Constrictive pericarditis in the modern era: novel criteria for diagnosis in the cardiac catheterization laboratory

Magnetic resonance imaging in the evaluation of congestive cardiac failure

Congestive cardiac failure is the end-result of various cardiac disorders, and is a major contributor to morbidity, mortality, and financial burden throughout the world. Due to advances in the knowledge of the disease and scanner technology, magnetic resonance imaging (MRI) is playing an increasingly important role in the evaluation of cardiac failure, including in establishing diagnosis, problem solving, risk stratification, and monitoring of therapy. This review discusses and illustrates the role of MRI in the assessment of congestive cardiac failure.

Simultaneous right and left heart real-time, free-breathing CMR flow quantification identifies constrictive physiology

OBJECTIVES

The purpose of this study was to evaluate the ability of a novel cardiac magnetic resonance (CMR) real-time phase contrast (RT-PC) flow measurement technique to reveal the discordant respirophasic changes in mitral and tricuspid valve in flow indicative of the abnormal hemodynamics seen in constrictive pericarditis (CP).

BACKGROUND

Definitive diagnosis of CP requires identification of constrictive hemodynamics with or without pericardial thickening. CMR to date has primarily provided morphological assessment of the pericardium.

METHODS

Sixteen patients (age 57 ± 13 years) undergoing CMR to assess known or suspected CP and 10 controls underwent RT-PC that acquired simultaneous mitral valve and tricuspid valve inflow velocities over 10 s of unrestricted breathing. The diagnosis of CP was confirmed via clinical history, diagnostic imaging, cardiac catheterization, intraoperative findings, and histopathology.

RESULTS

Ten patients had CP, all with increased pericardial thickness (6.2 ± 1.0 mm). RT-PC imaging demonstrated discordant respirophasic changes in atrioventricular valve inflow velocities in all CP patients, with mean ± SD mitral valve and tricuspid valve inflow velocity variation of 46 ± 20% and 60 ± 15%, respectively, compared with 16 ± 8% and 24 ± 11% in patients without CP (p < 0.004 vs. patients with CP for both) and 17 ± 5% and 31 ± 13% in controls (p < 0.001 vs. patients with CP for both). There was no difference in atrioventricular valve inflow velocity variation between patients without CP compared with controls (p > 0.3 for both). Respiratory variation exceeding 25% across the mitral valve yielded a sensitivity of 100%, a specificity of 100%, and an area under the receiver-operating characteristic curve of 1.0 to detect CP physiology. Using a cutoff of 45%, variation of transtricuspid valve velocity had a sensitivity of 90%, a specificity of 88%, and an area under the receiver-operating characteristic curve of 0.98.

CONCLUSIONS

Accentuated and discordant respirophasic changes in mitral valve and tricuspid valve inflow velocities characteristic of CP can be identified noninvasively with RT-PC CMR. When incorporated into existing CMR protocols for imaging pericardial morphology, RT-PC CMR provides important hemodynamic evidence with which to make a definite diagnosis of CP.

Cardiac Magnetic Resonance Imaging Pericardial Late Gadolinium Enhancement and Elevated Inflammatory Markers Can Predict the Reversibility of Constrictive Pericarditis After Antiinflammatory Medical Therapy

Background—

Constrictive pericarditis (CP) is a disabling disease, and usually requires pericardiectomy to relieve heart failure. Reversible CP has been described, but there is no known method to predict the reversibility. Pericardial inflammation may be a marker for reversibility. As a pilot study, we assessed whether cardiac magnetic resonance imaging pericardial late gadolinium enhancement (LGE) and inflammatory biomarkers could predict the reversibility of CP after antiinflammatory therapy.

Method and Results—

Twenty-nine CP patients received antiinflammatory medications after cardiac magnetic resonance imaging. Fourteen patients had resolution of CP, whereas 15 patients had persistent CP after 13 months of follow-up. Baseline LGE pericardial thickness was greater in the group with reversible CP than in the persistent CP group (4±1 versus 2±1 mm, P =0.001). Qualitative intensity of pericardial LGE was moderate or severe in 93% of the group with reversible CP and in 33% of the persistent CP group ( P =0.002). Cardiac magnetic resonance imaging LGE pericardial thickness ≥3 mm had 86% sensitivity and 80% specificity to predict CP reversibility. The group with reversible CP also had higher baseline C-reactive protein and erythrocyte sedimentation rate than the persistent CP group (59±52 versus 12±14 mg/L, P =0.04 and 49±25 versus 15±16 mm/h, P =0.04, respectively). Antiinflammatory therapy was associated with a reduction in C-reactive protein, erythrocyte sedimentation rate, and pericardial LGE in the group with reversible CP but not in the persistent CP group.

