failure, Echocardiography/Ultrasound, Magnetic Resonance Imaging

Keywords: Chest Pain, Citrus sinensis, Constriction, Diagnostic Tests, Routine, Echocardiography, Edema, Fibroblasts, Gadolinium, Heart Failure, Heart Ventricles, Hemodynamics, Hepatic Veins, Inflammation, Magnetic Resonance Imaging, Myocardium, Pericardial Effusion, Pericarditis, Pericarditis, Constrictive, Pericardium, Recurrence, Retrospective Studies, Tomography, Vena Cava, Inferior

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