Constrictive pericarditis at abdominal CT: a commonly overlooked diagnosis

Background The purpose of this study was to evaluate findings at abdominal computed tomography (CT) in patients with proven constrictive pericarditis. Methods The medical records of 25 patients with surgically proven constrictive pericarditis and abdominal CT examinations within 30 days of operation were reviewed. Clinical symptoms, laboratory findings and prospective CT findings were collated. The CT examinations were also retrospectively reviewed in an unblinded fashion. Results Direct CT findings of constrictive pericarditis with an abnormal pericardium were present in 23/25 patients. Only 9 of 25 (36%) patients were detected prospectively. Findings on retrospective review included pericardial calcification (10/25, 40%) or thickening (13/25, 52%), dilated IVC (20/25), dilated hepatic veins (14/25), ascites (14/25), mesenteric soft tissue stranding (12/25), mottled enhancement of the hepatic parenchyma (8/25), and cirrhosis (6/25). Anemia was present in (17/25), and an elevated AST levels occurred in 48% (12/25) of patients. The most common abdominal symptoms were pain (4/12), diarrhea (4/12), distention (3/12), and bloating (1/12). Conclusions Constrictive pericarditis can present with vague abdominal symptoms. Anemia and elevated liver function tests are common laboratory abnormalities. Indirect CT findings of dilated IVC and/or hepatic veins, ascites, or cirrhosis should prompt inspection of the pericardium. In the majority of cases an abnormal pericardium could be identified (thickened, calcified or both).     

Index of biventricular interdependence calculated using cardiac MRI: a proof of concept study in patients with and without constrictive pericarditis

We sought to propose a magnetic resonance (MR) imaging-derived index of biventricular interdependence as a diagnostic parameter to distinguish patients with surgically-confirmed pericardial constriction from those without. Free-breathing real time MR pulse sequences of seventeen subjects with surgically proven constrictive pericarditis and thirty-five patients referred for clinically-indicated cardiac MR examinations but without documented constriction were analyzed using a novel index of biventricular interdependence. Cross-sectional biventricular areas at end diastole using the epicardial surface were traced at the mid left ventricular level at end-inspiration and end-expiration and an index of biventricular interdependence, defined as the ratio of (biventricular end-diastolic area at end-inspiration)/(biventricular end-diastolic area at end-expiration) was calculated for each subject. The mean index for both groups was calculated and results were statistically compared. The index of biventricular interdependence approximated unity (mean index 1.03 ± 0.03 SD) in patients with surgically confirmed pericardial constriction, indicating similar biventricular area at end-inspiration and end-expiration, and was significantly lower than in individuals without constrictive pericarditis (mean index 1.28 ± 0.10 SD; p < 0.0001). The MR-derived index of biventricular interdependence was significantly different between subjects with surgically-confirmed pericardial constriction and subjects where pericardial constraint was not suspected and may serve as a useful metric in the hemodynamic assessment of patients with a potential diagnosis of constrictive pericarditis.     

Spectrum of pericardial disease: part II

Pericardial disease is a common disorder seen in varying clinical settings, and may be the first manifestation of an underlying systemic disease. In part I, we focused on the current knowledge and management of the more common pericardial diseases: acute pericarditis, pericardial effusion, cardiac tamponade, chronic pericarditis and relapsing pericarditis. In part II, we will focus on the knowledge and management of pericardial involvement in chylous pericardial effusion cholesterol pericarditis, radiation pericarditis, pericardial involvement in systemic inflammatory diseases, autoreactive pericarditis, pericarditis in renal failure, pericardial constriction and effusive constrictive pericarditis.     

