Imaging of pericardial diseases

Unexpected death in a newborn due to a congenital partial pericardial defect: a case report

Background

Pericardial defects are rare anatomical variations that can present as an isolated variation or be associated with other conditions. They are usually asymptomatic and misdiagnosed conditions, and given their rarity, partial pericardial defects can have devastating outcomes. The sudden death of an apparently healthy newborn certainly raises concerns, and a medico-legal investigation is crucial in establishing the cause of death. This case report highlights the importance of awareness on the part of obstetric professionals of the lethal outcomes of pericardial partial congenital defects. This case also demonstrates the difficulty of establishing a correct diagnosis.

Case presentation

The autopsy of a 15-h-old neonate revealed a partial pericardial defect ending in a biventricular strangulation by the defective pericardium. Other findings, such as the patency of the arterial ductus, a subarachnoid hemorrhage, and aspiration of amniotic fluid, were also reported.

Conclusions

Although imaging techniques have evolved, fetal detection of cardiac abnormalities can be tricky, especially when occurring as an isolated variation.

Review of pericardial disease on computed tomography

Echocardiography has long been the mainstay in the evaluation of cardiac and pericardial disease. As computed tomography (CT) has advanced, it has become a valuable partner in the imaging of the pericardium. The advantages of CT include a larger field of view, multiplanar reconstruction and increased discrimination between various soft tissues and fluids. CT is less operator dependent and can more easily, and reproducibly, image areas of the pericardium for which echocardiography has poor windows such as the right pericardium. The introduction of EKG gating has decreased cardiac motion artifact and can allow functional evaluation although echocardiography remains the primary source of real-time imaging of cardiac and valve motion. It is essential for the skilled cardiac imager to understand the strengths and weaknesses of CT and its role in the definition and assessment of pericardial disease.

Computed tomography and magnetic resonance imaging evaluation of pericardial disease

Pericardial diseases are commonly encountered in clinical practice and may present as an isolated process or in association with various systemic conditions. Traditionally transthoracic echocardiography (TTE) has been the method of choice for the evaluation of suspected pericardial disease but increasingly computed tomography (CT) and magnetic resonance imaging (MRI) are also being used as part of a rational multi-modality imaging approach tailored to the specific clinical scenario. This paper reviews the role of CT and MRI across the spectrum of pericardial diseases.

Bleeding heart: a case of spontaneous hemopericardium and tamponade in a hyperthyroid patient on warfarin

We describe the case of an 81-year-old female, diagnosed with hyperthyroidism-related atrial fibrillation. Given her CHA2DS2VASc score of 3, she was started on warfarin for stroke prevention. One month later, she was admitted with cardiac tamponade. This tamponade was suspected to be secondary to hemopericardium, based on the elevated international normalized ratio (INR), drop in haemoglobin and the radiodensity (55 HU) of the pericardial effusion on CT. The patient was a Jehovah's witness who therefore initially refused measures for reversing coagulopathy. Given her coagulopathy and absence of imminent haemodynamic compromise, pericardiocentesis was deferred. Unfortunately, 1 day later, the patient deteriorated rapidly. By the time pericardiocentesis was performed and factor VIIa administered, the patient had already started developing multiple organ failure. She developed cardiac arrest and died 3 days after her admission. Only 10 cases of hemopericardium attributable to warfarin have previously been reported. In this report, we review the literature and also describe how hyperthyroidism most likely predisposed our patient to bleeding complications from warfarin.

Congenital partial defect of the left pericardium presenting as chest pain

Congenital pericardial defect is a rare cardiac defect with variable clinical presentations. It is usually an unexpected finding during cardiac surgery or autopsy. The clinical detection of congenital absence of pericardium is important because of its life-threatening complications such as fatal myocardial strangulation, myocardial ischaemia and sudden death. We present a patient with the incidental finding of left-sided partial defect of the pericardium during evaluation of chest pain.

Clinical indications for cardiac computed tomography. From the Working Group of the Cardiac Radiology Section of the Italian Society of Medical Radiology (SIRM)

Cardiac computed tomography (CCT) has grown as a useful means in different clinical contexts. Technological development has progressively extended the indications for CCT while reducing the required radiation dose. Even today there is little documentation from the main international scientific societies describing the proper use and clinical indications of CCT; in particular, there are no complete guidelines. This document reflects the position of the Working Group of the Cardiac Radiology Section of the Italian Society of Radiology concerning the indications for CCT.

