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Rev Sci Instrum, Messroghli, D. N Engl J Med, Baksi, A. Top Magn Reson and severity of myocardial injury after acute reperfused Imaging, Pennell, D. Bello, D. Orn, S. J Thorac Imaging, Pericardial sac contributes to minimize Pericardial pathology has attained raising interest due ventricular dilatation, to physically protect the heart, to both increasing comprehension of its complex patho- through production of fluid and surfactants and limits physiology and the development and widespread dif- its displacement in the mediastinum [1,3].

Subserosal fat is localized in normal better depiction and characterization of the underlying weight people, especially over the interventricular process. The outer layer fibrous pericardium is clasped inter- 3. The serosa is a complete sac distended by a variable When surgically incised, fibrous retraction of peri- amount of 15—50 mL of plasmatic ultrafiltrate, and it is cardium reflects the mechanical stress that is predomi- separated from the heart by loose epicardial connective nantly applied on thinner wall structures such as the tissue and a single line of mesothelial cells.

The adipose right ventricle and atrium, opposing to the pathologi- cal overdistension of those chambers as in presence of chronic large effusions and directly influencing endo- cavitary diastolic pressure. The relative pericardial inelasticity is also necessary to maintain ventricular coupling or interdependence in order to equalize the filling and relaxation between two ventricles, as confirmed in pathological conditions such as CP or cardiac tamponade see Sections 3.

Another property of the pericardium that deserves to be mentioned because of its potential implications in constrictive physiology attains its adaptation to pleu- ral and intrathoracic pressures [2,8,17], in which the membrane acts as a sort of transducer between pleu- ral spaces and cardiac chambers, directly transmitting intrathoracic respiratory changes to the heart.

This phe- nomenon can be physiologically observed during inspi- ration in which respiratory fall of pleural pressures is transmitted to cardiac chambers as a consequence of the pleura—pericardial interactions causing an increment FIGURE 3. These reflections delimit two pocket-like structures described as oblique and CT and MR imaging allows excellent anatomical delin- transverse sinuses, which include several recesses, and eation of the pericardial sac in most of the cases, which contribute to create the so-called pericardial reserve appears on both techniques as a thin linear band parallel volume in which fluid can strategically accumulate in to the myocardium, surrounded by a variable amount of presence of increased fluid content [11,18] epicardial fat tissue Figure 3.

Pericardial line is better depicted at the level of the Transverse sinus is interposed between the great arter- right ventricular free wall due to the greater amount of ies, atria, and vena cava, and it is characterized by fat surrounding the heart, usually not or poorly vis- a linear-shaped virtual cavity, which sometimes ible in the lateral and posterior walls of the left ventricle can be misinterpreted to simulate an aortic focal [2,12,19].

Mechanical: It ensures the maintenance of normal CT images of the pericardial membrane show a single- ventricular compliance to minimize ventricular layered hyper dense structure, which is easily detectable dilatation; the production of pericardial fluid using or not using contrast media because of its natural protects the heart from stretching, underlying contrast against the low attenuation of the surround- some physical stress.

Pericardium has a crucial ing fat; the membrane slightly linearly enhances after role in the physiological interaction between iodine administration and is likely due to the presence the right and the left ventricles, defined as of small capillary vessels within the fibrous component ventricular coupling, which in normal loading of the parietal layer [22,26]. Some pericardial diseases may affect or triggering is beneficial to minimize heart-related the interventricular interaction, such as in a motion artifacts and to improve depiction of sinuses condition where the pericardial compliance or and recesses at the level of the upper mediastinum, par- pressure is altered; the RV diastolic pressure is ticularly to avoid a misdiagnosis of lymphadenopathy higher than the LV pressure, with subsequent or other mediastinal or hilar disease [18,27].

The pericardium also regulates the ation of septal motion has also been proposed in the pressure relationships between the heart and clinical setting of constrictive pericarditis [22,28,29] to the pleura, so that in normal condition, the evaluate the impact of pericardial pathology on inter- respiratory changes are transmitted to the ventricular septal motion and configuration at the price heart with an increase of RV filling during of a non-negligible radiation dose; however, the use of inspiration.

This important physiological fea- MRI or echocardiogram is preferable for this purpose. Contrast-enhanced CT images of the heart obtained from a dual-source multidetector scanner with 1. Pericardium is typically best visible along the free wall of right ventricle as a thin line surrounded by fat arrows. On horizontal long-axis balanced steady-state free-precession SSFP cine MR image c pericardium can be easily depicted when a little amount of pericardial effusion is present because of the chemical shift artifact, which produce black lines at fat—water interfaces also known as black boundary artifact.

