Clinical Recommendations for Multimodality Cardiovascular Imaging of Patients with Pericardial Disease

Introduction

Pericardial diseases are commonly encountered in clinical practice and may involve cardiologists as well as different sub-specialty settings such as rheumatology, infectious diseases, oncology, internal medicine, cardiac and thoracic surgery. Pericardial diseases can be grouped into a constellation of clinical syndromes, including acute pericarditis, recurrent pericarditis, pericardial effusion or tamponade, constrictive pericarditis, pericardial masses, and congenital anomalies of the pericardium. The evaluation of these pericardial conditions can be difficult to detect clinically; therefore, there is an increasing role for the use of different imaging techniques including echocardiography, CMR, and CT, in the diagnosis and management of these conditions. The modern approach includes a multimodality imaging evaluation.

Current available guidelines on pericardial diseases have been issued in 2004 by the European Society of Cardiology (ESC) and did not address the specific issue of multimodality imaging for pericardial diseases (1) and moreover they are going to be updated in 2015. At present no other specific guidelines or recommendation is available beyond some reviews (2-4).

In late 2013 the American Society of Echocardiography (ASE), the Society for Cardiovascular Magnetic Resonance Imaging, and the Society of Cardiovascular Computed Tomography have published an expert consensus document (5) that was reviewed by the ASE Guidelines and Standards Committee and official reviewers nominated by the Society for Cardiovascular Magnetic Resonance Imaging and the Society of Cardiovascular Computed Tomography. The aim of the paper was to provide a consensus expert opinion on the appropriate use of multimodality imaging in the diagnosis and management of pericardial diseases.

Methods

The objective of this document was to provide a consensus expert opinion on the appropriate use of multimodality imaging in the diagnosis and management of pericardial diseases. Since, there have been only a small number of randomized clinical trials on pericardial diseases (6-9); the authors used consensus of expert opinions in this report and did not attempt to use the standard level-of-evidence grading system (Levels A–C). The document is focused on multimodality imaging of pericardial diseases, including echocardiography, computed tomography (CT), and cardiovascular magnetic reso- nance (CMR), and is not comprehensive with regard to clinical presentation and treatment, which have been discussed in recent reviews (10-13).

Document highlights

The document is divided according to specific sections dedicated to main pericardial syndromes with discussion of the main findings, relative strengths and flaws of different imaging techniques and final recommendations. The main key points are reported in the following list.

A. Acute Pericarditis Key Point

1. All patients with acute pericarditis should undergo transthoracic echocardiography (TTE) to assess for pericardial effusion, tamponade physiology, and myocardial involvement.

2. In addition to echocardiography, computed tomography (CT) and cardiac magnetic resonance (CMR) should be considered when there are complexities associated with the clinical presentation of acute pericarditis, including

i. inconclusive echocardiographic findings and ongoing clinical concern;

ii. failure to respond promptly to anti-inflammatory therapy;

iii. atypical clinical presentation;

iv. suspicion of CP on the basis of clinical examination;

v. associated trauma (penetrating injury, chest injury)

vi. in setting of acute myocardial infarction, neoplasm, lung or chest infection, pancreatitis.

B. Recurrent Pericarditis Key Points

1. Key points are similar to those for acute pericarditis (see above).

C. Pericardial Effusion and Tamponade Key Points

1. All patients with pericardial effusion or tamponade should undergo TTE to assess for the extent of effusion and hemodynamic compromise.

2. CT and/or CMR should be done for those patients with complex pericardial effusions with subacute tamponade with the need for drainage.

3. CT and/or CMR should be done for those with suspected hemopericardium or pericardial clot and to assess the source of the effusion as in malignancy or inflammation.

4. TEE, CT, or CMR can be used to assess regional tamponade, which occurs in the postoperative or postprocedural setting.

D. Constrictive Pericarditis Key Points

1. All patients with clinically suspected constriction should undergo TTE with Doppler echocardiography as the initial imaging test, which can provide a definite diagnosis in most patients.

2. CMR and/or CT should be used as a complementary technique to confirm constrictive pericarditis and in selected patients with poor echocardiographic windows or unclear findings. CT and/or CMR can additionally provide more accurate pericardial thickness measurements as well as tissue characterization, including T2 STIR (edema) and LGE (inflammation).

3. CT can be used in the preoperative planning of patients with known constriction to assess for the degree of calcification and proximity to critical vascular structures in patients who previously had cardiac surgery.

E. Effusive Constriction Key Points

1. Key points are similar to those for Constrictive Pericarditis (see above).

F. Pericardial Masses, Cysts and Diverticulum Key Points

1. Echocardiography is the initial imaging test to assess pericardial masses, cysts, and diverticulum.

2. CT and/or CMR should be done for better tissue characterization of the mass and detection of metastasis (if malignancy suspected).

3. CT and/or CMR should be done to evaluate for a pericardial diverticulum and cyst.

G. Congenital Absence of the Pericardium Key Points

1. Echocardiography is the initial imaging test to identify functional aspects (e.g., bulging of cardiac chambers and excessive motion) for those patients with suspected absence of pericardium and symptoms.

2. CT and CMR can be used for morphologic identification of a pericardial defect. 

Conclusion:

Conclusions

In the modern era, multimodality imaging is essential in the diagnosis and management of pericardial syndromes. Echocardiography is the initial test for most pericardial syndromes, including acute pericarditis, recurrent pericarditis, and constrictive pericarditis. CMR and CT can usually be added in complex cases or in case of technically limited windows or when tissue characterization is needed. In the future, clinical trials are warranted to further assess the role of multimodality imaging in the diagnosis and management of pericardial diseases. An ongoing document of the European Association of Cardiovascular Imaging (EACVI) with the contribution of the WG on Myocardial and Pericardial Diseases is expected in 2014 to provide the European perspective on the issue.