Radiography
Findings
Plain chest radiographs may show pericardial calcification in as many as 50% of CP patients, although anecdotal evidence suggests that this number is decreasing. The cardiac silhouette should be small in a patient with uncomplicated CP. CP can also coexist with cardiomyopathy, and a large heart does not exclude the disease. Other, less reliable plain radiographic findings include an abnormal cardiac contour, such as straightening of the right atrial border and, more rarely, straightening of the right and left cardiac borders, with obliteration of the normal curves, on frontal images.
On fluoroscopy, diminished cardiac pulsation may be seen.
Degree of Confidence
In a patient with diffuse pericardial calcification on radiographs and appropriate clinical symptoms of constrictive physiology, the diagnosis of CP can be reliably made. The absence of calcification does not exclude the disease, and further testing should include an extensive workup in the echocardiography laboratory, with an assessment of the Doppler velocities across the mitral and tricuspid valves during inspiration and expiration.
Because complete surgical pericardiectomy is usually effective (but not without a risk of morbidity and mortality), most patients also undergo simultaneous right- and left-sided heart catheterization, with a measurement of various pressures during inspiration and expiration.
False Positives/Negatives
If the radiograph is positive for pericardial calcifications and the patient's symptoms are consistent with CP, false-positive findings should not occur. The diagnosis is difficult to make in patients with CP but without pericardial calcifications. In these patients, normal findings on plain radiographs are false negatives.
Computed Tomography
Findings
Abdominal CT is most often performed in patients in whom the diagnosis of CP is not being considered on the basis of clinical findings. The symptoms in these patients are usually thought to be associated with a liver disorder. The radiologist can be of great service to the patient if CP is considered in the presence of appropriate imaging findings.
The pericardium should be diffusely thicker than 3 mm; however, many patients do not present with this finding, and the diagnosis of CP should not be discarded if thickening is not present. The size of all 4 heart chambers should be within the normal range; however, CP can coexist with other diseases, and global or focal dilatation of the cardiac chambers does not exclude CP.
The inflow veins to the right atrium, including the SVC, inferior vena cava (IVC), and hepatic veins, should be dilated. This finding is necessary but not sufficient to make the diagnosis of CP because it commonly occurs in the setting of congestive heart failure brought on by a variety of causes. Most often, when the hepatic veins and IVC are dilated for reasons other than CP, dilatation of 1 or all of the cardiac chambers is present and caused by systolic dysfunction or valve disease. If significant cirrhosis has already occurred, the hepatic veins may not be dilated.
There should be no progression of the contrast-agent bolus through the vascular system, and evidence of significant systolic dysfunction should be absent. For example, if the injection protocol involves a 60-second delay from the time of the injection to the start of scanning, contrast enhancement in the portal veins and waning of that enhancement in the abdominal aorta are usually seen. In CP, there should be poor opacification of liver parenchyma due to congestion and there should be no contrast enhancement in the portal vein.Degree of Confidence
In the appropriate patient, CT findings can be highly suggestive of CP; however, because the preferred treatment is total pericardiectomy, which has significant morbidity and mortality risks, almost all patients should be referred for cardiac echocardiography and/or simultaneous right- and left-sided heart catheterization.
False Positives/Negatives
Many of the CT findings of CP can also be found in patients with other diseases and in some asymptomatic conditions.
Focal or diffuse thickening of the pericardium can occur in the absence of constrictive physiology. An apparently delayed bolus of contrast material can be caused by technical factors in the acquisition of the CT scan. Dilated veins can be caused by right-sided heart failure. Liver cirrhosis can mimic the CT findings of CP.
Magnetic Resonance Imaging
Findings
Diffuse thickening of the pericardium greater than 3 mm can be observed on multiplanar MRIs.
ECG-triggered MRI is sensitive to constrictive disease of the pericardium because the fibrous layers are bordered by fat, which produces a distinct MRI signal. MRI can be used to measure pericardial thickness; the ideal views for measuring pericardial thickness are oriented perpendicular to the long axis of the left ventricle. MRI can also be used to measure chamber sizes at successive 50-msec delays after the R wave and to determine whether or not a filling plateau is present.
Like echocardiography and/or Doppler imaging, velocity-encoded (VENC) MRI can be used to assess volumetric flow and regurgitant flow to the pulmonary veins and the hepatic vein. MRI can demonstrate focal abnormalities and can cover the heart to determine whether the disease encapsulates its entirety.
Fast imaging can be performed during deep respiration to establish whether filling is concordant or discordant. CP restriction creates discordance with reduced left ventricular filling, which corresponds to increased right ventricular filling.
