Cardiovascular magnetic resonance in pericardial diseases

Epicardial Nodules as the Initial Manifestation of Immunoglobulin G4-Related Pericarditis

Immunoglobulin G4 (IgG4)-related pericarditis, an immune-mediated fibro-inflammatory condition, is a rare yet life-threatening disease presenting with constrictive pericarditis. We describe a case of IgG4-related pericarditis presenting with epicardial nodules successfully treated with corticosteroids. This case highlights the clinical significance of assessing IgG4-related pericarditis in the diagnostic workup of pericardial masses. (Level of Difficulty: Advanced.).

Nuclear cardiology in the context of multimodality imaging to detect cardiac toxicity from cancer therapeutics: Established and emerging methods

The complexity of cancer therapies has vastly expanded in the last decade, along with type and severity of cardiac toxicities associated with these treatments. Prevention of pre-clinical cardiotoxicity may improve cardiovascular outcomes and circumvent the decision to place life-sustaining chemotherapeutic agents on hold, making the early detection of cancer therapeutic related cardiac toxicity with non-invasive imaging essential to the care of these patients. There are several established methods of cardiac imaging in the areas of nuclear cardiology, echocardiography, computed tomography, and cardiac magnetic resonance imaging that are used to assess for cardiovascular toxicity of cancer treatments, with several methods under development. The following review will provide an overview of current and emerging imaging techniques in these areas.

Magnetic Resonance Imaging to Detect Cardiovascular Effects of Cancer Therapy: JACC CardioOncology State-of-the-Art Review

This paper aims to empower and inform cardio-oncologists by providing a practical guide to the clinical application of cardiac magnetic resonance (CMR) in the rapidly evolving field of cardio-oncology. Specifically, we describe how CMR can be used to assess the cardiovascular effects of cancer therapy. The CMR literature, relevant societal guidelines, indication-specific imaging protocols, and methods to overcome some of the challenges encountered in performing and accessing CMR are reviewed.

The role of cardiac imaging in the management of non-ischemic cardiovascular diseases in human immunodeficiency virus infection

Infection with human immunodeficiency virus (HIV) has become the pandemic of the new century. About 36.9 million people are living with HIV worldwide. The introduction of antiretroviral therapy in 1996 has dramatically changed the global landscape of HIV care, resulting in significantly improved survival and changing HIV to a chronic disease. With near-normal life expectancy, contemporary cardiac care faces multiple challenges of cardiovascular diseases, disorders specific to HIV/AIDS, and those related to aging and higher prevalence of traditional risk factors. Non-ischemic cardiovascular diseases are major components of cardiovascular morbidity and mortality in HIV/AIDS. Non-invasive cardiac imaging plays a pivotal role in the management of these diseases. This review summarizes the non-ischemic presentation of the HIV cardiovascular spectrum focusing on the role of cardiac imaging in the management of these disorders.

Cardiovascular magnetic resonance imaging for structural heart disease

Cardiovascular magnetic resonance (CMR) has increasingly become a powerful imaging technique over the past few decades due to increasing knowledge about clinical applications, operator experience and technological advances, including the introduction of high field strength magnets, leading to improved signal-to-noise ratio. Its success is attributed to the free choice of imaging planes, the wide variety of imaging techniques, and the lack of harmful radiation. Developments in CMR have led to the accurate evaluation of cardiac structure, function and tissues characterisation, so this non-invasive technique has become a powerful tool for a broad range of cardiac pathologies. This review will provide an introduction of magnetic resonance imaging (MRI) physics, an overview of the current techniques and clinical application of CMR in structural heart disease, and illustrated examples of its use in clinical practice.