Conclusions—

Reversible CP was associated with pericardial and systemic inflammation. Antiinflammatory therapy was associated with a reduction in pericardial and systemic inflammation and LGE pericardial thickness, with resolution of CP physiology and symptoms. Further studies in a larger number of patients are needed.

Neoplastic pericardial effusion

Neoplastic pericardial effusion is a serious and common clinical disorder encountered by cardiologists, cardiothoracic surgeons, oncologists, and radiation oncologists. It may develop from direct extension or metastatic spread of the underlying malignancy, from an opportunistic infection, or from a complication of radiation therapy or chemotherapeutic toxicity. The clinical presentation varies, and the patient may be hemodynamically unstable in the setting of constrictive pericarditis and cardiac tamponade. The management depends on the patient's prognosis and varies from pericardiocentesis, sclerotherapy, and balloon pericardiotomy to cardiothoracic surgery. Patients with neoplastic pericardial effusion face a grave prognosis, as their malignancy is usually more advanced. This review article discusses the epidemiology and etiology, pathophysiology, clinical presentation, diagnosis, management, and prognosis of neoplastic pericardial effusion.

Constrictive pericarditis and restrictive cardiomyopathy in the modern era

The differentiation between constrictive pericarditis and restrictive cardiomyopathy can be clinically challenging. Pericardial constriction results from scarring and consequent loss of pericardial elasticity leading to impaired ventricular filling. Restrictive cardiomyopathy is characterized by a nondilated rigid ventricle, severe diastolic dysfunction and restrictive filling producing hemodynamic changes, similar to those in constrictive pericarditis. While constrictive pericarditis is usually curable by surgical treatment, restrictive cardiomyopathy requires medical therapy and in appropriate patients, the definitive treatment is cardiac transplantation. Sufficient differences exist between the two conditions to allow noninvasive differentiation, but no single diagnostic tool can be relied upon to make this distinction. Newer echocardiographic techniques such as speckle-track imaging, velocity vector imaging, as well as cardiac computed tomography and cardiac MRI can help differentiate constriction from restriction with high sensitivity and specificity. Outcomes are better with early diagnosis of constriction in particular and early surgical resection.

[Pericarditis and cardiac tamponade: urgent condition not only in cardiology]

INTRODUCTION

Pericarditis is a condition with inflammation of the pericardium; however, most of these conditions are not infective and many of them are not even inflammatory. Pericarditis by its development can be acute, sub-acute and chronic, and later, recurring or relapsing. Apart from idiopathic, the causes of pericarditis are numerous, very often inflammatory, most frequently caused by viruses, or tumours and neoplasms, diseases of connective tissue, vasculitis, different allergic reactions, radiation, thyroid gland diseases, uraemia, dissection of aorta etc.

CLINICAL PICTURE

Accumulation of fluid in the pericardium in the amount sufficient to cause significant obstruction of blood inflow in chambers can cause cardiac tamponade. If it is not treated immediately, the outcome may be fatal. The most common causes are tumours, viruses or uraemia. Cardiac tamponade should be suspected in patients with a decrease in systemic arterial pressure or presence of hypotension, tachycardia, silent and discreet heart beats, increase in systemic venous pressure (Beck triad). Electrocardiogram may result in tachycardia, QRS complex is of smaller voltage, often of reversed polarity. The amount of effusion is estimated by echocardiography

CONCLUSION

The cause of pericarditis should always be searched for. On the other hand, during monitoring or treatment of numerous conditions which could be a frequent cause of pericarditis, the presence of pericardial effusion or cardiac tamponade should be suspected and detected in due time. A timely intervention--pericardiocentesis, can prevent the fatal outcome. Besides non-steroid anti-inflammatory medication, many prospective randomised studies propose colchicine as addition to the standard therapy. When opting for the proper treatment for pericarditis always keep in mind the current diagnosis and cause of this condition.

The relative atrial volume ratio and late gadolinium enhancement provide additive information to differentiate constrictive pericarditis from restrictive cardiomyopathy

BACKGROUND

The differentiation of constrictive pericarditis (CP) from restrictive cardiomyopathy (RCM) is often difficult. This study sought to determine the clinical utility of cardiovascular magnetic resonance imaging (CMR) for differentiating both these disorders.