Pericardial Disease: Diagnosis and Management

Pericardial diseases can present clinically as acute pericarditis, pericardial effusion, cardiac tamponade, and constrictive pericarditis. Patients can subsequently develop chronic or recurrent pericarditis. Structural abnormalities including congenitally absent pericardium and pericardial cysts are usually asymptomatic and are uncommon. Clinicians are often faced with several diagnostic and management questions relating to the various pericardial syndromes: What are the diagnostic criteria for the vast array of pericardial diseases? Which diagnostic tools should be used? Who requires hospitalization and who can be treated as an outpatient? Which medical management strategies have the best evidence base? When should corticosteroids be used? When should surgical pericardiectomy be considered? To identify relevant literature, we searched PubMed and MEDLINE using the keywords diagnosis, treatment, management, acute pericarditis, relapsing or recurrent pericarditis, pericardial effusion, cardiac tamponade, constrictive pericarditis, and restrictive cardiomyopathy. Studies were selected on the basis of clinical relevance and the impact on clinical practice. This review represents the currently available evidence and the experiences from the pericardial clinic at our institution to help guide the clinician in answering difficult diagnostic and management questions on pericardial diseases.CMR = cardiac magnetic resonance imaging; CT = computed tomography; CYP = cytochrome P450; ECG = electrocardiographic; ESC = European Society of Cardiology; IVC = inferior vena cava; LV = left ventricular; NSAID = nonsteroidal anti-inflammatory drug; RA = right atrium; RV = right ventricleThe pericardium is a thin covering that separates the heart from the remaining mediastinal structures and provides structural support while also having a substantial hemodynamic impact on the heart. The pericardium is not essential—normal cardiac function can be maintained in its absence—however, diseased pericardium presenting clinically as acute or chronic recurrent pericarditis, pericardial effusion, cardiac tamponade, and pericardial constriction can be challenging to manage and life-threatening in some cases. The etiology of pericardial disease is often difficult to determine or remains idiopathic. However, microorganisms, including viruses and bacteria; systemic illnesses, including neoplasia, autoimmune disease, and connective tissue disease; renal failure; previous cardiac surgery; previous myocardial infarction; trauma; aortic dissection; radiation; and, rarely, drugs have been associated with pericardial diseases.The diagnosis and management of pericardial diseases remain challenging because of the vast spectrum of manifestations and the lack of clinical data on which to base guidelines by the American College of Cardiology and the American Heart Association. However, the European Society of Cardiology (ESC) published guidelines on pericardial disease in 2004.¹ This review aims to describe the methods of diagnosing and managing major pericardial syndromes on the basis of the literature and the clinical experience of our pericardial clinic. Searches were performed on PubMed and MEDLINE using the keywords diagnosis, treatment, management, acute pericarditis, relapsing or recurrent pericarditis, pericardial effusion, cardiac tamponade, constrictive pericarditis, and restrictive cardiomyopathy. No date limitations were set. Studies were selected on the basis of clinical relevance and the impact on clinical practice.     

Calcific constrictive pericarditis in Degos' disease

A 31-year-old woman presented with symptoms and signs of constrictive pericarditis. She had a history of Degos' disease, a rare disorder characterized by skin and bowel lesions thought to be secondary to vasculitis. A chest roentgenogram showed extensive calcification of the pericardium. Although pleural and pericardial involvement has been reported in this disease, constrictive pericarditis is most unusual, and radiographically demonstrable calcification of the pericardium has not been reported previously.     

Constrictive pericarditis from an embolized hypodermic needle: radiographic, CT and MR imaging findings

We present the radiographic, computed tomographic (CT), and magnetic resonance (MR) findings in a woman with constrictive pericarditis due to an embolized hypodermic needle. The chest films revealed pleural effusions but no foreign body. The CT showed pericardial thickening and a linear foreign body of metallic attenuation in the right ventricular apex, and MR imaging revealed a signal void with magnetic susceptibility artifact. This case illustrates the capabilities and limitations of CT and MR imaging in hypodermic needle-induced constrictive pericarditis.     

Clinical review: Intrapericardial fibrinolysis in management of purulent pericarditis

Purulent pericarditis (PP) is a potentially life-threatening disease. Reported mortality rates are between 20 and 30%. Constrictive pericarditis occurs over the course of PP in at least 3.5% of cases. The frequency of persistent PP (chronic or recurrent purulent pericardial effusion occurring despite drainage and adequate antibiotherapy) is unknown because this entity was not previously classified as a complication of PP. No consensus exists on the optimal management of PP. Nevertheless, the cornerstone of PP management is complete eradication of the focus of infection. In retrospective studies, compared to simple drainage, systematic pericardiectomy provided a prevention of constrictive pericarditis with better clinical outcome. Because of potential morbidity associated with pericardiectomy, intrapericardial fibrinolysis has been proposed as a less invasive method for prevention of persistent PP and constrictive pericarditis. Experimental data demonstrate that fibrin formation, which occurs during the first week of the disease, is an essential step in the evolution to constrictive pericarditis and persistent PP. We reviewed the literature using the MEDLINE database. We evaluated the clinical efficacy, outcome, and complications of pericardial fibrinolysis. Seventy-four cases of fibrinolysis in PP were analysed. Pericarditis of tuberculous origin were excluded. Among the 40 included cases, only two treated by late fibrinolysis encountered failure requiring pericardiectomy. No patient encountered clinical or echocardiographic features of constriction during follow-up. Only one serious complication was described. Despite the lack of definitive evidence, potential benefits of fibrinolysis as a less invasive alternative to surgery in the management of PP seem promising. Early consideration should be given to fibrinolysis in order to prevent both constrictive and persistent PP. Nevertheless, in case of failure of fibrinolysis, pericardiectomy remains the primary option for complete eradication of infection.     