Tuberculous pericardial disease: a focused update on diagnosis, therapy and prevention of complications

Tuberculous pericarditis (TBP) is the most important manifestation of tuberculous heart disease and is still associated with a significant morbidity and mortality in TB endemic areas. The high prevalence of the disorder over the last 3 decades has been fueled by the human immunodeficiency virus/AIDS (HIV/AIDS) pandemic in these areas. The objective of this review is to provide a focused update on developments in the diagnosis and therapy of this condition, prevention of its complications, as well as future novel therapies. The definitive diagnosis of a tuberculous etiology in patients with suspected TBP continues to pose a challenge for clinicians. Clinical prediction scores, although never formally validated have been used with some success. However, they may be prone to both over and underdiagnosis due to lack of pericardial fluid analysis. Recent studies evaluating Xpert MTB/RIF, suggest that this advanced polymerase chain reaction (PCR) based technology does not provide increased accuracy compared to earlier iterations. However a combined two test approach starting with Xpert MTB/RIF followed by either adenosine deaminase (ADA) or interferon gamma (IFN-γ) may provide for significantly enhanced specificity and sensitivity cost permitting. Pericardiocentesis remains the gold standard for managing the compressive pericardial fluid and its adverse hemodynamic sequelae. A four drug anti-TB drug regimen at standard doses and duration is recommended. However recent evidence suggests that these drugs penetrate the pericardium very poorly potentially explaining the high mortality observed particularly in those who are culture positive with a high bacillary load. Constrictive pericarditis is the main long-term complication of TBP and is still a significant cause of heart failure in Sub-Saharan Africa. This is important because access to definitive surgical therapy where TBP is prevalent continues to be low, highlighting the need to develop strategies or interventions to prevent fibrosis and constriction. Recent detailed advanced studies of pericardial fluid in TBP have revealed a strong profibrotic transcriptomic profile, with high amounts of pro-inflammatory cytokines and low levels of the anti-fibrotic tetrapeptide N-Acetyl-Seryl-Aspartyl-Lysyl-Proline (Ac-SDKP). These new insights may explain in part the high propensity to fibrosis associated with the condition and offer hope for the future use of targeted therapy to interrupt pathways and mediators of tissue damage and subsequent maladaptive healing and fibrosis. The value of effective pericardiocentesis in reducing these pro-inflammatory and pro-fibrotic cytokines and peptides in an attempt to prevent pericardial constriction has yet to be established but has generated hypotheses for ongoing and future research.

Multimodality imaging in patients with post-cardiac injury syndrome

This review article is focused on the role of echocardiography, cardiac CT and cardiac magnetic resonance (CMR) imaging in diagnosing and managing patients with post-cardiac injury syndrome (PCIS). Clinically, the spectrum of pericardial diseases under PCIS varies not only in form and severity of presentation but also in the timing varying from weeks to months, thus making it difficult to diagnose. Pericarditis developing after recent or remote myocardial infarction, cardiac surgery or ablation if left untreated or under-treated could worsen into complicated pericarditis which can lead to decreased quality of life and increased morbidity. Colchicine in combination with other anti-inflammatory agents (non-steroidal anti-inflammatory drugs) is proven to prevent and treat acute pericarditis as well as its relapses under various scenarios. Imaging modalities such as echocardiography, CT and CMR play a pivotal role in diagnosing PCIS especially in difficult cases or when clinical suspicion is low. Echocardiography is the tool of choice for emergent bedside evaluation for cardiac tamponade and to electively study the haemodynamics impact of constrictive pericarditis. CT can provide information on pericardial thickening, calcification, effusions and lead perforations. CMR can provide pericardial tissue characterisation, haemodynamics changes and guide long-term treatment course with anti-inflammatory agents. It is important to be familiar with the indications as well as findings from these multimodality imaging tools for clinical decision-making.

Usefulness of Cardiac Magnetic Resonance for Recurrent Pericarditis

Cardiac magnetic resonance (CMR) offers the capability to objectively detect pericarditis by identifying pericardial thickening, edema/inflammation by Short-TI Inversion Recovery-T2 weighted (STIR-T2w) imaging, edema/inflammation or fibrosis by late gadolinium enhancement (LGE), and presence of pericardial effusion. This is especially helpful for the diagnosis of recurrent pericarditis. Aim of the present paper is to assess the diagnostic accuracy of CMR findings as well as their potential prognostic value for the diagnosis of recurrent pericarditis. Multicenter cohort study of consecutive patients with recurrent pericarditis evaluated by CMR. We included 128 consecutive cases (60 males, 47%; mean age 48 ± 14 years). CMR was performed at a mean time of 12 days (95% confidence interval 15 to 21) after the clinical diagnosis. We evaluated the diagnostic accuracy and areas under the receiver operating characteristic (ROC) curve for CMR diagnostic criteria and complications (additional recurrences, cardiac tamponade, and constrictive pericarditis). Areas under the ROC curve were respectively 64% for pericardial thickening, 84% for pericardial edema, 82% for pericardial LGE, and 71% for pericardial effusion. After a mean follow-up of 34 months, recurrences occurred in 52% of patients, tamponade in 6%, and constrictive pericarditis in 11%. Using a multivariable Cox model, elevation of CRP and presence of CMR pericardial thickening were predictors of adverse events, whereas the presence of CMR LGE was associated with a lower risk. The prognostic model for adverse events using gender, age, CRP level, and all CMR variables showed a C-index of 0.84. In conclusion, CMR findings show high diagnostic accuracy and may help identifying patients at higher risk of complications.