METHODS

Twenty-three patients with surgically documented CP, 22 patients with RCM and 25 normal subjects were included in the study. CMR yielded information about cardiac morphology, function and tissue characteristics. The left (LA) and right atrial (RA) volume was calculated using the area-length method. The relative atrial volume ratio (RAR) was defined as the LA volume divided by RA volume. Receiver operating characteristic curve analysis was used to test the ability of different variables in differentiating CP from RCM.

RESULTS

The maximal pericardial thickness in CP patients was significantly larger than in normal subjects and RCM patients. The RA volume index in RCM patients (90.5 ± 35.3 mL/m2) was significantly larger than in CP patients (71.4 ± 15.7 mL/m2, p = 0.006) and normal subjects (38.1 ± 9.0 mL/m2, p < 0.001). The LA volume index in RCM (96.0 ± 37.0 mL/m2) and CP patients (105.6 ± 25.1 mL/m2) was significantly larger than in normal subjects (39.5 ± 9.5 mL/m2, p < 0.001 for all). The RAR in CP patients (1.50 ± 0.29) was significantly larger than in RCM patients (1.12 ± 0.33, p < 0.001) and normal subjects (1.06 ± 0.20, p < 0.001). There were no differences between RCM patients and normal subjects in the RAR (p = 0.452). At a cut-off value of 1.32 for the RAR, the sensitivity was 82.6%, and the specificity was 86.4% in the detection of CP. Septal bounce was identified in 95.7% CP patients, in none of RCM patients and normal subjects. Late gadolinium enhancement (LGE) was present in 31.8% RCM patients and absence in all CP patients and normal subjects.

CONCLUSIONS

CMR with LGE and RAR can facilitate differentiation of CP from RCM.

Pericardial disease: diagnosis and management

Pericardial diseases can present clinically as acute pericarditis, pericardial effusion, cardiac tamponade, and constrictive pericarditis. Patients can subsequently develop chronic or recurrent pericarditis. Structural abnormalities including congenitally absent pericardium and pericardial cysts are usually asymptomatic and are uncommon. Clinicians are often faced with several diagnostic and management questions relating to the various pericardial syndromes: What are the diagnostic criteria for the vast array of pericardial diseases? Which diagnostic tools should be used? Who requires hospitalization and who can be treated as an outpatient? Which medical management strategies have the best evidence base? When should corticosteroids be used? When should surgical pericardiectomy be considered? To identify relevant literature, we searched PubMed and MEDLINE using the keywords diagnosis, treatment, management, acute pericarditis, relapsing or recurrent pericarditis, pericardial effusion, cardiac tamponade, constrictive pericarditis, and restrictive cardiomyopathy. Studies were selected on the basis of clinical relevance and the impact on clinical practice. This review represents the currently available evidence and the experiences from the pericardial clinic at our institution to help guide the clinician in answering difficult diagnostic and management questions on pericardial diseases.

Constrictive pericarditis after lung transplantation: an under-recognized complication

Primary graft dysfunction, acute rejection, and infection account for most of the early morbidity after lung transplantation, with bronchiolitis obliterans syndrome accounting for most late morbidity. Mediastinal and pericardial complications, in the form of constriction, are not common. We present 4 patients with constrictive pericarditis after lung transplantation and recommend that constrictive pericarditis be considered in the differential diagnosis in lung transplant recipients who present with signs and symptoms of systemic and pulmonary venous congestion.

Spectrum of pericardial disease: part II

Pericardial disease is a common disorder seen in varying clinical settings, and may be the first manifestation of an underlying systemic disease. In part I, we focused on the current knowledge and management of the more common pericardial diseases: acute pericarditis, pericardial effusion, cardiac tamponade, chronic pericarditis and relapsing pericarditis. In part II, we will focus on the knowledge and management of pericardial involvement in chylous pericardial effusion cholesterol pericarditis, radiation pericarditis, pericardial involvement in systemic inflammatory diseases, autoreactive pericarditis, pericarditis in renal failure, pericardial constriction and effusive constrictive pericarditis.

