Advances in multi-modality imaging for constrictive pericarditis and pericardial inflammation: role of imaging-guided therapy

ABSTRACT

Introduction

Constrictive pericarditis (CP) can result from uncontrolled inflammation of the pericardium. This can be due to various etiologies. CP can lead to both left- and right-sided heart failure with associated poor quality of life, so early recognition is key. The evolving role of multimodality cardiac imaging allows for earlier diagnosis and facilitates management to help mitigate this adverse outcome.

Areas covered

This review discusses the pathophysiology of constrictive pericarditis, chronic inflammation and autoimmune etiologies, clinical presentation of CP, and advances in multimodality cardiac imaging for diagnosis and management. Echocardiography and cardiac magnetic resonance (CMR) imaging remain cornerstone modalities to evaluate this condition, whereas additional imaging modalities such as computed tomography and FDG-positron emission tomography can provide complementary information.

Expert opinion

Advances in multimodality imaging allow for a more precision diagnosis of constrictive pericarditis. There has been a paradigm shift in pericardial disease management with advances in multimodality imaging, especially CMR, to detect subacute and chronic inflammation. This has enabled imaging-guided therapy (IGT) to both help prevent and potentially reverse established constrictive pericarditis.

KEYWORDS:

• Echocardiography
• cardiac computed tomography
• cardiac magnetic resonance
• constrictive pericarditis
• delayed hyperenhancement
• Imaging-Guided therapy
• late gadolinium enhancement
• pericardium

Article highlights

• Advanced cardiac imaging modalities provide complementary information in the evaluation of pericardial disease and constrictive pericarditis. Imaging Guided Therapy (IGT) plays a major role in the diagnosis and treatment of pericardial diseases.

• Echocardiography remains the initial screen for constrictive pericarditis with three important features being respiration-related ventricular septal shift, medial e’ velocity ≥9 cm/s, and hepatic vein expiratory diastolic reversal. Global longitudinal strain imaging may provide additional insight with reduced strain in the lateral wall.

• Cardiac magnetic resonance (CMR) imaging provides valuable pericardial tissue characterization and assessment of inflammation including subacute and chronic inflammation. Cardiac magnetic strain imaging can help distinguish constrictive pericarditis from restrictive cardiomyopathy.

• Persistent delayed hyperenhancement (late gadolinium enhancement) in the pericardium on CMR imaging suggests persistent inflammation. Escalation of anti-inflammatory therapies in this setting can potentially reverse constrictive pericarditis.

• Cardiac computed tomography (CT) provides valuable assessment of pericardial calcification burden and distribution, and for pre-operative evaluation for pericardiectomy.

• Autoimmune etiologies are under-recognized causes of constrictive pericarditis. Additional information provided by CMR and FDG-PET imaging can help suggest autoimmune etiologies and extra-cardiac inflammation.

Declaration of interest

AL Klein has received research funding from Kiniksa Pharmaceuticals, Ltd; and have served on scientific advisory boards for Kiniksa Pharmaceuticals, Ltd., Cardiol Therapeutics, and Pfizer, Inc. TKM Wang is supported by the National Heart Foundation of New Zealand Overseas Clinical and Research Fellowship (grant no. 1775).

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Additional information

Funding

This paper was not funded.