A Rapid Development of a Right Ventricular Aneurysm Postmyocardial Infarction

Myocardial infarctions may cause ventricular aneurysms. Ischemia-induced ventricular changes are more common in the left ventricle owing to the larger vascular supply, greater volume of myocardium, and increased intra-ventricular pressure. Ischemia-induced right ventricular free wall abnormalities are rare owing to the lower ventricular pressure. The authors describe the echocardiographic progression of a right ventricular ischemic aneurysm resulting from an ST-elevated myocardial infarction in a 71- year-old man. In this E-Challenge, the authors will review the echocardiographic findings and pathophysiology of ischemic aneurysms.

Partial Congenital Absence of The Pericardium: A Case Report

The complete or the partial absence of pericardium is a rare congenital malformation for which the patients are commonly asymptomatic and the diagnosis is incidental. The absence of the left side of the pericardium is the most common anomaly that is reported in the literature while the complete absence of pericardium or the absence of the right side of the pericardium are uncommon and their criteria are still unrecognized given their rare occurrence in clinical practice. This paper aims to report a case of 19-year-old male with the congenital partial absence of both sides of the pericardium and to highlight the symptoms and the different cardiac imaging modalities used to confirm the diagnosis of this defect.

Cardio-oncology, the myth of Sisyphus, and cardiovascular disease in breast cancer survivors

The number of breast cancer (BC) survivors has been increasing lately, due to the improvement in early detection strategies and oncological treatments. However, BC survivors are 3 times as likely to develop heart failure (HF) within 5 years of cancer diagnosis, and 7/100 of them will develop HF in a median follow-up of 8.5 years. Furthermore, HF in BC survivors has a worse prognosis compared to other causes of HF. Anthracyclines and trastuzumab have been proven to improve survival. However, they are also considered as the main causative factors of HF in BC survivors. Old patients, those with a pre-existing cardiovascular (CV) risk factors/disease, prior exposure to chemotherapy and radiotherapy are at increased risk. Serial evaluation of troponins and cardiac imaging parameters using echocardiography and cardiovascular magnetic resonance can significantly contribute to the early diagnosis of cardiac involvement before overt HF will develop. Assessment and immediate treatment of traditional CV risk factors is the first step for cardiotoxicity prevention. In BC survivors with known heart disease, the clinical stabilization is strongly recommended for cardiotoxicity prevention. Finally, in high-risk CV patients, primary prevention including cardioprotectants and/or CV drugs should be applied. According to recent studies, the early start of ACE inhibitors and β-blockers and the modification of anti-cancer treatment can prevent the decline in left ventricular ejection fraction. However, further multicenter studies are needed to establish both prevention and treatment protocols to successfully overcome HF development in BC survivors.

Cardiovascular Magnetic Resonance in Nonischemic Myocardial Inflammation: Expert Recommendations

This JACC Scientific Expert Panel provides consensus recommendations for an update of the cardiovascular magnetic resonance (CMR) diagnostic criteria for myocardial inflammation in patients with suspected acute or active myocardial inflammation (Lake Louise Criteria) that include options to use parametric mapping techniques. While each parameter may indicate myocardial inflammation, the authors propose that CMR provides strong evidence for myocardial inflammation, with increasing specificity, if the CMR scan demonstrates the combination of myocardial edema with other CMR markers of inflammatory myocardial injury. This is based on at least one T2-based criterion (global or regional increase of myocardial T2 relaxation time or an increased signal intensity in T2-weighted CMR images), with at least one T1-based criterion (increased myocardial T1, extracellular volume, or late gadolinium enhancement). While having both a positive T2-based marker and a T1-based marker will increase specificity for diagnosing acute myocardial inflammation, having only one (i.e., T2-based OR T1-based) marker may still support a diagnosis of acute myocardial inflammation in an appropriate clinical scenario, albeit with less specificity. The update is expected to improve the diagnostic accuracy of CMR further in detecting myocardial inflammation.

