תשובה ל – Case 6

מרצה: Dr. Orly goitein
Department of Radiology University of Pittsburgh Medical Center

 

Constrictive Pericarditis is present when a fibrotic, thickened, and adherent pericardium restricts diastolic filling of the heart. It usually begins with an initial episode of acute pericarditis, progressing to a subacute and chronic stage consisting of fibrous scarring and thickening of the pericardium with obliteration of the pericardial space, producing uniform restriction of the filling of all heart chambers. In this stage, calcium deposition may contribute to stiffening of the pericardium.

Etiology includes idiopathic cases (more then half), TB (15%), radiation, post surgical, renal failure with dialysis, connective tissue d, neoplastic ,fungal parsitic, post MI (Dressler) etc…

Diagnostic approach: Pericardial calcification can be seen but a calcified pericardium is not necessarily constricted. Ct is the modality to demonstrate ca++.CT can demonstrate a thickened pericardium, a large RA and RV and reflux of contrast into the hepatic veins.

MRI can demonstrate the diastolic dysfunction with the “classic“ flattening or sigmoid motion of the interventricular septum (specificity 100% sensitivity 81%), occurring due to the elevation and equalization of pressures in the cardiac chambers, seen also in cardiac catheterization.

Figure:
Fig 1: Un enhanced CT: small pericardial effusion, no calcifications

Fig 2: Contrast enhanced CT one month later: pericardial effusion is slightly bigger; there is compression of the RV worrisome for constrictive pericarditis.

Fig 3: Cine short axis Steady state free precession (SSFP), pericardial effusion is seen, the classic “sigmoid” motion of the interventricular septum, with the septum instead of being slightly buldged towards the RV is bouncing into the LV.

Fig 4: Cine 4 Chamber SSFP, pericardial effusion is seen, the classic “sigmoid” motion of the interventricular septum, with the septum instead of being slightly buldged towards the RV is bouncing into the LV.

From: Giorgi BG, Mollet N. R. A, Dymarkowski S, Rademakers F.E, Bogaert J. Clinically suspected constrictive pericarditis: MR imaging assessment of ventricular septal motion and configuration in patients and healthy subjects. Radiology. 2003 Aug;228(2):417-24. Epub 2003 Jun 11.


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