Multimodality Imaging of Constrictive Pericarditis: Pathophysiology and New Concepts

Quantitative Detection of Pericardial Adhesions Using Four-Dimensional Computed Tomography: A Novel Motion-Based Analysis Framework

OBJECTIVE

Pericardial adhesions can unexpectedly occur prior to cardiac surgery or catheter ablation, even in patients without known risk factors, potentially increasing procedural risks. This study proposed and validated a novel, quantitative, and noninvasive method for detecting pericardial adhesions using four-dimensional computed tomography (4D CT).

METHODS

We evaluated preoperative 4D CT datasets from 20 patients undergoing cardiac surgery with and without pericardial adhesions. Our novel approach integrates expert-guided pericardial segmentation, symmetric diffeomorphic registration, and motion disparity analysis. The method quantifies tissue motion differences by computing the displacement fields between the pericardium and epicardial adipose tissue (EAT), with a particular focus on the left anterior descending (LAD) region.

RESULTS

Statistical analysis revealed significant differences between adhesion and non-adhesion groups (p < 0.01) using two newly developed metrics: peak ratio (PR) and distribution width index (DWI). Adhesion cases demonstrated characteristic high PR values (>100) with low DWI values (<0.3), while non-adhesion cases showed moderate PR values (<50) with higher DWI values (>0.4).

CONCLUSIONS

This proof-of-concept study validated a novel quantitative framework for assessing pericardial adhesions using 4D CT imaging and provides an objective and computationally efficient tool for preoperative assessment in clinical settings. These findings suggest the potential clinical utility of this framework in surgical planning and risk assessment.

Overcoming diagnostic challenges in constrictive pericarditis: why volume is important?

A 65-year-old male with chronic liver disease and refractory ascites was being evaluated for liver transplant, when constrictive pericarditis (CP) was suspected. Initial diagnostics were inconclusive due to overdiuresis. After suspension of diuretics, cardiac magnetic resonance confirmed CP, leading to successful pericardiectomy and normalization of liver function, emphasizing volume status and multimodality imaging role in CP diagnosis.

Delayed Diagnosis of Constrictive Pericarditis Resulting in Recurrent Heart Failure: A Case Report

Constrictive pericarditis can lead to compromised diastolic ventricular filling due to pericardial inflammation and fibrosis. A diagnosis of constrictive pericarditis was established by identifying structural and hemodynamic features through echocardiography. We present a case of constrictive pericarditis, which manifested in the form of gradually worsening dyspnea and lower-extremity edema over a 7 years period. The patient was diagnosed with constrictive pericarditis using echocardiography, and underwent a pericardiectomy.

The Constricted Heart: A 31-Year-Old Man with a Case of Constrictive Tuberculous Pericarditis

BACKGROUND Constrictive pericarditis occurs due to chronic pericardial inflammation and adherence of the cardiac pericardial layer. Etiologies include toxins, infection, cardiac surgery, and idiopathic causes. Outside the United States, the most common cause of constrictive pericarditis is tuberculosis (TB). Constrictive pericarditis is the most severe complication of tuberculous pericardial disease. CASE REPORT A 31-year-old man who recently immigrated to the United States presented with a 2-week history of constitutional symptoms, dyspnea, and pleuritic chest pain. Physical examination was pertinent for bilateral lower extremity pitting edema, decreased bilateral breath sounds, and jugular venous distension. Transthoracic echocardiogram revealed a left ventricular ejection fraction of 45%, pericardial thickening, and an exaggerated septal bounce. Right heart catheterization showed discordant and concordant right ventricular pressure tracings. Cardiac magnetic resonance imaging revealed bilateral pleural effusions and circumferential pericardial thickening. Thoracocentesis was significant for an exudative effusion, with elevated adenosine deaminase levels. Subsequent QuantiFERON-TB Gold testing was positive, and he underwent elective pericardiectomy. Pericardial histopathology revealed necrotizing caseating granulomas. He was discharged on a 6-month course of rifampicin, isoniazid, pyrazinamide, and ethambutol therapy, with close multidisciplinary care team outpatient follow-up. CONCLUSIONS This case highlights the importance of a high index of clinical suspicion for tuberculous pericarditis in patients presenting with constitutional and heart failure symptoms and a relevant travel history, to ensure prompt diagnosis and treatment. This case also reflects the importance of coordination of care between cardiology, infectious disease, pathology, and cardiothoracic surgery teams in the management of tuberculous constrictive pericarditis.