Advanced Imaging Modalities to Monitor for Cardiotoxicity

Early detection and treatment of cardiotoxicity from cancer therapies is key to preventing a rise in adverse cardiovascular outcomes in cancer patients. Over-diagnosis of cardiotoxicity in this context is however equally hazardous, leading to patients receiving suboptimal cancer treatment, thereby impacting cancer outcomes. Accurate screening therefore depends on the widespread availability of sensitive and reproducible biomarkers of cardiotoxicity, which can clearly discriminate early disease. Blood biomarkers are limited in cardiovascular disease and clinicians generally still use generic screening with ejection fraction, based on historical local expertise and resources. Recently, however, there has been growing recognition that simple measurement of left ventricular ejection fraction using 2D echocardiography may not be optimal for screening: diagnostic accuracy, reproducibility and feasibility are limited. Modern cancer therapies affect many myocardial pathways: inflammatory, fibrotic, metabolic, vascular and myocyte function, meaning that multiple biomarkers may be needed to track myocardial cardiotoxicity. Advanced imaging modalities including cardiovascular magnetic resonance (CMR), computed tomography (CT) and positron emission tomography (PET) add improved sensitivity and insights into the underlying pathophysiology, as well as the ability to screen for other cardiotoxicities including coronary artery, valve and pericardial diseases resulting from cancer treatment. Delivering screening for cardiotoxicity using advanced imaging modalities will however require a significant change in current clinical pathways, with incorporation of machine learning algorithms into imaging analysis fundamental to improving efficiency and precision. In the future, we should aspire to personalized rather than generic screening, based on a patient’s individual risk factors and the pathophysiological mechanisms of the cancer treatment they are receiving. We should aspire that progress in cardiooncology is able to track progress in oncology, and to ensure that the current ‘one size fits all’ approach to screening be obsolete in the very near future.

Radiation-Associated Pericardial Disease

PURPOSE OF REVIEW

This review highlights the literature related to pericardial injury following radiation for oncologic diseases.

RECENT FINDINGS

Radiation-associated pericardial disease can have devastating consequences. Unfortunately, there is considerably less evidence regarding pericardial syndromes following thoracic radiation as compared to other cardiovascular outcomes. Pericardial complications of radiation may arise acutely or have an insidious onset several decades after treatment. Transthoracic echocardiography is the screening imaging modality of choice, while cardiac magnetic resonance imaging further characterizes the pericardium and guides treatment decision-making. Cardiac CT can be useful for assessing pericardial calcification. Ongoing efforts to lessen inadvertent cardiac injury are directed towards the revision of radiation techniques and protocols. As survival of mediastinal and thoracic malignancies continues to improve, radiation-associated pericardial disease is increasingly relevant. Though advances in radiation oncology demonstrate promise in curtailing cardiotoxicity, the long-term effects pertaining to pericardial complications remain to be seen.

The Role of Cardiac Magnetic Resonance Imaging to Detect Cardiac Toxicity From Cancer Therapeutics

PURPOSE OF REVIEW

The emerging complexity of cardiac toxicity caused by cancer therapies has created demand for more advanced non-invasive methods to better evaluate cardiac structure, function, and myocardial tissue characteristics. Cardiac magnetic resonance imaging meets these needs without exposure to ionizing radiation, and with superior spatial resolution.

RECENT FINDINGS

Special applications of cardiac magnetic resonance (CMR) to assess for cancer therapy-induced cardiac toxicity include the detection of subclinical LV dysfunction through novel methods of measuring myocardial strain, detection of microcirculatory dysfunction, identification of LV and LA fibrosis, and more sensitive detection of inflammation caused by immune checkpoint inhibitors. CMR plays a significant role in the non-invasive workup of cardiac toxicity from cancer therapies, with recent advancements in the field that have opened avenues for further research and development.

