Multimodality approach to the diagnosis and management of constrictive pericarditis

Constrictive pericarditis in the new millennium

Constrictive pericarditis (CP) is a complex clinical syndrome in which an inflamed pericardium becomes fibrotic and non-compliant, ultimately reducing cardiac pump performance. Although we have known about CP for centuries, it remains a challenge to diagnose. Recent advances in cardiac imaging, along with an expanding armamentarium of treatment options, have improved the quality and precision of care for patients with CP. This article reviews important historical and contemporary perspectives on the pathophysiology of CP, as well as our approach to diagnosis and management.

Constrictive pericarditis heart failure in a patient with atrial fibrillation: A diagnostic challenge

Constrictive pericarditis is an infrequent cause of heart failure. Diagnosis is challenging and requires a high level of suspicion. Subtle echocardiographic findings, as the pericardial bounce, could be the clue to diagnosis.

The role of multi-modality cardiovascular imaging in a patient presenting with acute liver failure secondary to constrictive pericarditis: a case report

Background

Constrictive pericarditis is a rare cause of heart failure which often presents a diagnostic challenge to clinicians.

Case summary

We describe the case of a 62-year-old male who presented to our institution with symptoms and signs suggestive of acute liver failure. Abdominal imaging demonstrated congestive hepatopathy. Clinical suspicion despite a 'normal' echocardiogram and sub-threshold NT-proBNP led to multi-modality cardiovascular imaging investigations to determine the cause of the heart failure syndrome. His cardiovascular magnetic resonance scan confirmed ventricular interdependence and extensive late enhancement in the pericardium with associated pericardial effusion. An 18F-fluorodeoxyglucose-positron emission tomography scan confirmed active pericardial inflammation. Cardiac computed tomography showed minimal pericardial calcification. Following confirming the diagnosis of effusive-constrictive pericarditis with evidence of active pericardial inflammation on imaging, a discussion within the Heart multidisciplinary team concluded that a trial of medical therapy with steroids is justifiable to avoid high-risk pericardiectomy. The patient was successfully treated with a combination of ibuprofen, colchicine, and prednisolone resulting in clinical improvement and remission of his symptoms. The imaging investigations were repeated 6 months later and confirmed radiological remission and medical therapy was discontinued.

Discussion

We stress the importance of multi-modality cardiovascular imaging in the diagnosis of constrictive pericarditis and also emphasize its role in identifying the subset of patients who may respond to medical therapy, therefore reducing the risk of high need surgical pericardiectomy.

Dual energy imaging in cardiothoracic pathologies: A primer for radiologists and clinicians

Recent advances in dual-energy imaging techniques, dual-energy subtraction radiography (DESR) and dual-energy CT (DECT), offer new and useful additional information to conventional imaging, thus improving assessment of cardiothoracic abnormalities. DESR facilitates detection and characterization of pulmonary nodules. Other advantages of DESR include better depiction of pleural, lung parenchymal, airway and chest wall abnormalities, detection of foreign bodies and indwelling devices, improved visualization of cardiac and coronary artery calcifications helping in risk stratification of coronary artery disease, and diagnosing conditions like constrictive pericarditis and valvular stenosis. Commercially available DECT approaches are classified into emission based (dual rotation/spin, dual source, rapid kilovoltage switching and split beam) and detector-based (dual layer) systems. DECT provide several specialized image reconstructions. Virtual non-contrast images (VNC) allow for radiation dose reduction by obviating need for true non contrast images, low energy virtual mono-energetic images (VMI) boost contrast enhancement and help in salvaging otherwise non-diagnostic vascular studies, high energy VMI reduce beam hardening artifacts from metallic hardware or dense contrast material, and iodine density images allow quantitative and qualitative assessment of enhancement/iodine distribution. The large amount of data generated by DECT can affect interpreting physician efficiency but also limit clinical adoption of the technology. Optimization of the existing workflow and streamlining the integration between post-processing software and picture archiving and communication system (PACS) is therefore warranted.