Pericardial Disease Dynamic Imaging
Apichaya Sripariwuth, MD
Department of Radiology, Faculty of Medicine
Naresaun University Hospital
Outline
▪ Pericardial Anatomy and Basic Physiology
▪ MRI Protocol for Pericardial Disease and Normal Imaging
▪ Pericardial Disease – Dynamic Imaging
Pericardial AnatomyThin, avascular, relatively inelastic, flask-shape sac enveloping the heart
Pericardial Anatomy
▪ Fibrous pericardium
▪ Serous pericardium
▪ Parietal layer:
- Lines the inner surface of the fibrous pericardium
▪ Visceral layer:
- Envelops the epicardial surface of the heart
- Produces pericardial fluid
Pericardial Anatomy
▪ Pericardial Cavity/ Sac
▪ Space between parietal and visceral layer
▪ Normally contains a small amount of fluid
Pericardial Function
▪ Fixed heart position within mediastinum
▪ Barrier to infection
▪ Decreased friction of cardiac movement
▪ Makes the hearts as semirigid structure
Basic Principles of Cardiac Function
Clinical Cardiac MRI 2nd edition
Diastole
▪ Filling phase of ventricles
▪ Period between MV opening and MV closure –depends on ventricular pressure
▪ Determine by
▪ Myocardial relaxation
▪ Atrial contraction
▪ Compliance of the ventricle and atrium
MRI Protocol for Pericardial Disease
Clinical Cardiac MRI 2nd edition
Basic MRI Protocol and Normal Imaging
▪ Black-blood image
▪ Cine SSFP
▪ Real-time cine image
▪ Myocardial tagging image
▪ Delayed enhancement image
Black-Blood Image
▪ ECG-gated image
▪ T1-weighted, Double inversion
▪ Normal pericardium:
▪ Hypo-intensity
▪ 1-2 mm in thickness
Cine SSFP
▪ T1/T2-weighted
▪ Global & Regional Cardiac Function
▪ Pericardial mobility
Real-time cine image
• Cine SSFP during inspiration and expiration
• Evaluating right to left ventricular interaction known as ventricular coupling/interdependence
• Normally, septum has concave shape toward the RV during entire cardiac cycle
Myocardial tagging image
• Using a grid• For pericardial adhesion
and myocardial involvement
Delayed Enhancement Image
Pericardial MassPericardial Enhancement
Sripariwuth A et al. Multimodality Cardiac Imaging Assessment of a Large Metastatic Pericardial Leiomyosarcoma. CASE. 2018 Aug; 2(4): 156–162
Pericardial Disease – Dynamic Imaging
▪ Pericardial Effusion
▪ Cardiac Tamponade
▪ Constrictive Pericarditis
Pericardial Effusion
▪ Fluid in pericardial sac
▪ Normal volume:5-10 ml
▪ Grading : Distance between heart and parietal pericardium
Small Moderate Large
< 0.5 cm 0.5-2 cm > 2 cm
Textbook of Clinical Echocardiography 6th edition
Pericardial Effusion
▪ The Development of Tamponade depends on
▪ Volume
▪ Rate of Accumulation
▪ Pericardial Stiffness
Cardiac Tamponade
▪ Defined as hemodynamically significant cardiac compression from accumulating pericardial contents (fluid, pus, hemorrhage, tumor)
▪ ↑Intrapericardial pressure → ↓diastolic compliance → ↓ cardiac filling → ↓cardiac output
Cardiac Tamponade
▪ Clinical diagnosis
▪ Imaging findings are reflecting to
▪ ↑Intrapericardial pressure
▪ ↓ Diastolic compliance
Cardiac Tamponade
Non dynamic Imaging Dynamic Imaging
Chamber collapse Chamber collapse- Right atrial systolic collapse- Right ventricular diastolic collapse
Straightening/blowing of the interventricular septum
Ventricular interdependence
Content in pericardial sac
Dilate SVC, IVC, Hepatic veins
Cardiac Tamponade?
Constrictive Pericarditis
▪ Rigid fixed pericardial volume
▪ Ventricular filling is limited by pericardial volume
▪ Diastolic Dysfunction (DDx from Restrictive cardiomyopathy)
Constrictive Pericarditis
▪ Findings:
▪ Dissociation of intrathoracic and intracardiac diastolic pressure
▪ Increased ventricular coupling
▪ Increased cardiac filling pressure with pressure equalization in all cardiac chamber
Constrictive Pericarditis
Non dynamic Imaging Dynamic Imaging
Pericardial thickening > 4 mm Ventricular coupling/interdependence
Calcified/Irregular pericardium Diastolic septal bounce
Conical/tubular deformity of ventricles Pericardial adhesion
Unilateral or bilateral atrial enlargement
Dilate SVC, IVC, Hepatic veins
Pleural effusion, Ascites
Pericardial enhancement (Inflammation)
Constrictive Pericarditis
Constrictive Pericarditis
Constrictive Pericarditis
Circulation 2018
Take Home Message
▪ The development of Tamponade depends not only on the volume, but also on the rate of accumulation and the pericardial stiffness.
▪ Constrictive Pericarditis effects Diastolic function
▪ Pericardial thickening and calcification do not always imply constrictive pericarditis