The imaging appearances of various pericardial disorders

The pericardium could be involved in a variety of clinical disorders. The imaging findings are not specific for an individual pathology in most of the cases; however, patient’s clinical history may guide radiologist to a definitive diagnosis. Congenital absence of the pericardium could be recognized with the imaging appearance of interposed lung tissue between the main pulmonary artery and aorta. Pericardial effusion is a non-specific condition that may occur due to inflammatory, infectious, and neoplastic disorders. Cardiac tamponade may occur in case of massive or rapid accumulation of fluid in the pericardial sac. Pericardial calcification is a common and easily identified entity on a computed tomography (CT) scan. Presence of calcification and/or fibrosis may result in pericardial constriction. Nevertheless, the pulsation of an adjacent coronary artery may prevent calcification formation in a focal area and consequently may result in pericardial diverticulum containing epicardial fat and coronary artery. The imaging findings encountered in patients with pericardial hydatid disease and Erdheim-Chester disease may mimic those of pericardial neoplasia. Pericardial adhesions and pedicled fat flaps may cause confusion on a CT scan in the post-surgical period following cardiac surgery. Pericardial fat necrosis can be diagnosed by CT in patients with chest pain. The radiologists should be familiar with the medical devices placed in pericardial space for certain individual indications. A pericardial patch and temporary epicardial pacemaker wires could be identified on a CT scan.

Imaging of Pericardial Disease

Although the pericardium is simply a 2-layered membrane enveloping the heart and great vessels, there are numerous anatomic variations, congenital anomalies, and pathologic conditions that can occur. Although echocardiography is most often the first imaging modality used to assess the pericardium, computed tomography and MR imaging are frequently being used to aid in diagnosis and assess response to therapy. Therefore, detailed knowledge of the pericardium in both its normal and diseased states is important to best direct patient care and potentially improve patient outcomes.

Cardiac MRI for the evaluation of oncologic cardiotoxicity

Cancer therapeutics-related cardiac dysfunction (CTRCD) is a well-established adverse effect resulting from a number of cancer therapeutics. Newer immunotherapy has been associated with cardiomyopathy and myocarditis making comprehensive imaging useful for early recognition. Cardiac MRI (CMR) offers a comprehensive evaluation to detect CTRCD. Established guidelines for monitoring left ventricular ejection fraction for potential cardiotoxicity have recently incorporated CMR. We will review the utility of CMR in contemporary evaluation for potential oncologic cardiotoxicity.

Clinical Utility of Cardiac Magnetic Resonance Imaging in Pericardial Diseases

Background:

Pericardial diseases are relatively common in clinical practice and encountered in various clinical settings with consequent significant morbidity and mortality. However, the diagnosis as well as management can be complex and challenging, as the clinical presentation is usually non-specific. Therefore, there is an increasing role for Cardiac Magnetic Resonance Imaging (CMR) as an imaging tool to facilitate the diagnosis of pericardial diseases.

Conclusion:

Herein we describe conventional and unique CMR approaches to provide an increased non-invasive understanding of the pericardium in health and disease including a novel method to diagnose constrictive pericarditis via radio-frequency tissue tagging by defining unique visceral-parietal adherence patterns easily learned by the cardiologist and radiologist.

Cardiovascular Magnetic Resonance in the Oncology Patient

Patients with or receiving potentially cardiotoxic treatment for cancer are susceptible to developing decrements in left ventricular mass, diastolic function, or systolic function. They may also experience valvular heart disease, pericardial disease, or intracardiac masses. Cardiovascular magnetic resonance may be used to assess cardiac anatomy, structure, and function and to characterize myocardial tissue. This combination of features facilitates the diagnosis and management of disease processes in patients with or those who have survived cancer. This report outlines and describes prior research involving cardiovascular magnetic resonance for assessing cardiovascular disease in patients with or previously having received treatment for cancer.

Cardiac magnetic resonance imaging in heart failure: where the alphabet begins!