A difficult diagnosis - constrictive pericarditis and its treatment: a case report

The diagnosis of constrictive pericarditis requires a high degree of clinical suspicion, for the signs and symptoms of this disease can be falsely attributed to other causes. Herein, we present a case of a 70-year old retired farmer whose symptoms of right heart failure were initially attributed to co-existing pneumonia and pulmonary embolism. He was discharged. Three weeks later he presented with worsening breathlessness and ascites. Echocardiography, computed tomography and cardiac catheterization revealed the diagnosis of constrictive pericarditis. He underwent complete pericardectomy and to date has made a good recovery. This case exemplifies the difficulty in diagnosing this condition, the investigation required, and provides a discussion of the benefit and outcomes of prompt treatment.

Quantification of left ventricular twisting mechanics by velocity vector imaging in an animal model of pericardial adhesions

Diagnosis of constrictive pericarditis remains clinically challenging. Untwisting of the left ventricle (LV) is essential for normal LV diastolic function. Echocardiography is able to measure LV twisting mechanics. We designed an animal model of constrictive pericarditis to determine how pericardial-epicardial adhesions impair LV twisting mechanics. In eight open-chest pigs, the heart was exposed while preserving the pericardium. We simulated early constrictive pericarditis by pericardial constriction and patchy adhesions induced with instant glue and pericardial-epicardial stitches. Using Velocity Vector Imaging (VVI), LV magnitudes of twisting and untwisting were measured along with hemodynamic data at baseline and after the experimental intervention. Significant decreases in end-diastolic volume, ejection fraction, stroke volume, and late diastolic filling velocity reflected the effects of the pericardial adhesions. Magnitude of LV untwisting rate decreased from -80+/-23 degrees /s to -26+/-10 degrees /s (p=0.0009). LV twisting rate dropped from 78+/-20 degrees /s to 40+/-8 degrees /s (p=0.0039) and LV twist magnitude decreased from 9+/-2 degrees to 5+/-2 degrees (p=0.0081). Patchy pericardial adhesions are associated with reductions in LV untwisting rate and twisting magnitude, consistent with a negative impact of constrictive pericarditis on systolic and diastolic function. Impairments in LV twisting mechanics may have a diagnostic role in the detection of early stages of constrictive pericarditis.

Invasive hemodynamic assessment in heart failure

Routine cardiac catheterization provides data on left heart, right heart, systemic and pulmonary arterial pressures, vascular resistances, cardiac output, and ejection fraction. These data are often then applied as markers of cardiac preload, afterload, and global function, although each of these parameters reflects more complex interactions between the heart and its internal and external loads. This article reviews more specific gold standard assessments of ventricular and arterial properties, and how these relate to the parameters reported and utilized in practice, and then discusses the re-emerging importance of invasive hemodynamics in the assessment and management of heart failure.

Cardiovascular magnetic resonance in pericardial diseases

The pericardium and pericardial diseases in particular have received, in contrast to other topics in the field of cardiology, relatively limited interest. Today, despite improved knowledge of pathophysiology of pericardial diseases and the availability of a wide spectrum of diagnostic tools, the diagnostic challenge remains. Not only the clinical presentation may be atypical, mimicking other cardiac, pulmonary or pleural diseases; in developed countries a shift for instance in the epidemiology of constrictive pericarditis has been noted. Accurate decision making is crucial taking into account the significant morbidity and mortality caused by complicated pericardial diseases, and the potential benefit of therapeutic interventions. Imaging herein has an important role, and cardiovascular magnetic resonance (CMR) is definitely one of the most versatile modalities to study the pericardium. It fuses excellent anatomic detail and tissue characterization with accurate evaluation of cardiac function and assessment of the haemodynamic consequences of pericardial constraint on cardiac filling. This review focuses on the current state of knowledge how CMR can be used to study the most common pericardial diseases.

In vivo imaging of stem cells and Beta cells using direct cell labeling and reporter gene methods

Cellular transplantation therapy offers a means to stimulate cardiovascular repair either by direct (graft-induced) or indirect (host-induced) tissue regeneration or angiogenesis. Typically, autologous or donor cells of specific subpopulations are expanded exogenously before administration to enrich the cells most likely to participate in tissue repair. In animal models of cardiovascular disease, the fate of these exogenous cells can be determined using histopathology. Recently, methods to label cells with contrast agents or transduce cells with reporter genes to produce imaging beacons has enabled the serial and dynamic assessment of the survival, fate, and engraftment of these cells with noninvasive imaging. Although cell tracking methods for cardiovascular applications have been most studied in stem or progenitor cells, research in tracking of whole islet transplants and particularly insulin producing beta cells has implications to the cardiovascular community attributable to the vascular changes associated with diabetes mellitus. In this review article, we will explore some of the state-of-the art methods for stem, progenitor, and beta cell tracking.

