Pericardial Disease Dynamic Imaging

Apichaya Sripariwuth, MD

Department of Radiology, Faculty of Medicine

Naresaun University Hospital

Outline

▪ Pericardial Anatomy and Basic Physiology

▪ MRI Protocol for Pericardial Disease and Normal Imaging

▪ Pericardial Disease – Dynamic Imaging

Pericardial AnatomyThin, avascular, relatively inelastic, flask-shape sac enveloping the heart

Pericardial Anatomy

▪ Fibrous pericardium

▪ Serous pericardium

▪ Parietal layer:

- Lines the inner surface of the fibrous pericardium

▪ Visceral layer:

- Envelops the epicardial surface of the heart

- Produces pericardial fluid

Pericardial Anatomy

▪ Pericardial Cavity/ Sac

▪ Space between parietal and visceral layer

▪ Normally contains a small amount of fluid

Pericardial Function

▪ Fixed heart position within mediastinum

▪ Barrier to infection

▪ Decreased friction of cardiac movement

▪ Makes the hearts as semirigid structure

Basic Principles of Cardiac Function

Clinical Cardiac MRI 2nd edition

Diastole

▪ Filling phase of ventricles

▪ Period between MV opening and MV closure –depends on ventricular pressure

▪ Determine by

▪ Myocardial relaxation

▪ Atrial contraction

▪ Compliance of the ventricle and atrium

MRI Protocol for Pericardial Disease

Clinical Cardiac MRI 2nd edition

Basic MRI Protocol and Normal Imaging

▪ Black-blood image

▪ Cine SSFP

▪ Real-time cine image

▪ Myocardial tagging image

▪ Delayed enhancement image

Black-Blood Image

▪ ECG-gated image

▪ T1-weighted, Double inversion

▪ Normal pericardium:

▪ Hypo-intensity

▪ 1-2 mm in thickness

Cine SSFP

▪ T1/T2-weighted

▪ Global & Regional Cardiac Function

▪ Pericardial mobility

Real-time cine image

• Cine SSFP during inspiration and expiration

• Evaluating right to left ventricular interaction known as ventricular coupling/interdependence

• Normally, septum has concave shape toward the RV during entire cardiac cycle

Myocardial tagging image

• Using a grid• For pericardial adhesion

and myocardial involvement

Delayed Enhancement Image

Pericardial MassPericardial Enhancement

Sripariwuth A et al. Multimodality Cardiac Imaging Assessment of a Large Metastatic Pericardial Leiomyosarcoma. CASE. 2018 Aug; 2(4): 156–162

Pericardial Disease – Dynamic Imaging

▪ Pericardial Effusion

▪ Cardiac Tamponade

▪ Constrictive Pericarditis

Pericardial Effusion

▪ Fluid in pericardial sac

▪ Normal volume:5-10 ml

▪ Grading : Distance between heart and parietal pericardium

Small Moderate Large

< 0.5 cm 0.5-2 cm > 2 cm

Textbook of Clinical Echocardiography 6th edition

Pericardial Effusion

▪ The Development of Tamponade depends on

▪ Volume

▪ Rate of Accumulation

▪ Pericardial Stiffness

Cardiac Tamponade

▪ Defined as hemodynamically significant cardiac compression from accumulating pericardial contents (fluid, pus, hemorrhage, tumor)

▪ ↑Intrapericardial pressure → ↓diastolic compliance → ↓ cardiac filling → ↓cardiac output

Cardiac Tamponade

▪ Clinical diagnosis

▪ Imaging findings are reflecting to

▪ ↑Intrapericardial pressure

▪ ↓ Diastolic compliance

Cardiac Tamponade

Non dynamic Imaging Dynamic Imaging

Chamber collapse Chamber collapse- Right atrial systolic collapse- Right ventricular diastolic collapse

Straightening/blowing of the interventricular septum

Ventricular interdependence

Content in pericardial sac

Dilate SVC, IVC, Hepatic veins

Cardiac Tamponade?

Constrictive Pericarditis

▪ Rigid fixed pericardial volume

▪ Ventricular filling is limited by pericardial volume

▪ Diastolic Dysfunction (DDx from Restrictive cardiomyopathy)

Constrictive Pericarditis

▪ Findings:

▪ Dissociation of intrathoracic and intracardiac diastolic pressure

▪ Increased ventricular coupling

▪ Increased cardiac filling pressure with pressure equalization in all cardiac chamber

Constrictive Pericarditis

Non dynamic Imaging Dynamic Imaging

Pericardial thickening > 4 mm Ventricular coupling/interdependence

Calcified/Irregular pericardium Diastolic septal bounce

Conical/tubular deformity of ventricles Pericardial adhesion

Unilateral or bilateral atrial enlargement

Dilate SVC, IVC, Hepatic veins

Pleural effusion, Ascites

Pericardial enhancement (Inflammation)

Constrictive Pericarditis

Constrictive Pericarditis

Constrictive Pericarditis

Circulation 2018

Take Home Message

▪ The development of Tamponade depends not only on the volume, but also on the rate of accumulation and the pericardial stiffness.

▪ Constrictive Pericarditis effects Diastolic function

▪ Pericardial thickening and calcification do not always imply constrictive pericarditis