On black-blood T1-weighted fast spin-echo MR images in short axis d , the peri- cardium appears as a thin curvilinear hypointense structure arrows , because of the presence of a small amount of pericardial fluid interposed between two layers, best appreciable when surrounded by fat tissue. A further MR functional technique that can be 3. This nal veins supplying the pleuro-pericardial folds during technique enables to assess the effects of respiratory embryogenesis, resulting in developmental arrest of the activity on interventricular septal motion as explained membrane.

The extent of the defect, likely determined above [8,17]. Most pericardial defects may highlight inflamed-enhancing pericardial layers in are asymptomatic and are an unexpected finding at sur- the clinical setting of inflammatory pericardial disease, gery or postmortem [39], although a partial defect may offering indirect information about disease activity and have an acute presentation with chest pain, dyspnea, allowing discrimination of the different components of dysrhythmias, syncope, and even sudden death when pericardial and myocardial inflammation e.

Paramagnetic contrast agent is also recommended Partial defects are predominantly on the left side when pericardial masses are suspected and in case of of the heart, but they can be located anywhere in the underlying myocardial involvement e. Pericardial abnormalities may be associ- pericardio-myocarditis.

They usually present on both CT and MR imaging 3. The cyst has low density attenuation: 7 HU and no wall thickening on CT scan a. SSFP cine MR image b is helpful to confirm thin and regular margins and to exclude the presence of clot or any corpuscolar content. Low signal intensity in spin echo T1-weighted sequence c and high signal intensity in coronal STIR T2-weighted sequence d suggest liquid content.

Transthoracic echocardiography is the preferred CT and MR imaging techniques are usually required imaging modality to detect pericardial effusion and also to rule out underlying secondary causes of effu- to address a correct diagnosis in most of the cases, by sion from pericarditis to neoplastic lesions, or when a being a rapid, widely available, and a relatively inex- complex inhomogeneously echoic exudate is observed pensive diagnostic tool.

However, echocardiography is at echocardiography [5]. Signal intensity is compatible with inhomogeneous corpuscolated content. The slow and gradual accumulation of a large amount of pericardial effusion stretches the pericardial sac and increases compliance without increasing the pericardial pressure. Axial unenhanced CT image a shows a huge pericardial effusion approximately — mL in a patient with bone marrow aplasia, with low-intermediate attenuation content 15—25 Hounsfield Units.

Please note how ECG-gated short-tau inversion recovery STIR T2-weighted sequence d is not very useful to characterize pericardial fluid content, because it is prone to flow artifact due to cardiac beat, especially for great amount of effusion.

Bilateral small pleural effusion can be also detected. Bright-blood dynamic cine hemodynamic potentially life-threatening condition in MR imaging often enables the recognition of intraperi- which a rapid diagnosis must be established followed cardial contents, such as the visualization of fibrinous by urgent therapy [71]. Cardiac tamponade can be triggered by multiple 3.

Coronal a and axial b contrast-enhanced CT images show intimal flap in the ascending aorta extending into the aortic arch arrows , corresponding to Stanford type A aortic dissection, and large high-attenuation peri- cardial effusion asterisks corresponding to abundant hemopericardium.

The patient died immediately after CT angiography. Courtesy of G. Gualdi, MD, and C. Pericardial hematoma is located on cardiac basis and compress superior svc and inferior ivc vena cava, right atrium arrow , and left atrium la ; this condition determines a significant obstacle to systemic venous return and distolic filling of the right ventricle rv , which is of reduced dimensions.

CE-IR T1-weighted short-axis image d shows hypointense fluid content bordered by thick and enhancing pericardial layers arrows. Great emphasis has been recently given to the grow- ing number of cases of tuberculous-related pericardi- 3. STIR T2-weighted a and black-blood TSE T1-weighted b images acquired on short axis view show an abundant amount of pericardial effusion with inhomogeneous signal with mixed fluid-solid composition, hyperintense both on T1- and T2-weighted sequence as caseous content.

Corresponding short-axis LGE image c reveals thickening of pericardial layers, particularly of visceral layer, and irregular streaks of enhancement for bridges, adhesions, and fibrinous strands internal to organized effusion. Early postinfarction pericarditis in a year-old patient with a recent large anteroapical myocardial infarction. Thickening of pericardial layers of the entire sac with edematous signal is shown in STIR T2-weighted images a, c , which corresponds intense late enhancement b, d , reflecting active pericardial inflammation arrows.

Chronic fibrosing pericarditis is characterized on Depending on the pathological substrate, imaging find- both CT and MR imaging by the presence of a non- ings may vary from the presence of a simple pericardial enhancing focally or diffusely thickened pericardium effusion to more exudative or purulent forms with abun- very often showing loculated effusions caused by the dant highly proteinaceous effusion potentially causing presence of focal adhesions [32,61].

