Pericardial Disease Dynamic Imaging · 2020. 2. 12. · Pericardial Disease –Dynamic Imaging....
Transcript of Pericardial Disease Dynamic Imaging · 2020. 2. 12. · Pericardial Disease –Dynamic Imaging....
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Pericardial Disease Dynamic Imaging
Apichaya Sripariwuth, MD
Department of Radiology, Faculty of Medicine
Naresaun University Hospital
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Outline
▪ Pericardial Anatomy and Basic Physiology
▪ MRI Protocol for Pericardial Disease and Normal Imaging
▪ Pericardial Disease – Dynamic Imaging
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Pericardial AnatomyThin, avascular, relatively inelastic, flask-shape sac enveloping the heart
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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
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Pericardial Anatomy
▪ Pericardial Cavity/ Sac
▪ Space between parietal and visceral layer
▪ Normally contains a small amount of fluid
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Pericardial Function
▪ Fixed heart position within mediastinum
▪ Barrier to infection
▪ Decreased friction of cardiac movement
▪ Makes the hearts as semirigid structure
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Basic Principles of Cardiac Function
Clinical Cardiac MRI 2nd edition
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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
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MRI Protocol for Pericardial Disease
Clinical Cardiac MRI 2nd edition
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Basic MRI Protocol and Normal Imaging
▪ Black-blood image
▪ Cine SSFP
▪ Real-time cine image
▪ Myocardial tagging image
▪ Delayed enhancement image
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Black-Blood Image
▪ ECG-gated image
▪ T1-weighted, Double inversion
▪ Normal pericardium:
▪ Hypo-intensity
▪ 1-2 mm in thickness
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Cine SSFP
▪ T1/T2-weighted
▪ Global & Regional Cardiac Function
▪ Pericardial mobility
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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
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Myocardial tagging image
• Using a grid• For pericardial adhesion
and myocardial involvement
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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
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Pericardial Disease – Dynamic Imaging
▪ Pericardial Effusion
▪ Cardiac Tamponade
▪ Constrictive Pericarditis
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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
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Pericardial Effusion
▪ The Development of Tamponade depends on
▪ Volume
▪ Rate of Accumulation
▪ Pericardial Stiffness
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Cardiac Tamponade
▪ Defined as hemodynamically significant cardiac compression from accumulating pericardial contents (fluid, pus, hemorrhage, tumor)
▪ ↑Intrapericardial pressure → ↓diastolic compliance → ↓ cardiac filling → ↓cardiac output
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Cardiac Tamponade
▪ Clinical diagnosis
▪ Imaging findings are reflecting to
▪ ↑Intrapericardial pressure
▪ ↓ Diastolic compliance
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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
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Cardiac Tamponade?
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Constrictive Pericarditis
▪ Rigid fixed pericardial volume
▪ Ventricular filling is limited by pericardial volume
▪ Diastolic Dysfunction (DDx from Restrictive cardiomyopathy)
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Constrictive Pericarditis
▪ Findings:
▪ Dissociation of intrathoracic and intracardiac diastolic pressure
▪ Increased ventricular coupling
▪ Increased cardiac filling pressure with pressure equalization in all cardiac chamber
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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)
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Constrictive Pericarditis
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Constrictive Pericarditis
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Constrictive Pericarditis
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Circulation 2018
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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
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