Cardiac Magnetic Resonance Imaging has become a cornerstone in the evaluation of heart failure. It provides a comprehensive evaluation by answering all the pertinent clinical questions across the full pathological spectrum of heart failure. Nowadays, CMR is considered the gold standard in evaluation of ventricular volumes, wall motion and systolic function. Through its unique ability of tissue characterization, it provides incremental diagnostic and prognostic information and thus has emerged as a comprehensive imaging modality in heart failure. This review outlines the role of main conventional CMR sequences in the evaluation of heart failure and their impact in the management and prognosis.

Optimized respiratory-resolved motion-compensated 3D Cartesian coronary MR angiography

Purpose

To develop a robust and efficient reconstruction framework that provides high‐quality motion‐compensated respiratory‐resolved images from free‐breathing 3D whole‐heart Cartesian coronary magnetic resonance angiography (CMRA) acquisitions.

Methods

Recently, XD‐GRASP (eXtra‐Dimensional Golden‐angle RAdial Sparse Parallel MRI) was proposed to achieve 100% scan efficiency and provide respiratory‐resolved 3D radial CMRA images by exploiting sparsity in the respiratory dimension. Here, a reconstruction framework for Cartesian CMRA imaging is proposed, which provides respiratory‐resolved motion‐compensated images by incorporating 2D beat‐to‐beat translational motion information to increase sparsity in the respiratory dimension. The motion information is extracted from interleaved image navigators and is also used to compensate for 2D translational motion within each respiratory phase. The proposed Optimized Respiratory‐resolved Cartesian Coronary MR Angiography (XD‐ORCCA) method was tested on 10 healthy subjects and 2 patients with cardiovascular disease, and compared against XD‐GRASP.

Results

The proposed XD‐ORCCA provides high‐quality respiratory‐resolved images, allowing clear visualization of the right and left coronary arteries, even for irregular breathing patterns. Compared with XD‐GRASP, the proposed method improves the visibility and sharpness of both coronaries. Significant differences (p < .05) in visible vessel length and proximal vessel sharpness were found between the 2 methods. The XD‐GRASP method provides good‐quality images in the absence of intraphase motion. However, motion blurring is observed in XD‐GRASP images for respiratory phases with larger motion amplitudes and subjects with irregular breathing patterns.

Conclusion

A robust respiratory‐resolved motion‐compensated framework for Cartesian CMRA has been proposed and tested in healthy subjects and patients. The proposed XD‐ORCCA provides high‐quality images for all respiratory phases, independently of the regularity of the breathing pattern.

The growth and evolution of cardiovascular magnetic resonance: a 20-year history of the Society for Cardiovascular Magnetic Resonance (SCMR) annual scientific sessions

BACKGROUND AND PURPOSE

The purpose of this work is to summarize cardiovascular magnetic resonance (CMR) research trends and highlights presented at the annual Society for Cardiovascular Magnetic Resonance (SCMR) scientific sessions over the past 20 years.

METHODS

Scientific programs from all SCMR Annual Scientific Sessions from 1998 to 2017 were obtained. SCMR Headquarters also provided data for the number and the country of origin of attendees and the number of accepted abstracts according to type. Data analysis included text analysis (key word extraction) and visualization by 'word clouds' representing the most frequently used words in session titles for 5-year intervals. In addition, session titles were sorted into 17 major subject categories to further evaluate research and clinical CMR trends over time.

RESULTS

Analysis of SCMR annual scientific sessions locations, attendance, and number of accepted abstracts demonstrated substantial growth of CMR research and clinical applications. As an international field of study, significant growth of CMR was documented by a strong increase in SCMR scientific session attendance (> 500%, 270 to 1406 from 1998 to 2017, number of accepted abstracts (> 700%, 98 to 701 from 1998 to 2018) and number of international participants (42-415% increase for participants from Asia, Central and South America, Middle East and Africa in 2004-2017). 'Word clouds' based evaluation of research trends illustrated a shift from early focus on 'MRI technique feasibility' to new established techniques (e.g. late gadolinium enhancement) and their clinical applications and translation (key words 'patient', 'disease') and more recently novel techniques and quantitative CMR imaging (key words 'mapping', 'T1', 'flow', 'function'). Nearly every topic category demonstrated an increase in the number of sessions over the 20-year period with 'Clinical Practice' leading all categories. Our analysis identified three growth areas 'Congenital', 'Clinical Practice', and 'Structure/function/flow'.