Canadian Cardiovascular Society Consensus Conference guidelines on heart failure, update 2009: diagnosis and management of right-sided heart failure, myocarditis, device therapy and recent important clinical trials

The Canadian Cardiovascular Society published a comprehensive set of recommendations on the diagnosis and management of heart failure in January 2006. Based on feedback obtained through a national program of heart failure workshops and through active solicitation of stakeholders, several topics were identified because of their importance to the practicing clinician. Topics chosen for the present update include best practices for the diagnosis and management of right-sided heart failure, myocarditis and device therapy, and a review of recent important or landmark clinical trials. These recommendations were developed using the structured approach for the review and assessment of evidence adopted and previously described by the Society. The present update has been written from a clinical perspective to provide a user-friendly and practical approach. Specific clinical questions that are addressed include: What is right-sided heart failure and how should one approach the diagnostic work-up? What other clinical entities may masquerade as this nebulous condition and how can we tell them apart? When should we be concerned about the presence of myocarditis and how quickly should patients with this condition be referred to an experienced centre? Among the myriad of recently published landmark clinical trials, which ones will impact our standards of clinical care? The goals are to aid physicians and other health care providers to optimally treat heart failure patients, resulting in a measurable impact on patient health and clinical outcomes in Canada.

A case of constrictive pericarditis associated with huge epicardial fat volume

Massive deposits of fat around heart are seen in overweight persons and are associated with coronary artery disease. Investigators have focused on the clinical significance of epicardial fat with respect to metabolic effects such as insulin resistance and inflammation, but the mechanical effects, such as constriction, have been largely ignored. We present an unusual case of a 59-year-old woman with obesity and diabetes mellitus who had been undergoing peritoneal dialysis due to end-stage renal disease, and who developed constrictive pericarditis, possibly secondary to extensive epicardial fatty accumulation.

Constrictive pericarditis

Constrictive pericarditis (CP) is characterized by scarring and loss of elasticity of the pericardium, resulting in external impedance of cardiac filling. In the developed world, CP is most frequently encountered as a consequence of previous cardiac surgery, thoracic irradiation, viral or idiopathic causes. Tuberculosis still remains a common cause of CP in the developing world, immigrants from underdeveloped nations, and immunosuppressed patients. Clinical signs and symptoms of right heart failure coupled with risk factors for pericardial disease should raise suspicion for CP. Echocardiographic evaluation and often cardiac catheterization are essential components of accurate diagnosis of CP. Enhanced interventricular dependence, with respiratory variation in the ventricular pressures, and ventricular discordance are the pathophysiologic hallmarks of CP. Imaging findings such as increased pericardial thickness or pericardial calcification on computed tomography can be supportive, but are not necessary for the diagnosis of CP. Pericardiectomy remains the most effective therapy for symptomatic CP.

Upregulation of rat P23 (a member of the YjgF protein family) by fasting, glucose diet and fatty acid feeding

In a previous study, we identified and purified a 99-amino-acid rat liver-kidney perchloric-acid-soluble 23-kDa protein (P23) which displays 30% identity with a highly conserved domain of heat shock proteins (HSPs), as well as an AT-rich 3' untranslated region, which has also been described to play a role in H70 mRNA life span and protein expression. An identical perchloric-acid-soluble protein inhibiting protein synthesis in a rabbit reticulocyte lysate system was also found 2 years later by another group. More recently, the novel, the YjgF, protein family has been described, comprising, 24 full-length homologues, including P23, highly conserved through evolution, and consisting of approximately 130 residues each and sharing a common ternary structure. Independent studies from different laboratories have provided various hypothetical functions for each of these proteins. The high degree of evolutionary conservation may suggest that these proteins play an important role in cellular regulation. Although the function of none of these proteins is known precisely, we present experimental evidence which, combined with the relationship to glucose-regulating protein revealed here, and the relationship to fatty-acid-binding protein revealed by others, allow us to propose a role for P23. In rat liver, P23 expression is developmentally regulated and modulated by dietary glucose, and its mRNA is induced by starvation, in the presence of fatty-acids and in 3-MeDAB-induced hepatomas. The mRNA encoding mouse liver P23 is also hormonally modulated in a mouse line AT1F8. These data indicate that P23 protein might be a key controller of intermediary metabolism during fasting.