AMOEBIC PERICARDITIS

Twenty-five patients with amoebic pericarditis were studiedand the clinical findings described. Two types were recognized,one with a serous effusion associated with a left lobe liverabscess and the other with a purulent effusion resulting fromrupture of a liver abscess into the pericardium. These havebeen termed presuppurative and suppurative amoebic pericarditisrespectively. The first type may progress to the second. Five patients suffered from the presuppurative variety of pericarditisand all recovered following treatment of the liver abscess. Of the 20 patients with suppurative pericarditis 12 recoveredand had no residual disability. In the eight patients who succumbed,death was due to cardiac tamponade (usually when the correctdiagnosis had not been made) or to constrictive pericarditisin which surgery was unsuccessful. It appears from this series that if suppurative amoebio pericarditisis treated by pericardial aspiration to relieve tamponade, andby the anti-amoebic drugs emetine hydrochloride and chloroquine,a proportion of patients recover fully without developing constriction.When constrictive pericarditis develops, conservative treatmentshould be continued as resolution often occurs. Pericardectomyshould be reserved for cases in which death seems inevitableunless constriction is relieved. ² The Amoebiasis Research Unit is sponsored by the followingbodies: The South African Council for Scientific and IndustrialResearch, University of Natal, Natal Pro vincial Administration,United States Public Health Service (Grant E-1592).     

Septal bounce, vena cava plethora, and pericardial adhesion: informative two-dimensional echocardiographic signs in the diagnosis of pericardial constriction

To assess the diagnostic value of three different two-dimensional echocardiographic signs of pericardial constriction (early diastolic septal bounce, plethora of the inferior vena cava with blunted respiratory response, and pericardial adhesion), two independent observers retrospectively evaluated echocardiograms in 100 patients, 39 of whom had pericardial constriction, 15 had hemodynamically insignificant pericardial thickening, 16 had restrictive cardiomyopathy, and 30 had normal hearts. Causes of pericardial disease included cardiac surgery, malignancy, and uremia. Sensitivity and specificity of the three signs for constriction were 62% and 93% for septal bounce, 79% and 80% for vena cava plethora, and 79% and 90% for pericardial adhesion, respectively. The presence of either vena cava plethora or pericardial adhesion increased sensitivity, whereas the presence of both plethora and adhesion increased specificity. Between the two readers, septal bounce was the most consistent and pericardial adhesion the least consistent sign. False positive results included right ventricular pacing or left bundle branch block (septal bounce), postpericardiotomy (pericardial adhesion), and right heart failure (vena cava plethora). False negative results were often caused by technical problems with imaging. We conclude that these three two-dimensional echocardiographic signs are useful in differentiating pericardial constriction from hemodynamically insignificant pericardial thickening or restrictive cardiomyopathy.     

Constrictive pericarditis associated with combined idiopathic retroperitoneal and mediastinal fibrosis

Idiopathic retroperitoneal fibrosis and mediastinal fibrosis are localized expressions of a systemic sclerosing disease of unknown cause which, on rare occasions, may coexist in the same patient. Although pericardial involvement may occur, recurrent constrictive pericarditis that is unrelieved by pericardiectomy has not previously been reported in association with either idiopathic retroperitoneal or mediastinal fibrosis. Reported herein is a case of recurrent constrictive pericarditis that was unrelieved by two pericardiectomies , and autopsy revealed unsuspected combined idiopathic retroperitoneal and mediastinal fibrosis. The clinical, echocardiographic, and pathologic findings are described.     