CONCLUSION

The analysis of the SCMR historical archives demonstrates a healthy and internationally active field of study which continues to undergo substantial growth and expansion into new and emerging CMR topics and clinical application areas.

Multimodal Imaging for the Assessment of a Cardiac Mass - A Case of Primary Cardiac Sarcoma

We present a case of an 85-year-old patient who underwent clinical work-up for chronic heart failure, acute coronary syndrome, and pulmonary embolism, until she was diagnosed with a cardiac mass that was histologically identified as sarcoma. The aim of this educational case report is to raise awareness of cardiac masses and to point out diagnostic hints towards a cardiac tumor on chest X-ray, coronary angiography, echocardiography, and chest CT. Moreover, the vital role of cardiac magnetic resonance for the diagnosis of a cardiac mass is highlighted.

Complicated Pericarditis: Understanding Risk Factors and Pathophysiology to Inform Imaging and Treatment

Most patients with acute pericarditis have a benign course and a good prognosis. However, a minority of patients develop complicated pericarditis, and the care of these patients is the focus of this review. Specifically, we address risk factors, multimodality imaging, pathophysiology, and novel treatments. The authors conclude that: 1) early high-dose corticosteroids, a lack of colchicine, and an elevated high-sensitivity C-reactive protein are associated with the development of complicated pericarditis; 2) in select cases, cardiovascular magnetic resonance imaging may aid in the assessment of pericardial inflammation and constriction; 3) given phenotypic similarities between recurrent idiopathic pericarditis and periodic fever syndromes, disorders of the inflammasome may contribute to relapsing attacks; and 4) therapies that target the inflammasome may lead to more durable remission and resolution. Finally, regarding future investigations, the authors discuss the potential of cardiovascular magnetic resonance to inform treatment duration and the need to compare steroid-sparing treatments to pericardiectomy.

Transient Constrictive Pericarditis: Current Diagnostic and Therapeutic Strategies

Transient constrictive pericarditis is increasingly recognized as a distinct sub-type of constrictive pericarditis. The underlying pathophysiology typically relates to impaired pericardial distensibility, associated with acute or sub-acute inflammation, rather than the fibrosis or calcification often seen in chronic pericardial constriction. Accordingly, patients may present clinically with concomitant features of pericarditis and constrictive physiology. Non-invasive multimodality imaging is advocated for diagnosis of transient constrictive pericarditis. Echocardiography remains the mainstay for initial evaluation of the dynamic features of constriction. However, cardiac magnetic resonance imaging can provide complimentary functional information, with the addition of dedicated sequences to assess for active pericardial edema and inflammation. Although transient pericardial constriction can spontaneously resolve, institution of anti-inflammatory therapy may hasten resolution or even prevent progression to chronic pericardial constriction. Non-steroidal anti-inflammatory agents remain the initial treatment of choice, with subsequent consideration of colchicine, steroids, and other immune-modulating agents in more refractory cases.

Infectious Diseases of the Heart: Pathophysiology, Clinical and Imaging Overview

Myriad infectious organisms can infect the endocardium, myocardium, and pericardium, including bacteria, fungi, parasites, and viruses. Significant cardiac infections are rare in the general population but are associated with high morbidity and mortality as well as increased risk in certain populations, such as the elderly, those undergoing cardiac instrumentation, and intravenous drug abusers. Diagnostic imaging of cardiac infections plays an important role despite its variable sensitivity and specificity, which are due in part to the nonspecific manifestations of the central inflammatory process of infection and the time of onset with respect to the time of imaging. The primary imaging modality remains echocardiography. However, cardiac computed tomography and magnetic resonance (MR) imaging have emerged as the modalities of choice wherever available, especially for diagnosis of complex infectious complications including abscesses, infected prosthetic material, central lines and instruments, and the cryptic manifestations of viral and parasitic diseases. MR imaging can provide functional, morphologic, and prognostic value in a single examination by allowing characterization of inflammatory changes from the acute to chronic stages, including edema and the patterns and extent of delayed gadolinium enhancement. We review the heterogeneous and diverse group of cardiac infections based on their site of primary cardiac involvement with emphasis on their cross-sectional imaging manifestations. Online supplemental material is available for this article. (©)RSNA, 2016.