MRI dynamically shows a reversed curvature of the intraventricular septum clearly.
Degree of Confidence
MRI does not depict pericardial calcifications, but otherwise, MRI is highly sensitive and specific.
The main limitation with MRI is the greater cost relative to echocardiography. Furthermore, most patients with CP who are referred for imaging are not suspected of having the disease; therefore, MRI is rarely ordered to rule out CP.
False Positives/Negatives
A patient may have focal or even diffuse thickening on MRIs without a constrictive physiology. Conversely, a patient may have a constrictive physiology with subtle, diffuse thickening of the pericardium of less than 3 mm (which is the upper limit of the normal range); however, the physiologic alteration created by CP can be evaluated by performing VENC MRI of the pulmonary and hepatic veins and velocities across the mitral and tricuspid valves. This technique is usually reliable in detecting constrictive physiology.
Ultrasonography
Findings
Liver sonograms show dilated hepatic veins and abnormal pulse Doppler waveforms in the portal and hepatic veins due to outflow obstruction.
Cardiac echograms show normal contraction and systolic function. Special procedures, including an assessment of Doppler velocities across the mitral and tricuspid valves during inspiration and expiration, are needed to demonstrate ventricular interdependence. Unless the staff in the echocardiography laboratory is alerted to the clinical suspicion of CP, the diagnosis is often not considered and, therefore, is missed.
Newer echocardiographic procedures, such as the evaluation of the early diastolic Doppler myocardial velocity gradients at the posterior wall, tissue Doppler echocardiography, and color M mode flow propagation, have recently been reported to enhance the differentiation between CP and restrictive cardiomyopathy.
Degree of Confidence
Abdominal ultrasonographic findings are nonspecific and must be confirmed with echocardiography and cardiac catheterization results.
False Positives/Negatives
Budd-Chiari syndrome, cirrhosis, and right-sided heart failure can mimic some of the findings of CP at liver ultrasonography.
Nuclear Imaging
Findings
Because of liver function abnormalities caused by hepatic congestion, hepatobiliary scanning is often ordered for patients in whom CP is not suspected. The hepatobiliary scan findings are impaired hepatic clearance of the agent from the blood pool and severely impaired excretion of the radiopharmaceutical agent into the biliary tree.
Gated nuclear ventriculography may show rapid ventricular filling in CP. Reportedly, these findings can be used to differentiate CP from restrictive cardiomyopathy.
Degree of Confidence
Many conditions that are more common than CP can impair hepatic uptake and excretion of the radiopharmaceutical agent. If the physician is perceptive enough to consider the diagnosis of CP, the diagnosis must be confirmed with echocardiography and heart catheterization.
False Positives/Negatives
Hepatitis, drug-induced cholestatic liver disease, severe cirrhosis, and severe right-sided heart failure can cause findings similar to those of CP.
Angiography
Findings
Angiography usually has no role in the evaluation of CP. Simultaneous right- and left-sided heart catheterization and measurement of cardiac chamber pressures during inspiration and expiration are the most useful confirmatory tests.
Degree of Confidence
Measurements obtained in the catheterization laboratory can be highly suggestive of CP. Although considered the criterion standards, the traditional hemodynamic criteria used in the catheterization laboratory for the diagnosis of CP are neither sensitive nor specific, and they significantly overlap with those of restrictive diseases that can also alter the diastolic filling properties. The criteria are the following:
- End-diastolic pressure equalization is present: The difference between the left and the right ventricular end-diastolic pressures is 5 mm Hg or less.
- Pulmonary artery pressure is less than 55 mm Hg.
- The right ventricular end-diastolic pressure divided by the right ventricular end-systolic pressure is greater than 1/3.
- A dip-and-plateau diastolic pressure morphology, as reflected by height of the left ventricular rapid filling wave (>7 mm Hg) is present.
- The Kussmaul sign is present: The mean right atrial pressure does not decrease during inspiration.
Significant information can also be gained from echocardiography. Ultimately, the diagnosis must be confirmed surgically at the time of complete pericardiectomy. Only 50% of patients respond to surgery, but in many patients, the symptoms dramatically resolve.
False Positives/Negatives
Restrictive heart disease can mimic some manifestations of CP at catheterization or echocardiography.
More on Constrictive Pericarditis |
| Overview: Constrictive Pericarditis |
 Imaging: Constrictive Pericarditis |
| Follow-up: Constrictive Pericarditis |
| Multimedia: Constrictive Pericarditis |
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Further Reading
Keywords
CP, constriction of the cardiac chambers, pericardium, thickened pericardium, pericardial thickening, stiffened pericardium, pericardial stiffening