Transitory effusive-constrictive pericarditis

Pericardial effusion of various sizes is a quite common clinical finding, while its progression to effusive-constrictive pericarditis occurs in about 1.4–14% of cases. Although available evidence on prevalence and prognosis of this rare pericardial syndrome is poor, apparently a considerable proportion of patients conservatively managed has a spontaneous resolution after several weeks.A 61-year-old female presented to our emergency department reporting fatigue, effort dyspnea and abdominal swelling. The echocardiography showed large pericardial effusion with initial hemodynamic impact, so she underwent a pericardiocentesis with drainage of 800–850 cm³ of exudative fluid, on which diagnostic investigations were undertaken: possible viral and bacterial infections, medical conditions, iatrogenic causes, neoplastic and connective tissue diseases were all excluded. Despite empirical therapy with NSAIDs and colchicine, after about one week she had a recurrence of pericardial effusion and progressive development of constriction. Echocardiography performed after a few weeks of anti-inflammatory therapy showed resolution of constriction and PE, with clinical improvement.If progression of pericardial syndromes to a constrictive form is rarely described in literature, cases of transitory effusive-constrictive phase are even more uncommon, mainly reported during the evolution of pericardial effusion. According to the available data, risk of progression to a constrictive form is very low in case of idiopathic pericardial effusion. We report a case of large idiopathic subacute pericardial effusion, treated with pericardiocentesis and then evolved into an effusive-constrictive pericarditis. A prolonged anti-inflammatory treatment leads to complete resolution of pericardial syndrome without necessity of pericardiectomy.     

MR imaging of the pericardium

Imaging of the pericardium requires understanding of anatomy and the normal and abnormal physiology of the pericardium. MR imaging is well-suited for answering clinical questions regarding suspected pericardial disease. Pericardial diseases that may be effectively imaged with MR imaging include pericarditis, pericardial effusion, cardiac-pericardial tamponade, constrictive pericarditis, pericardial cysts, absence of the pericardium, and pericardial masses. Although benign and malignant primary tumors of the pericardium may be occasionally encountered, the most common etiology of a pericardial mass is metastatic disease.     

Constrictive pericarditis: detection of mycobacterium tuberculosis in paraffin-embedded pericardial tissues by polymerase chain reaction

BACKGROUND: Although the utility of polymerase chain reaction (PCR) for diagnosis of acute pleuro-pericardial tuberculosis has been well established, its use for chronic constrictive pericarditis is yet to be reported. AIMS: To define the sensitivity and specificity of PCR for diagnosis of tuberculosis (TB) in patients with constrictive pericarditis. METHODS: The medical records of 30 consecutive patients with constrictive pericarditis were reviewed. In addition their historical paraffin-embedded pericardial tissues were used for new histopathologic examination and PCR amplification for Mycobacterium tuberculosis genome. RESULTS: There were 23 males and 7 females with a mean age of 35+/-19.5 years. The anticipated causes of constriction included idiopathic (n=21), tuberculosis (n=5), cardiac surgery (n=2) and post traumatic (n=2). PCR became positive in nine patients. Four out of 5 patients with tuberculous granuloma had a positive test result. In addition all 4 patients with non-tuberculous constrictive pericarditis had a negative test result. Therefore considering the presence or absence of granuloma as a diagnostic criteria, the sensitivity and specificity of PCR were 4/5 (80%) and 20/25 (80%), respectively.     

