Utility of multimodality cardiac imaging in disorders of the pericardium

Figure 1. Doppler assessment in constrictive pericarditis. Classically, a restrictive pattern of transmitral inflow profile is seen in constrictive pericarditis (A). Respirophasic variation in transmitral inflow, with a decrease in peak E wave velocity on the first heart beat following inspiration (B). Respirophasic variation in transtricuspid inflow, with an increase in peak E wave velocity on the first heart beat following inspiration (C). Exp, expiration; Insp, inspiration; MV, transmitral inflow; TV, transtricuspid inflow.

Figure 2. Annulus reversus is a feature of constrictive pathophysiology. On Doppler assessment, in annulus reversus, medial mitral annular early diastolic velocity (14 cm/s; A), is higher than the lateral mitral annular early diastolic velocity (11 cm/s; B). On strain imaging using two-dimensional speckle tracking (C and D), the peak systolic strain in the basal and mid-anterolateral wall segments are reduced, while the peak systolic strain in the other segments are preserved.

Figure 3. Echocardiographic assessment of pericardial effusion in pulmonary hypertension. Significant elevation of estimated right ventricular systolic pressure is consistent with pulmonary hypertension (A). Transthoracic echocardiographic imaging (parasternal long-axis imaging (B); parasternal short-axis imaging (C)) demonstrates a significant pericardial effusion. However, in the presence of right ventricular hypertrophy and pulmonary hypertension, there are no echocardiographic features of tamponade physiology, such as significant chamber compression (B and C). The inferior vena cava is also normal in caliber, collapsing more than 50% on forced inspiration, suggesting normal estimated right atrial pressure (D).

Figure 4. Axial multi-detector computed tomography, demonstrating significant, near circumferential pericardial calcification (white arrow) in a 62-year-old female patient with end-stage calcific pericardial constriction.

Figure 5. Cardiac magnetic resonance imaging in pericarditis. T2-weighted short tau inversion recovery (STIR) imaging at the apical (A), mid (B) and basal (C) levels, demonstrating increased pericardial signal (white arrows) consistent with pericardial edema. Delayed enhancement imaging with gadolinium at the apical (D), mid (E) and basal (F) levels, demonstrating increased pericardial signal (white arrows) consistent with pericardial inflammation. Following treatment with anti-inflammatory therapies (colchicine and ibuprofen) and azathioprine, serial follow-up delayed-enhancement imaging with gadolinium at the apical (G), mid (H) and basal (I) levels, demonstrating complete resolution of pericardial delayed enhancement.

Figure 6. Demonstration of thickened pericardium (white arrow) on black-blood cardiac magnetic resonance imaging (sagittal projection).

Figure 7. Evaluation of pericardial effusion on cardiac magnetic resonance imaging (axial projection on steady-state free precession), demonstrating the presence of septations within the pericardial effusion (white arrow).