The "Old yet New" Echocardiographic Finding for Constrictive Pericarditis Following Purulent Pericarditis: A Case Report

Purulent pericarditis (PP) is a localized infection of the pericardial cavity with suppuration that can be life-threatening. Treatment for PP consists of pericardial drainage and antimicrobial therapy. Constrictive pericarditis (CP), a form of diastolic heart failure that arises because an inelastic thickened pericardium, is a possible related dreadful complication of PP. Several echocardiographic findings suggestive of CP have been reported, but some require measurements or are difficult to reproduce. This case report presents a simple echocardiographic finding that reflects the clinical course of transient CP (TCP). A 76-year-old Japanese man presented to our hospital with chest pain and dyspnea. He was diagnosed with PP caused by Streptococcus pyogenes and treated with pericardial drainage and benzylpenicillin. The response to the treatment of the infection was favorable, but subsequent echocardiography and cardiac catheterization revealed a CP complication. Treatment with colchicine and ibuprofen was initiated, with improvement in CP within three months. During CP, a restricted right ventricular (RV) motion and movement of the liver towards the heart were observed before other echocardiographic findings suggestive of CP. Furthermore, this echocardiographic finding disappeared and normalized as CP improved. In this case of TCP following PP, changes in the echocardiographic "RV sliding" sensitively reflected the clinical course of CP. This simple finding may indicate inflammation of the pericardium and could be useful for the diagnosis and follow-up of CP.

A Rare Case of Immunoglobulin G4-Related Constrictive Pericarditis Diagnosed Via Multimodality Imaging

Constrictive pericarditis (CP) presents as a pathophysiological state where the pericardium becomes inelastic due to fibrotic changes, most commonly secondary to a protracted inflammatory process. The disease is characterized by compromised diastolic cardiac function due to loss of pericardial compliance. Immunoglobulin G4 (IgG4)-related disease, an entity marked by the insidious proliferation of IgG4-positive plasma cells and subsequent fibrosis within various organs, is an infrequent but recognized cause of CP. A case of a 55-year-old male patient with clinical manifestations of dyspnea and edema in the lower extremities elucidates the diagnostic complexity inherent to CP. Echocardiography revealed a constellation of signs, including annulus reversus, septal bounce, and a congested inferior vena cava; cardiac magnetic resonance imaging (MRI) demonstrated diffuse pericardial thickening with delayed gadolinium enhancement, suggestive of a long-term inflammatory state; and right heart catheterization confirmed the hemodynamic hallmark of CP-equalization of diastolic pressures across the cardiac chambers. The serological analysis elicited elevated serum levels of IgG4 and IgE, pointing to the differential diagnosis of IgG4-related disease. Given the nonspecific clinical presentation of IgG4-related CP, a heightened index of suspicion combined with a systematic approach to imaging and serological evaluation is paramount.

Epicardial Involvement of Constrictive Pericarditis Can Be Detected by Magnetic Resonance Imaging

Constrictive pericarditis is a surgical disease that requires removal of the pericardium. In cases in which the disease process involves the epicardium, removing the pericardium may not adequately treat the constrictive process. Current imaging techniques are limited in their ability to preoperatively determine epicardial involvement. Cardiac magnetic resonance imaging with late gadolinium enhancement of the pericardium is useful in conjunction with echocardiography to define extent of disease, pericardial compliance, and hemodynamics. We propose the use of cardiac magnetic resonance imaging, and specifically late gadolinium enhancement extending into the epicardium, as a marker of epicardial involvement based on our initial experience.

Constrictive Pericarditis: An Update on Noninvasive Multimodal Diagnosis

Constrictive pericarditis (CP) is a rare condition that can affect the pericardium after every pericardial disease process and has been described even after SARS-CoV-2 infection or vaccine. In CP, the affected pericardium, usually the inner layer, is noncompliant, constraining the heart to a fixed maximum volume and impairing the diastolic function. This leads to several clinical features, that, however, can be pleomorphic. In its difficult diagnostic workup, noninvasive multimodal imaging plays a central role, providing important morphological and functional data, like the enhanced ventricular interdependence and the dissociation between intrathoracic and intracardiac pressures. An early and proper diagnosis is crucial to set an appropriate therapy, changing the prognosis of patients affected by CP. In this review, we cover in detail the main elements of each imaging technique, after a reminder of pathophysiology useful for understanding the diagnostic findings.

