MRI of the abnormal pericardium

To evaluate the use of MRI in the diagnosis of pericardial disease, 63 patients with pericardial abnormalities or clinically suspected pericardial disease were studied retrospectively. Twenty-three patients had pericardial effusion, 19 patients had pericardial thickening, and 11 patients were referred for evaluation of masses with possible pericardial involvement. The other 10 patients were referred for differentiation of constrictive pericarditis from restrictive cardiomyopathy and eventually were found to have pericardial hematoma or normal pericardium as assessed by MRI. The calculated size of pericardial effusion by MRI showed a good correlation with semiquantitative echocardiographic estimations. MRI could demonstrate fibrinous adhesions in patients with uremic pericarditis. It was also of great value in the differential diagnosis of constrictive pericarditis vs restrictive cardiomyopathy. Pericardial thickness of more than 4 mm was found in patients with constrictive pericarditis. Normal pericardial thickness was demonstrated by MRI in the three patients with restrictive cardiomyopathy. MRI diagnosed hemopericardium correctly as the cause of constrictive symptoms in two patients. Pericardial thickening in patients after cardiac surgery was commonly found by MRI and usually was not associated with clinical signs of constrictive pericarditis. MRI proved to be useful in the diagnosis of pericardial cysts and in the evaluation of paracardiac masses with possible pericardial involvement. MRI is an important technique in the evaluation of the pericardium. It can provide important additional information when diagnosis cannot be made adequately by other noninvasive imaging techniques.

Yield of endomyocardial biopsy in patients with biventricular failure. Comparison of patients with normal vs reduced left ventricular ejection fraction

Twenty five patients with biventricular failure underwent endomyocardial biopsy procedures. Twelve of these 25 patients had normal left ventricular ejection fraction. Endomyocardial biopsy sampling was useful in eight of 12 patients (67 percent) with biventricular failure and normal left ventricular ejection fraction. Biopsy specimens in five of these 12 patients demonstrated endocardial or infiltrative heart disease and excluded these diseases in three other patients with constrictive pericarditis. This study suggests that the clinical presentation of biventricular failure, combined with the noninvasive determination of a normal left ventricular ejection fraction, is helpful in selecting patients for endomyocardial biopsy study. Patients with biventricular failure and normal left ventricular ejection fractions have a high probability of having pericardial or infiltrative heart disease, conditions that often can be differentiated only by analysis of myocardial tissue. Hemodynamic assessment of patients without infiltrative processes further allows one to eliminate those patients with a high likelihood of having constrictive pericardial disease.

[Calcification of the heart]

A case of chronic calcific constrictive pericarditis in a 39-year-old Ugandan is presented. According to recent views this condition is only rarely caused by tuberculosis.

[Features of the course and evaluation of the efficacy of surgical treatment of adhesive pericarditis with constriction]

Two groups of patients with constrictive pericarditis were identified on the basis of clinical and instrumental examination including echocardiography and computerized tomography of the heart: patients with complete obliteration of the pericardial sac and constriction, and those with exudative/adhesive pericarditis and constriction. Part of the patients were subjected to subtotal pericardectomy. An improvement of left-ventricular diastolic function and hemodynamic parameters was demonstrated 1 to 1.5 months after the operation. Postoperative echocardiography showed persistent disorders of interventricular septum movement and multilayer abnormal echoes in the left-ventricular posterior wall area.

Constrictive pericarditis mimicking Budd-Chiari syndrome

Budd-Chiari syndrome and constrictive pericarditis share many clinical and histologic features. Clinicians must continue to reassess patients when given histologic data that are not specific for a particular disease entity, so that subtle clinical differences are recognized, appropriate diagnosis made, and therapy instituted.

Constrictive pericarditis and pregnancy

A case discussing the medical management of a 30-year-old gravid patient with recurrent pericarditis and pericardial constriction secondary to juvenile rheumatoid arthritis is presented.

M-mode echocardiography in constrictive pericarditis

M-mode echocardiograms from 40 patients with proven constrictive pericarditis and 40 subjects without evidence of cardiac disease were reviewed for features previously described in constrictive pericarditis. In this large series, no single feature of the M-mode echocardiogram could be considered diagnostic, although a pattern of normal left ventricular size and systolic function, mild left atrial dilation, flattened diastolic left ventricular posterior wall motion and abnormal septal motion was found in most patients. It is concluded that the M-mode echocardiogram can provide findings suggestive of constrictive pericarditis but must be used in conjunction with hemodynamic and other studies to establish the diagnosis.