As previously mentioned, a limitation of CT imaging 3. Echocardiography remains the modality of choice for Pericardial inflammation is often accompanied by a diagnosis, and generally it is sufficient to support the variable degree of myocarditis and vice versa , which clinical management of the patient; however, in some occurs as a consequence of direct epicardial propaga- cases, the use of cross-sectional methods may provide tion or vice versa of the inflammatory process and additional information for pathology characterization because of their common etiologic agents, mainly car- or guide diagnostic or therapeutic procedures pericar- diotropic viruses.

In particular, myopericarditis refers primarily to a variable amount of effusion and irregular thickening of pericarditis with lesser myocarditis, as opposed to a the membrane that depicted with T1-weighted TSE and perimyocarditis, which indicates a predominantly myo- cine-SSFP sequences Figure 3. Active inflammation is also characterized by a certain Recognition of overlapping myocarditis may be clini- degree of pericardial contrast enhancement, such as cally relevant representing a negative prognostic pre- that described in various reports in patients with pure dictor in patients with pericarditis, often requiring acute inflammatory forms and with clinically recur- hospitalization and a full etiologic search [12,53,64,65].

STIR spin-echo T2-weighted a and unenhanced black-blood TSE T1 weighted b images on short axis view well demonstrate a diffuse pericardial thickening in viral pericarditis. The contrast-enhancement ECG-gated fat-suppressed TSE T1-weighted image c on the corresponding short-axis view excellently highlights the strong homogeneous enhancement of the entire pericardium fol- lowing gadolinium administration reflecting the inflammation activity, even if compared to similar image obtained with the traditional late gadolinium-enhancement technique d , which poorly distinguish between pericardial enhancement and epicardial fat tissue.

QT prolongation associated with transient regional and meso-epicardial late enhancement with associated focal global wall motion abnormalities, and raise of cardiac edema on T2-weighted STIR and a variable degree of enzymes.

Diagnostic contribution of echocardiography in this clinical setting is limited by the fact that many 3. It usually shows an associa- material [1,54,61]. Clinical symptoms usually are due to the consequent impaired ventricular filling, severe diastolic dysfunc- tion, and the right heart failure, and start with signs of splanchnic and peripheral engorgement e.

CP is usually a chronic process that slowly progresses over time and becomes clinically manifest several years after the initial pathologic trigger; however, subacute i. CE-IR T1-weighted image on short-axis view shows a diffuse thickening and gadolinium enhancement of drainage removal [16,61].

Presence of contrast fibrous pericardial tissue with few inflammatory cells, enhancement is a feature of active inflammation. The spectrum of possible etiologies causing pericar- Despite the progress in understanding the complex dial constriction has progressively changed over time hemodynamics of pericardial constriction and the moving from pure infectious particularly tubercular advancement of noninvasive diagnostic tools, diagno- to postradiation and postsurgical forms, which have sis of CP remains challenging, particularly in the differ- become the most frequent causes of disease [71,72].

Short-axis STIR T2-weighted image a shows subepicardial patchy focal areas of myocardial edema on the LV lateral wall matching a thick subepicardial band- like area of myocardial enhancement on LGE T1-weighted image b. A LV myocardial biopsy con- firmed the myocardial inflammation. Short-axis a and axial b unenhanced CT image shows thickened and heavily calcified pericardium.

Three- dimensional volume rendered image c of unenhanced CT scan is useful to best depict global extent of pericardial calcifications. The absence of membrane thickening even focal , Clinical recognition of the CP should also be done as however, does not rule out the presence of constriction; early as possible because of the beneficial clinical and previous studies have shown that a normally thickened prognostic effects of pericardiectomy, which becomes but stiff pericardium may also be responsible of a severe less effective in the presence of extensive calcifications diastolic impairment impeding physiological ventricu- and significant myocardial involvement [71,74,76].

Since no single imaging modality could be considered Therefore, function assessment with cardiac MR is comprehensive or completely exhaustive to recognize all highly recommended in cases where symptoms of con- cases of CP, diagnostic strategy should be necessarily striction are not coupled with evidence of pericardial tailored according to each patient [16,77,78].

Moreover, some authors showed that evolution toward an end-stage irreversible fibrosing pericarditis is characterized by a thinning of the chroni- 3. Focal or diffuse pericardial thickening i. Short-axis ECG-gated a STIR T2-weighted and b TSE T1-weighted images show irregularly diffuse thick- ened hypointense appearance of the pericardium, predominantly involving the basal part of ventricles arrows , with subsequent flattening of septum.

On LGE short-axis c and horizontal long-axis d images, the enhancement of the thickened non-calcified pericardial layers is hardly distinguishable from the epicardial and adjacent paracardiac adipose tissue. Sagittal e and axial f CT images are given and the calcifications are visible. Inter-ventricular septum may exhibit a sinuous or The effects of increased filling pressures are partic- flattened morphology or may appear leftward bowed as ularly evident at the level of interventricular septum, a consequence of increased trans-septal pressures.

