Clinical Utility of Cardiac Magnetic Resonance Imaging in Pericardial Diseases

Figures

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  Fig. (1). Steady-State Free Precession (SSFP) sequence of 4-chamber (left) and short axis (right) view of the heart with mostly focal lateral wall large pericardial effusion (yellow arrow). The parietal and visceral pericardium’s (red arrows) are separated with the pericardial fluids. Epicardial fat (blue arrow head). (The color version of the figure is available in the electronic copy of the article)

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  Fig. (2). Left- T2 weighted edema (triple inversion) sequence of the short-axis of the cardiac muscle showing hyperintense signal from the pericardium suggesting high water content (edema, acute inflammatory process) (Yellow arrows). The epicardial fat is appears dark on this sequence (red arrow head) and the blood signal is suppressed (Green circle). Right- triple inversion recovery edema (T2 weighted images) showing hyperintense signal from the parietal (thick yellow arrow) and visceral pericardium (thin yellow arrow) over the RV anterior wall and the apex. There is moderate pericardial effusion (red arrow). Pleural effusion also seen (arrow head). This is a unique sequence to judge the acuity of the pericarditis (see text). (The color version of the figure is available in the electronic copy of the article)

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  Fig. (3). Late gadolinium enhancement of short-axis of the heart showing mild hyperenhancement of the parietal and visceral pericardium (arrows) with pericardial effusion in between (arrow head).

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  Fig. (4). Late gadolinium enhancement sequence of a short-axis view (left) and four-chamber view (right) of the cardiac muscle shows hyperenhancement of the pericardium (arrows). This post-contrast sequence conveys the chronicity of the pericarditis and the subsequent fibrotic conversion.

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  Fig. (5). Black blood T1 weighted (Double inversion recovery) showing thick pericardium in a patient with pericarditis. Blue arrow indicates the thickened pericardium. Yellow arrow indicates epicardial fat. Red arrow indicates pericardial fat. (The color version of the figure is available in the electronic copy of the article).

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  Fig. (6). Steady-State Free Precession (SSFP) showing very thick pericardium in a patient with pericarditis. Left; 3-chamber and right; short-axis views.

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  Fig. (7). Real time CMR imaging. Short-axis of LV and RV demonstrating the septal wall motion (Septal bounce) with interventricular interdependence. During inspiration (left) there is a decrease in intrathoracic pressure with consequent increase in IVC/SCV flow into the RA/RV tending to drive septal forces leftward that are reversed in expiration (right) due to the restricted pericardium and the pulmonary veins being outside the pericardium. With exaggerated real-time CMR images, this finding is nearly pathognomonic for constrictive pericarditis. Note the not subtle migration of the septum with no effective change in total ventricular volume.

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  Fig. (8). Radio-frequency tissue-tagging sequence demonstrating the lack of slippage between the parietal and visceral pericardium (adhesion) along the right ventricular base (arrows). The systolic frames have not revealed clear slippage planes between the visceral and parietal pericardium as evidenced by the distortion of the otherwise cuboidal tag interspaces diagnostic and pathognomonic for focal constrictive anatomy.

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  Fig. (9). Steady-state Free Precession (SSFP) sequence of short-axis view of the heart with moderate sized nearly constrictive pericardial effusion (Red arrow). The parietal and visceral pericardiums (yellow arrows) are separated with the pericardial fluids. (The color version of the figure is available in the electronic copy of the article).

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  Fig. (10). a. Late gadolinium enhancement shows no uptake of the pericardial cyst behind the right atrium (Blue arrow) (upper left). b. Triple inversion recovery (T2) demonstrates a hyperintense signal from the retro-right atrial pericardial cyst (Arrow) (upper right). This is a classical area in the right costophrenic angle for a benign pericardial cyst. c and d shows SSFP of the pericardial cyst in the coronal and axial position depicting their typical location in the right costophrenic angle (90% in right costophrenic angle vs. 10% in left costophrenic angle).

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  Fig. (11). Black-blood T1-weighted spin-echo MR imaging performed on asymptomatic 21 year old male who had levoposition of the heart in the posteroanterior projection of a CXR. He was found to have congenital absence of entire pericardium.

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  Fig. (12). A. Steady-state free precession (SSFP) 2 chamber (upper left) B. Steady-state free precession (SSFP) short-axis (upper right) of the LV showing an epicardial mass (arrow) over the anterior and anterolateral walls of the left ventricle in a 65-year-old male with lymphoma with pericardial involvement. C Black blood double inversion (T1 weighted) (left lower) sequence of the short axis of the heart showing the epicardial mass (lymphoma) as isointense. D (right lower) triple inversion edema (T2 sequence) short-axis of the heart showing slight hyperintensity of the epicardial mass (lymphoma).