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Pericardial imaging

Magnetic resonance (MR) imaging of the pericardium offers a useful, noninvasive method of evaluating various disorders affecting the pericardium, including characterization of pericardial effusions (loculated vs. hemorrhagic), distinguishing constrictive pericarditis (CP) from restrictive cardiomyopathy (RCM), and delineation of pericardial masses.

Short-axis view demonstrating pericardial effusion 4-chamber view showing pericardial effusion

Although echocardiography remains the initial exam for the evaluation of the pericardium, MR imaging provides several distinct advantages, including a larger field of view to evaluate not only the pericardium but also surrounding mediastinal and pleural structures, excellent anatomical detail, and definitive characterization of pericardial effusions and masses.

Key Points

  • The thickness of the normal pericardium is less than two millimeters, and may or may not be seen on routine Cardiac MR studies. Yet when the pericardium becomes abnormally thickened, it may reach a thickness of four mm or more, and becomes clearly visible on MR studies evaluating for pericardial disease.
  • MR imaging of the pericardium is indicated when loculated or hemorrhagic effusion is suspected or when echocardiograms are non-diagnositic for pericardial disease.
  • Distinguishing constrictive pericarditis from restrictive cardiomyopathy is an important clinical problem which can be resolved with MR imaging. Both diseases present clinically with symptoms of heart failure, such as dyspnea on exertion and fatigue. The pathophysiology of constrictive pericarditis, which includes impaired diastolic right ventricular filling and decreased left ventricular end diastolic volume and end systolic volume, results in changes which can be evaluated on MR images. These include anatomic remodeling of the heart as indicated by sphericity index (LV length/LV width) and septal flattening or inversion.
  • Secondary signs of constrictive pericarditis can also be demonstrated on MR images, including dilatation of the inferior vena cava (IVC), hepatomegaly, and ascites.
  • MR imaging can readily distinguish between various types of pericardial masses, including pericardial cysts, hematomas, and neoplasms. In addition to the administration of intravenous (IV) gadolinium to evaluate for enhancement, additional sequences such as magnitude and phase velocity-encoded cine images can be used to further characterize lesions.

Case in Point

Four-chamber view demonstrating findings consistent with constrictive pericarditis

65 year old female presenting with chest pain and dyspnea. Cine MR imaging demonstrates impaired filling and contraction of the right ventricle. These findings, when combined with the patient’s presenting symptoms, support a diagnosis of constrictive pericarditis.

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