Contemporary management of pericardial effusion: practical aspects for clinical practice

A pericardial effusion (PE) is a relatively common finding in clinical practice. It may be either isolated or associated with pericarditis with or without an underlying disease. The aetiology is varied and may be either infectious (especially tuberculosis as the most common cause in developing countries) or non-infectious (cancer, systemic inflammatory diseases). The management is essentially guided by the hemodynamic effect (presence or absence of cardiac tamponade), the presence of concomitant pericarditis or underlying disease, and its size and duration. The present paper reviews the current knowledge on the aetiology, classification, diagnosis, management, therapy, and prognosis of PE in clinical practice.

Pericardial Masses, Cysts and Diverticula: A Comprehensive Review Using Multimodality Imaging

Pericardial masses/tumors, cysts, and diverticula are quite rare. Presentation is variable and often patients may be asymptomatic with pericardial involvement initially only detected at time of autopsy. When patients do present with symptoms they are often non-specific and often mimic other conditions of the pericardium such as pericarditis, pericardial effusion, constriction or tamponade. Therefore, echocardiography and cross-sectional imaging are essential in identifying and characterizing pericardial disease. Imaging findings vary in specificity depending on the type of tumor. The purpose of this review is to describe the role of multi-modality imaging and characteristic findings in patients with pericardial masses/tumors, cysts, and diverticula.

Cardiovascular MRI of the pericardium: A case review of the anatomy, scan protocols and pathology of the pericardium

The aim of this article was to present a case based review of the anatomy, scan protocols and pathology of the pericardium. Cardiovascular magnetic resonance imaging provides excellent anatomic depiction of the pericardium, vital information on myocardial infiltration and characterisation of mass lesions and pericardial effusions. It adds valuable information in the assessment of complicated pericardial disease.

Left ventricular pseudoaneurysm - a challenging diagnosis

Left ventricular pseudoaneurysm is a rare complication of acute myocardial infarction, associated with high mortality. However, it can present in a non-specific manner, complicating and delaying the diagnosis. The authors present the case of a 65-year-old patient, hypertensive, with no other known relevant medical history, who presented with chest pain, cough and left pleural effusion, initially attributed to a pulmonary process. However, these were in fact the result of a left ventricular pseudoaneurysm following silent acute myocardial infarction. The diagnosis was suspected on echocardiography and confirmed by cardiac magnetic resonance imaging, and the patient underwent successful surgical pseudoaneurysm repair. This case illustrates an atypical presentation of a left ventricular pseudoaneurysm, in which the manifestations resulted from pericardial and pleural extension of the inflammatory process associated with contained myocardial rupture. The case demonstrates the need for a high index of suspicion, and the value of imaging techniques to confirm it, in order to proceed with appropriate surgical treatment, and thus modify the course of the disease.

Cardiovascular imaging in the diagnosis and monitoring of cardiotoxicity: cardiovascular magnetic resonance and nuclear cardiology

Chemotherapy-induced cardiotoxicity (CTX) is a determining factor for the quality of life and mortality of patients administered potentially cardiotoxic drugs and in long-term cancer survivors. Therefore, prevention and early detection of CTX are highly desirable, as is the exploration of alternative therapeutic strategies and/or the proposal of potentially cardioprotective treatments. In recent years, cardiovascular imaging has acquired a pivotal role in this setting. Although echocardiography remains the diagnostic method most used to monitor cancer patients, the need for more reliable, reproducible and accurate detection of early chemotherapy-induced CTX has encouraged the introduction of second-line advanced imaging modalities, such as cardiac magnetic resonance (CMR) and nuclear techniques, into the clinical setting. This review of the Working Group on Drug Cardiotoxicity and Cardioprotection of the Italian Society of Cardiology aims to afford an overview of the most important findings from the literature about the role of CMR and nuclear techniques in the management of chemotherapy-treated patients, describe conventional and new parameters for detecting CTX from both diagnostic and prognostic perspectives and provide integrated insight into the role of CMR and nuclear techniques compared with other imaging tools and versus the positions of the most important international societies.