快速进展型结核性心包炎的临床治疗

目的探讨不同治疗方案对于快速进展为缩窄性心包炎的结核性心包炎（快速进展型结核性心包炎）治疗效果、并发症、死亡率、患者预后的影响,以期对结核性心包炎的治疗获得更好的效果。 方法回顾性分析2014年6月至2019年5月成都市第三人民医院心脏大血管外科对38例快速进展型结核性心包炎的治疗方式、外科手术干预时机、手术方式及疗效、并发症、死亡率和随访情况等,治疗方式包括药物治疗、心包穿刺引流术、心包开窗术、心包剥脱术等。同期观察对慢性缩窄性心包炎行外科手术治疗患者115例。 结果对于快速进展型结核性心包炎采用不同的治疗方案,随访1~5年。所有患者均采用抗结核药物治疗,其中单纯药物治疗5例,全部进展为缩窄性心包炎;早期行心包穿刺引流术12例,治愈1例,其余11例进展为慢性缩窄性心包炎;早期行心包开窗术10例,进展为慢性缩窄性心包炎1例,治愈9例;早期行心包剥脱术11例,无进展为慢性缩窄性心包炎病例。全组无围术期死亡病例。与同期行慢性缩窄性心包炎外科手术治疗患者相比,快速进展型结核性心包炎外科手术治疗患者低心排综合征发生率较低（4.8% vs 24.3%,P＜0.05）,患者心功能改善情况较好（100.0% vs 80.7%,P＜0.05）,术后5年随访生存率较高（100% vs 78%,P＜0.05）。 结论快速进展型结核性心包炎单纯采用药物治疗和心包穿刺术治疗,有很高比例的患者会进展为缩窄性心包炎,从而严重影响患者的预后。早期外科干预能显著降低快速进展型结核性心包炎进展为缩窄性心包炎的概率,从而改善患者总体预后,改善患者生存质量,减轻社会负担。     

CT Imaging of the Pericardium

Pericardial disease can be challenging to diagnose, and imaging can play a useful role in confirming or even suggesting the diagnosis. Computed tomography (CT) is a particularly appealing option for investigating pericardial disease in many patients because the differential diagnosis for symptoms of acute pericarditis or constrictive pericarditis often includes other diseases which are also well assessed with CT. In addition, many patients will have findings of pericardial disease manifest on CT imaging for other suspected diseases, and these findings can be missed if careful attention is not paid to the pericardium. CT also can play an important role in evaluating specific pericardial lesions, such as cysts, tumors, and abscesses. We will review findings of various pericardial diseases on CT with illustrative cases.     

Acute pericarditis

Although acute pericarditis is most often associated with viral infection, it may also be caused by many diseases, drugs, invasive cardiothoracic procedures, and chest trauma. Diagnosing acute pericarditis is often a process of exclusion. A history of abrupt-onset chest pain, the presence of a pericardial friction rub, and changes on electrocardiography suggest acute pericarditis, as do PR-segment depression and upwardly concave ST-segment elevation. Although highly specific for pericarditis, the pericardial friction rub is often absent or transient. Auscultation during end expiration with the patient sitting up and leaning forward increases the likelihood of observing this physical finding. Echocardiography is recommended for most patients to confirm the diagnosis and to exclude tamponade. Outpatient management of select patients with acute pericarditis is an option. Complications may include pericardial effusion with tamponade, recurrence, and chronic constrictive pericarditis. Use of colchicine as an adjunct to conventional nonsteroidal anti-inflammatory drug therapy for acute viral pericarditis may hasten symptom resolution and reduce recurrences.     

Retroperitoneal schwannomas in the anterior pararenal space: dynamic enhanced multi-slice CT and MR findings

Background

To evaluate the imaging features of schwannomas in the anterior pararenal space (APS), especially focusing on dynamic enhanced multi-slice CT (MSCT) and MR findings.

Patients and methods

Eight patients with pathologically proved retroperitoneal schwannomas in the APS underwent dynamic enhanced multi-slice CT (MSCT), while three of these patients also had a contrast-enhanced MR examination. The imaging findings were retrospectively reviewed.

Results

All eight cases exhibited forward displacement of the pancreas, and three cases showed lateral displacement and compression of the inferior vena cava. The tumors had round or oval shape with a maximal axial diameter of 4.0–12.3 cm (average, 6.7 cm). All eight tumors were solitary and well circumscribed. Of the eight retroperitoneal schwannomas in the APS, six exhibited a capsule with thickness of 1.0–2.0 mm, one showed punctate calcification, two displayed cystic degeneration, and three revealed a “target sign” on CT and MR. The tumors were hypo-dense on unenhanced CT images, hyper-intense on T2W images, and homogeneously hypo-intense on T1W images. All eight tumors exhibited gradual enhancement on dynamic enhanced CT or MR images. One case showed delayed enhancement. Heterogeneous enhancement was the dominant pattern occurring in seven out of eight tumors.

Conclusion

The imaging findings of schwannoma in the APS correspond with its pathological composition. Schwannoma should be included in the differential diagnosis of tumors in the APS.     

