MRI of constrictive pericarditis

Clinical History

A 58 year old female was submitted to our hospital due to congestive heart failure with orthopnea and peripheral edema. The jugular veins were distended and Kussmaul’s sign was visible (increase of jugular venous pressure during inspiration). Auscultation revealed a pericardial knock.

Imaging Findings

A 58 year old female was submitted to our hospital due to congestive heart failure with orthopnea and peripheral edema. Constrictive pericarditis was known since 30 years, and the real cause had never been detected. The jugular veins were distended and Kussmaul’s sign was visible (increase of jugular venous pressure during inspiration). Auscultation revealed a pericardial knock. The heart catheterisation presented similar enddiastolic pressures (22 mm Hg) of all heart chambers. Cardiac silhouette was of normal size in the chest radiogram, and an excessive, shell-like calcification of the pericardium was present around the right and left heart chambers. MRI: The examination was performed using a dedicated cardiovascular magnetic resonance systeme (Horizon Signa CV/I, General Electric Medical Systems) and a phased-array cardiac coil. The apex and the ventricles were surrounded by a sharp, low-intensity pericardial line with no evidence of an accompanying effusion (see figure 1). There was an enormous right and left atrial enlargement. On the other hand, right and left diastolic ventricular volumes were moderately reduced (see figures 2 and 3). We observed an abnormal ventricular septal motion with a very early and late diastolic anterior motion. Furthermore, the posterior wall presented a so-called “flat motion” (see cine movie of figure 3). Hepatic veins and inferior vena cava were dilated.

Discussion

In constrictive pericarditis pericardium is thickened, fibrosed and/or calcified, and resembles a rigid shell in patients suffering from constrictive pericarditis. True etiology is unknown in many cases, often a clinically inapparent viral infection is presumed. Other causes are tuberculosis, postpericardiotomy syndrome, radiation therapy, chronic renal failure, connective tissue diseases, and neoplastic infiltration of the pericardium. The noncompliant pericardium restricts diastolic filling of the heart chambers. Symptoms secondary to systemic venous congestion (i.e. peripheral edema, ascites, hepatomegaly) and pulmonary venous congestion (i.e. dyspnea, cough) are leading signs in chronic constrictive pericarditis.ECG-gated MRI provides direct visualization of the pericardium. Non-diseased pericardium has low signal intensity and thickness ranging from 1 mm to 2,5 mm. MRI is a useful tool in depicting the thickened pericardium (> 4 mm) in patients suffering from chronic constrictive pericarditis. The distinction between the pericardium and pericardial effusion can easily be obtained by acquiring T2*-weighted cine MR images (dark line of the fibrous and calcified pericardium, and bright signal of the fluid). MRI is the most sensitive imaging tool to detect the thickened pericardium, whereas CT is sensitive for finding pericardial calcifications. Cardiac morphology and function can be evaluated using cine MRI. The most diagnostic signs in constrictive pericarditis are thickened and calcified pericardium, enlarged atrias, small ventricles with restricted diastolic filling, and abnormal movement of the interventricular septum. The motion abnormalities are presumably due to high filling pressures and restricted extension of the posterior wall caused by the fibrosed or calcified pericardium.

Differential Diagnosis List

Final Diagnosis

Constrictive pericarditis

URL:	https://www.eurorad.org/case/1918
DOI:	10.1594/EURORAD/CASE.1918
ISSN:	1563-4086