This phenom- systems, unilateral or bilateral atrial enlargement enon, also called paradoxical septal motion, represents a particularly the left , and ventricular tubular mor- typical feature of CP, which enables its differentiation phology caused by direct compression from the from RC [8,9]. A further relevant sign of CP is the dissociation Bilateral pleural effusion and ascites may also be between intracardiac and intrathoracic pressures dur- observed.

Typical morphological features of CP may ing respiration, which was initially described by Hatle also lack in various conditions, making diagnosis more and colleagues [85], and it causes pressure isolation challenging with need to combined clinical data with of cardiac cavities during normal respiratory changes.

During deep inspiration, if the heart is totally encased, Pericardial constriction may be determined by a focal, intrathoracic respiratory fall is not transmitted to the strategically located, thickening of the serosa, like in prox- high-pressure cardiac cavities, causing a decreased pul- imity to the right AV groove, causing severe hemody- monary venous return and a consequent decreased left namic impairment.

Panoramic assessment of pericardial ventricular filling; conversely, systolic function is gener- line with cross-sectional imaging modalities is extremely ally well preserved. Cardiac CT has very limited role in the assessment of The evidence of persistent chronic inflammation is CP-related functional changes, although dynamic eval- associated with reversible or transient forms of CP that uation of interventricular septal motion is theoretically respond to anti-inflammatory treatment.

In this clinical possible using a retrospective-ECG triggered technique setting, contrast-enhanced MR imaging can be helpful with a high temporal resolution scanner [28]. In phy of a superior contrast resolution [9]. This phenomenon was more pro- ventricular inflow [17,25].

In normal loading conditions, interventricular sep- CT and MR imaging techniques are usually required tum has a convex profile toward the right ventricle as to characterize a mass detected in a preliminary echo- a consequence of the left to right cavities positive pres- cardiographic exam or as incidental finding on a chest- sure gradient, and this configuration in normal subjects ray or CT examination.

Cross-sectional imaging allows is minimally affected by respiratory activity as a con- 1 to distinguish between a true pericardial mass from a sequence of pleuro—pericardial interactions with pres- so-called pseudo-mass, 2 to accurately define the loca- sures equalization.

Abundant epi- Impact of respiratory activity on ventricular septal cardial fat may be misinterpreted for a pericardial mass motion and configuration was previously described by at transthoracic echocardiography, even by experienced Francone using a real-time breath-hold technique in a operators and easily recognized on MR, using fat-satu- study population of patients with CP, RC, and inflamma- rated sequences, or CT imaging.

Results of the study showed typical Pseudoaneurysm occurs when a haemopericardium septal flattening or inversion in CP patients occurring in caused by myocardial wall rupture is contained by early diastole, which was more pronounced at the onset thickened pericardium [88].

CP and RC patients, especially in the presence of a It may be helpful to remember that pericardial masses normal or minimally thickened pericardium. Short-axis real-time SSFP cine MR images obtained a at the end-expiration and b during inspiration show inversion of septal shape arrow due to a rapid increase of right ventricular filling not compensated by pericardial distensibility.

Axial contrast-enhanced computed tomography a and black-blood TSE T1-weighted b images show a diffuse contrast enhancement of pericardial layers with some soft tissue attenuation nodular thickening and coexistence of moderate pericardial effusion with mixed corpuscular-fluid content. Pericardial fluid cytological analysis performed after pericardiocentesis diagnosed a primary malignant pericardial mesothelioma.

Benign tumors of the pericardium such as fibroma, from nearby anatomical structures such as the lung, teratoma, haemangioma, and lipoma are overall mediastinum lymphoma , or the myocardium angio- extremely rare. Unenhanced black-blood TSE T1-weighted images acquired on long axis a and short-axis b views dem- onstrate a severe diffuse thickening of pericardium with poorly demarcated soft tissue, invading the epicardial adipose space and completely surrounding cardiac cavities. ECG-gated contrast-enhanced CT images recon- structed on short-axis a and axial b views show a large infiltrating solid tissue arrowheads surrounding the posterior descending artery arrow with diffuse invasion of the pericardial sac and right ventricular cavity.

The pathological tissue spreads along the pericardium cov- ering the left ventricular inferolateral wall, infiltrating and causing stenosis of coronary sinus curved arrow. A moderate size pericardial effusion and presence of electrode in right ventricle are also seen.

Direct invasion of the visceral layer can be observed, 7. Clinical indi- for example, in the presence of primary angiosarcomas, cations for cardiovascular magnetic resonance CMR : which generally arise from the right atrium, and rapidly Consensus Panel report. European Heart Journal ; grow toward the causing infiltration and extensive exu- — Parietal pericardial layer is often infil- FE, Bogaert J. Assessment of ventricular coupling with trated by an aggressive primary lung perihilar neoplasia.

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