Triage and management of pericardial effusion

Pericardial effusion may be detected as an incidental finding during echocardiography or following a diagnostic imaging study for a symptomatic patient. When a pericardial effusion is detected the first step is to assess its size, hemodynamic importance, and possible associated diseases. The more common causes of pericardial effusions include infections (viral, bacterial, especially tuberculosis), cancer, connective tissue diseases, pericardial injury syndromes, metabolic causes (i.e. hypothyroidism), myopericardial and aortic diseases. The relative frequency of different causes depends on the local epidemiology, the hospital setting and the diagnostic protocol that has been adopted. Many cases still remain idiopathic in developed countries, whereas tuberculosis is the dominant cause in developing countries. Specific testing should be performed according to clinical suspicion. The presence of elevated inflammatory markers and other criteria (chest pain, pericardial rubs, ECG changes) suggest pericarditis and management should be directed accordingly. Treatment should be targeted at the etiology as much as possible. Nevertheless, when diagnosis is still unclear, or idiopathic and inflammatory markers are elevated, empiric anti-inflammatory therapy may be worthwhile. A true isolated effusion may not require a specific treatment if the patient is asymptomatic, but large ones have a theoretical risk of progression to cardiac tamponade (up to one-third) if subacute with signs of right-sided collapse, and especially chronic (>3 months). Pericardiocentesis alone may be curative for large effusions but recurrences are also common and pericardiectomy or less invasive options (i.e. pericardial window) should be considered whenever fluid re-accumulates (especially with tamponade), becomes loculated, or biopsy material is required.

[Chronic pericarditis: CT and MR imaging features]

A diagnosis of constrictive pericarditis is suggested by the presence of pericardial thickening (>=4 mm in thickness) and abnormal motion of the interventricular septum. Additional findings have been reported: tubular appearance of the right or left ventricles, dilatation of the vena cava, atrial dilatation or abnormal diastolic expansion of one or both ventricles. In patients with suspected chronic pericarditis, CT can more easily demonstrate the presence of pericardial calcifications compared to US and MRI, as well as detect the presence of mediastinal adenopathy and lung lesions, suggesting tuberculosis. Septal motion analysis should be performed during protodiastole and systole using a cine technique with both CT and MR.

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.

[Current indications for cardiac MR imaging]

MRI has acquired over the years a role in the evaluation of cardiovascular pathology especially with regards to its ability to assess right and left ventricular function and delayed postcontrast "viability" sequences. Current class I clinical indications include: viability for patients with ischemic cardiomyopathy and acute coronary syndrome, etiology and prognostic evaluation of non-ischemic cardiomyopathies including myocarditis and arrhytmogenic right ventricular cardiomyopathy, chronic pericarditis and cardiac masses, non-urgent aortic aneurysm and dissection, congenital cardiopathies: vascular malformations and follow-up after curative or palliative surgery. MRI provides a complete non operator dependent evaluation, and is particularly useful for follow-up since it may be repeated due to its absence of ionizing radiation

Calcific constrictive pericarditis demonstrated on 99mTc-MDP bone scintigraphy

The authors present a case of calcific constrictive pericarditis, imaged with bone scintigraphy. The patient presented with three months of shortness of breath, chest pain, and chest tightness during exercise, among other nonspecific symptoms. Although the diagnosis was made based on chest radiography and cardiac MRI, bone scintigraphy was used to corroborate the diagnosis of calcific constrictive pericarditis. Bone scintigraphy showed a pattern of tracer accumulation consistent with pericardial uptake. Calcific constrictive pericarditis was also confirmed at the time of surgery.

MR imaging of the pericardium

Imaging of the pericardium requires understanding of anatomy and the normal and abnormal physiology of the pericardium. MR imaging is well-suited for answering clinical questions regarding suspected pericardial disease. Pericardial diseases that may be effectively imaged with MR imaging include pericarditis, pericardial effusion, cardiac-pericardial tamponade, constrictive pericarditis, pericardial cysts, absence of the pericardium, and pericardial masses. Although benign and malignant primary tumors of the pericardium may be occasionally encountered, the most common etiology of a pericardial mass is metastatic disease.