Multimodality imaging for the diagnosis and treatment of constrictive pericarditis

ABSTRACT

Introduction: Constrictive pericarditis can result in debilitating congestive right heart failure and has been considered an important cause of morbidity and mortality in patients with cardiovascular disease. Multimodality imaging continues to play a fundamental role in the individual approach to diagnosis, management, and prognosis of patients with this clinical syndrome.

Areas covered: This article gives an overview of the clinical spectrum of constrictive pericardial diseases and the role of multimodality imaging in the diagnosis of constrictive pericarditis. There is a focus on the emerging role of cardiac magnetic resonance (CMR) for the diagnosis, management, and prognostication of patients with constrictive pericarditis based on more recent case series, retrospective and prospective studies, which have helped to define the role of CMR.

Expert opinion: Advanced multimodality imaging assists with identification of both overt and subclinical pericardial inflammation. This allows the pericardiologist to recognize patients with potentially reversible disease, trial medical therapy, and thereby avoid mechanical removal of the pericardium. Further, pericardial characterization by CMR has provided novel information about the natural history of these pericardial conditions, which can help tailor therapy and improve prognosis.     

Clinical experience with subxiphoid pericardiostomy in the management of pericardial effusions: a study of 240 cases

We aimed to assess the effectiveness of subxiphoid pericardiostomy for treating patients with pericardial effusions (PE), and its contribution to defining the aetiology of these effusions. We undertook retrospective analysis of 240 PE patients who underwent subxiphoid pericardiostomy and tube drainage between 1990 and 2000. Echocardiography classified PE as severe in 132 patients, moderate in 99, and mild in nine. The main causes of PE were uraemic, idiopathic and undefined, tuberculous and non-tuberculous pericarditis, malignancy and trauma. Peri-operative myocardial injury requiring sternotomy, and recurrent effusion requiring further surgical intervention, occurred in three and 24 patients, respectively. Histopathological examination assisted the diagnosis in 94% of patients with malignancy, and 96% with tuberculous pericarditis. Overall 30-day mortality was 1.3% and pericardial constriction, requiring pericardiectomy, developed in seven cases. In conclusion, we believe that adults and children with PE can be safely, effectively and quickly managed with subxiphoid pericardiostomy, irrespective of its aetiology.     

胰腺浆液性囊腺瘤MSCT表现与病理特征

目的:探讨胰腺浆液性囊腺瘤MSCT表现和病理特征。方法:回顾性分析经手术及病理证实的43例胰腺浆液性囊腺瘤的MSCT表现,观察病灶部位、大小、囊腔类型、中央瘢痕、钙化及强化特点等。结果:43例胰腺浆液性囊腺瘤中,浆液性微囊型囊腺瘤34例,浆液性寡囊型囊腺瘤9例。34例浆液性微囊型囊腺瘤的囊直径平均为(4.2±0.5)cm,其中多囊蜂窝型29例,囊内见多发厚薄不均的蜂窝状分隔,其囊隔厚度为0.03~0.2 cm;多囊海绵型5例,瘤内呈海绵状囊实混杂密度,囊隔显示不清。34例微囊型囊腺瘤内有中央星芒状纤维瘢痕14例,放射状或砂砾状和囊壁上斑点状钙化14例,上游胰管扩张4例。9例浆液性寡囊型囊腺瘤中单囊型4例,呈圆形或卵圆形,囊直径平均为(3.1±3)cm;多囊型5例,边缘呈分叶状,由数个小囊构成,囊壁薄而光滑、均匀,其囊壁厚度<0.1 cm。增强扫描表现:微囊型囊腺瘤中囊内分隔、中央星芒状纤维瘢痕及实性成分多呈轻中度强化,囊内分隔及实性成分越多,强化越明显,中央纤维瘢痕多呈延迟强化;寡囊型囊腺瘤囊内无强化,仅囊壁、囊隔呈轻度强化。结论:胰腺浆液性囊腺瘤CT表现具有一定特征性。微囊型囊腺瘤CT平扫呈蜂窝状或海绵状,瘤中央见星芒状纤维瘢痕及放射状钙化,增强扫描见囊壁、分隔及实性部分呈轻中度或显著强化,中央纤维瘢痕呈延迟强化;寡囊型囊腺瘤由单个或数个大囊组成,无中央纤维瘢痕及钙化,增强扫描见囊壁、囊隔呈轻度强化。