[M-mode echocardiography study of the left atrium, precordial and suprasternal: a comparative echocardiography angiocardiography study]

This study of 30 patients evaluates whether the size of the left atrium can be estimated echocardiographically with the precordial and suprasternal approach. Simultaneous imaging of the left atrium from both planes was possible in 24 patients. Angiographically, left atrial volume amounted to 107 +/- 69 ml for the minimal and 153 +/- 63 ml for the maximal left atrial size during the cardiac cycle. In each case, the diameter values of the left atrium were greatest from the suprasternal approach (p less than 0.001). All angiographic parameters were larger than the corresponding echocardiographic values (p less than 0.001). The study demonstrates that the size of the left atrium cannot be estimated reliably from biplane m-mode echocardiographic parameters.

Constrictive calcific pericarditis following coronary arterial bypass surgery

A case of postsurgical constrictive calcific pericarditis is reported. The unusual features of this case are the short interval (two months) from surgery to the development of pericarditis and the involvement of the coronary arterial grafts, resulting in tearing of the vessels and the death of the patient during decortication.

Severe constrictive pericarditis after single 16 MeV anterior mantle irradiation for Hodgkin's disease

Severe constrictive pericarditis developed in 4 of 73 patients after single anterior 16 MeV mantle field irradiation for Hodgkin's disease. 3 patients (4.1%) died; the other had successful pericardectomy. Use of a single anterior mantle field of high-energy X-rays is clearly more hazardous than conventional opposed-field techniques, and the resulting radiation pericarditis is difficult to treat.

[Right ventricular inflow tract obstruction in primary non-Hodgkin lymphoma of the heart]

An unusual case of non-Hodgkin lymphoma (centroblastic B-cell type) is described presenting with severe tricuspid stenosis due to a large right atrial intracavitary tumor mass obstructing the tricuspid orifice. The clinical picture of cardiogenic shock was relieved by surgical removal of the greater part of the tumor mass from the right atrium.

Magnetic resonance imaging of constrictive pericardial disease

Gated magnetic resonance imaging of 5 patients with suspected constrictive pericardial disease was performed using a superconducting magnet operating at 0.35 Tesla. Results were compared with those of echocardiography and hemodynamic measurements in all patients, with chest films in 5, computerized tomography in 2 and with histologic findings in 3. Pericardial thickness exceeded 5 mm in 4 patients and was 5 mm in 1 patient. Absence of magnetic resonance signal from the thickened pericardium was observed with extensive calcific deposits, and increased intensity of the thickened pericardium was associated with inflammatory disease. Dilatation of the right atrium, venae cavae and hepatic veins, and right ventricular narrowing was observed in all patients. The ventricular septum was straight in all patients. Magnetic resonance imaging allows both measurement of pericardial thickness and depicts internal cardiac anatomy without exposure to radiation or use of contrast medium. Satisfactory imaging with a large field of view can be performed in the presence of lung disease, thoracic deformity or surgical "hardware"--conditions that limit echocardiography and computerized tomography. The inherently 3-dimensional data permit imaging in any plane without loss of resolution. Thus, magnetic resonance appears to be the noninvasive method of choice for the diagnosis of constrictive pericardial disease.

Diagnosis of constrictive pericarditis by two-dimensional echocardiography: studies in a new experimental model and in patients

The purpose of this study was to determine the value of two-dimensional echocardiography in detecting constrictive pericarditis. Serial two-dimensional echocardiography was performed in eight closed chest conscious dogs with experimental constrictive pericarditis, using a new model that creates constrictive pericarditis by the introduction of a pericardial irritant mixture. Constrictive pericarditis was confirmed in these dogs by cardiac catheterization and pathologic examination. Four patients with constrictive pericarditis and three patients with restrictive cardiomyopathy (amyloidosis) were also studied. Analysis of short-axis two-dimensional echocardiograms was performed to determine the frame by frame change in left ventricular cavity areas throughout diastole. Curves of diastolic left ventricular cavity area change versus percent duration of diastole were constructed for each animal and human subject. Pericardial thickness was measured at various gain settings on two-dimensional and M-mode echocardiograms and at post-mortem examination. In dogs with constrictive pericarditis, the echocardiograms seriously overestimated and correlated poorly with pathologic measurements of pericardial thickness. In dogs after constrictive pericarditis developed, 69 +/- 11% (mean +/- SD) (range 50 to 84) of cavity area change occurred in the initial 30% of diastole compared with 35 +/- 7% (range 20 to 45) in control two-dimensional echocardiograms (p less than 0.001). Four patients with constrictive pericarditis showed similar accelerated cavity expansion in early diastole, but three patients with cardiac amyloidosis showed more variable left ventricular diastolic expansion rates. It is concluded that two-dimensional echocardiograms can demonstrate characteristic diastolic filling abnormalities in constrictive pericarditis, but cannot accurately measure pericardial thickness.

