“A Classic Case of Constrictive Pericarditis”

Johanne Neill , Wendy Strugnell, Christian Hamilton-Craig

The Prince Charles Hospital, Brisbane, QLD, Australia

Clinical History:

A 31 year old female presented with pleuritic central chest pain and breathlessness on a background of previous minimally invasive mitral valve repair.  The post operative period was complicated by 3 separate episodes of Dressler’s syndrome. CMR was performed for pericardial constriction.

CMR findings:

The study was performed on a Siemens Aera 1.5 Tesla magnet.

 

Movie 1 – The four chamber steady state free precession series demonstrates the mitral valve repair with annuloplasty ring with preserved systolic function of both ventricles.    Abnormal septal “bounce” is seen, suggesting abnormal ventricular filling.  The myocardium appears tethered to the visceral pericardium.

 

Figure 1 – Four chamber T2 weighted imaging (double inversion recovery series without fat suppression) demonstrates circumferentially thickened pericardium.  

 

Figure 2 – Short axis T2 weighted image (double inversion recovery with fat suppression) demonstrates thickened pericardium particularly affecting the right ventricular free wall. 

 

Movie 2 -  Non-gated free breathing, real time SSFP short axis imaging. Note the marked inter-ventricular septal flattening as the diaphragm descends during inspiration (“respirophasic variation”), with increased RV filling during inspiration at the expense of LV filling.  This is consistent with ventricular interdependence and constrictive physiology.1, 2

 

Figure 3 – Late gadolinium enhancement inversion recovery imaging with marked circumferential enhancement of the pericardium. Top) four chamber, Middle) LV long axis, Bottom) short axis

Conclusion:

The cardiac MRI of this patient was non-invasively able to characterize the pericardium and convincingly demonstrate constrictive physiology explaining her symptoms. 

Perspective:

The diagnosis of constrictive pericarditis can be difficult to make on standard echocardiography and invasive haemodynamic assessment can be challenging. Indirect features are small volume ventricles with abnormal septal motion exaggerated with inspiration.  The abnormal septal motion occurs because of ventricular interdependence.  The thickened rigid pericardium does not allow the ventricles to expand and fill adequately in diastole, therefore the normal filling patterns with respiration are exaggerated. During inspiration the right heart fills in preference to the left and the septum moves to the left to accommodate this.1, 2 

 

CMR is able to image the pericardial thickness on T2 imaging without fat saturation (note should be made that on standard SSFP imaging the pericardium can be difficult to assess due to chemical shift artefact). CMR also demonstrates the ventricular interdependence on ungated realtime SSFP imaging during respiration, which is concordant with the abnormal septal motion on gated-SSFP images and the appearance of pericardial tethering.

 

References

  1. Yared K, Baggish AL, Picard MH, Hoffman U, Hung J.  Multimodality Imaging of Pericardial Diseases.  Journal of the American College of Cardiology Imaging.  2010;3 (6):650-660.
  2. Bogaert J, Francone M.  Cardiovascular Magnetic Resonance in Pericardial Diseases.  Journal of Cardiovascular Magnetic Resonance.  2009;11:14