Chronic constrictive pericarditis: a rare cardiac involvement in primary Sjögren's syndrome

BACKGROUND

Constrictive pericarditis represents a chronic condition and systemic inflammatory diseases are a known, yet uncommon, cause. Pericardial involvement is seldom reported in primary Sjögren's syndrome, usually occurring in association with pericardial effusion or pericarditis. We report a case of constrictive pericarditis with an insidious course and unusual evolution associated with primary Sjögren's syndrome. Due to the challenging nature of the diagnosis, clinical suspicion and multimodality imaging are essential for early identification and prompt initiation of treatment. Long-term outcomes remain uncertain. To the best of our knowledge, no other cases linking this autoimmune disease to constrictive pericarditis have been reported.

CASE PRESENTATION

We present the case of a 48-year-old male patient with moderate alcohol habits and a history of two prior hospitalizations. On the first, the patient was diagnosed with primary Sjögren's syndrome after presenting with pleural effusion and ascites, and empirical corticosteroid regiment was initiated. On the second, two-years later, he was readmitted with complaints of dyspnea and abdominal distension. Thoracic computed tomography revealed a localized pericardial thickening and a thin pericardial effusion, both of which were attributed to his rheumatic disease. A liver biopsy showed hepatic peliosis, which was considered to be a consequence of glucocorticoid therapy. Diuretic therapy was adjusted to symptom-relief, and a tapering corticosteroid regimen was adopted. Four years after the initial diagnosis, the patient was admitted again with recurrent dyspnea, orthopnea and ascites. At this time, constrictive pericarditis was diagnosed and a partial pericardiectomy was performed. Although not completely asymptomatic, the patient reported clinical improvement since the surgery, but still with a need for baseline diuretic therapy.

CONCLUSION

Albeit uncommon, connective tissue disorders, such as primary Sjögren's syndrome, should be considered as a potential cause of constrictive pericarditis, especially in young patients with no other classical risk factors for constriction. In this case, after excluding possible infectious, neoplastic and autoimmune conditions, a primary Sjögren´s syndrome in association with constrictive pericarditis was assumed. This case presents an interesting and challenging clinical scenario, highlighting the importance of clinical awareness and the use of multimodal cardiac imaging for early recognition and treatment.

Early Postoperative Cardiac Complications Following Heart Transplantation:

Cardiovascular disorders remain the leading cause of death around the world. Heart transplantation is considered the only therapeutic choice defined as the gold standard strategy to manage end-stage heart failure. Nevertheless, the remaining postoperative complications compromise both the survival rate and quality of life in heart transplantation recipients. The present study aimed to review the current findings concerning the main early complications after heart transplantation, reliable predictors, diagnostic approaches, novel surgical techniques, and management strategies. The results demonstrated that significant advances in immunosuppressive pharmaceuticals, determining appropriate policies for donor acceptance, pre and post-operative treatment/care, selection of the most compatible donor with the recipient, and the suggestion of novel diagnostic and surgical techniques over the past decade had dropped the mortality and morbidity rates early after transplantation. However,marrhythmia, atrial flutter, atrial fibrillation, deep sternal wound infection along with other sites infections, low cardiac output syndrome, acute graft dysfunction, pericardial effusion, constrictive pericarditis, and acute cellular rejection could be considered as the major early complications following heart transplantations that pivotally require further investigations.

A Rare Case of Constrictive Pericarditis: Inflammatory Myofibroblastic Tumor

A previously healthy 15-year-old adolescent female presented with dependent edema, ascites, and dyspnea on exertion. The result of her initial evaluation was consistent with constrictive pericarditis in the setting of local low-grade spindle cell sarcoma. She was unresponsive to traditional medical management and required concurrent mass resection and radical pericardiectomy for definitive treatment. (Level of Difficulty: Intermediate.).

Constrictive Pericarditis in the Light of Multimodal Cardiac Imaging. A Case Report

Heart failure (HF) caused by constrictive pericarditis (CP) is very rare, but has a significant healing potential. In order to diagnose it, an initial high level of suspicion is imperative, given that HF presents in a setting lacking clinical signs capable of pinpointing a specific aetiology. However, current modern imaging techniques permit the accurate construction of a diagnosis for CP, clearing the way for surgical treatment. We are describing the case of a 60-year-old male who was hospitalised to our Cardiology Department due to a history of HF that gradually progressed to the congestion stage over the past six months. The diagnosis of CP was established after the examination of echocardiography and cardiac magnetic resonance imaging results. The patient underwent subtotal pericardectomy, and to this date, he has made a full recovery. The purpose of this case report is to highlight the importance of considering less common causes of HF, in addition to the common ones, in order to devise the most appropriate investigations and expedite surgical correction of this condition.