Recurrent cardiac constriction after pericardiectomy

Dependent edema, ascites, and exertional dyspnea developed in a patient seven months after pericardiectomy for constrictive pericarditis. Cardiac catheterization documented constrictive physiology. At the second operation, he was found to have extensive mediastinal fibrosis that encased the heart. Postmortem examination showed a fibrocartilagenous exoskeleton that encased both ventricles. Possible etiologies for this unusual reconstriction are discussed.

Simulation of acute myopericarditis by constrictive pericardial disease with endomyocardial fibrosis due to methysergide therapy

Methysergide ( Sansert ) has been associated with numerous fibrotic disorders. In particular, multiple cardiac lesions have been described in cases where methysergide was thought to have played a causative role. A patient is described who presented with cardiac findings suggestive of acute myopericarditis . An inflammatory myocarditis was subsequently excluded by endomyocardial biopsy. Hemodynamic findings suggested the presence of constrictive pericarditis or restrictive cardiomyopathy, or both. Radiographic evidence of constrictive pericarditis and biopsy evidence of endocardial fibrosis were documented in this patient with a long history of interrupted methysergide therapy.

Myocardial ischaemia in constrictive pericarditis--a morphometric and electron microscopical study

Left ventricular biopsies, taken during pericardiectomy, were morphometrically and morphologically examined to determine the pathology of the myocardium in constrictive pericarditis (CP). To serve as a normal control a similar appraisal was made of tissue from the left ventricle of a patient undergoing atrial septal repair. Morphometrically, mean cross-fibre diameters at the position of the nucleus in atrial septal defect (ASD) and CP hearts were within a range previously reported as normal. In hearts from patients with CP, the range of individual myocardial fibre diameters was extended. Ultrastructurally the myocardium in ASD appeared normal. In CP, myofibres could be divided into two groups: (a) small and morphologically normal; and (b) large and oedematous. Oedematous fibres contained abnormal nuclei and sarcoplasmic organelles and myofibrillar dissolution was a prominent feature in many cells. These pathological features are among those previously used to characterize myofibre ischaemia. In CP, prolonged cardiac compression is thought to predispose the heart to atrophy due to its inability to function properly (disuse atrophy). The results of this study suggest that in CP, myocardial ischaemia is a more important factor in the aetiology of myocardial dysfunction than is atrophy which arises from enforced cardiac disuse.

Constrictive pericarditis associated with combined idiopathic retroperitoneal and mediastinal fibrosis

Idiopathic retroperitoneal fibrosis and mediastinal fibrosis are localized expressions of a systemic sclerosing disease of unknown cause which, on rare occasions, may coexist in the same patient. Although pericardial involvement may occur, recurrent constrictive pericarditis that is unrelieved by pericardiectomy has not previously been reported in association with either idiopathic retroperitoneal or mediastinal fibrosis. Reported herein is a case of recurrent constrictive pericarditis that was unrelieved by two pericardiectomies , and autopsy revealed unsuspected combined idiopathic retroperitoneal and mediastinal fibrosis. The clinical, echocardiographic, and pathologic findings are described.

Constrictive pericardial disease in the dog

The clinicopathologic features of constrictive pericardial disease in 13 dogs were reviewed. The causes were infection (3 dogs), metallic foreign body (1 dog), and idiopathic (9 dogs). Owner complaints included abdominal enlargement, tachypnea, weakness or syncope, exertional fatigue, and weight loss. Ascites and jugular venous distention were consistently observed, whereas abnormalities of arterial pulses and heart sounds were variable and inconsistent. Diminished QRS voltages were common. Mild to moderate cardiomegaly, rounding of the cardiac silhouette, and variable and nonspecific angiographic findings were frequently observed. Cardiac catheterization consistently showed elevation and equilibration of atrial and ventricular diastolic pressures, but a prominent early diastolic (y) descent was uncommon. Fibrosis was confined to the parietal pericardium in 8 dogs, and included the epicardium in 5 dogs. Parietal pericardectomy was successful in relieving the syndrome in 6 of 10 dogs. Pulmonary thrombosis was the most common cause of early postoperative mortality.

Restrictive cardiomyopathy

Restrictive cardiomyopathy is a descriptive clinical and hemodynamic syndrome emphasizing the pathophysiologic mechanisms by which myocardial hypertrophy and/or infiltrative processes cause cardiocirculatory morbidity. This diagnosis can be made with precision only after pericardial construction is excluded and myocardial biopsy has identified the restrictive process. Though a variety of rather rare infiltrative pathological entities may be responsible for the restrictive cardiomyopathic picture, most commonly no definitive pathologic diagnosis is established despite extensive hemodynamic and histologic investigation. Nonetheless, a therapeutic trial with a calcium entry blocking agent is warranted.