Correct!
3. Cardiac MRI
Transesophageal echocardiography could certainly provide excellent assessment of the heart and pericardium, but is invasive and not required in this patient. Cardiac MRI can provide excellent anatomic delineation of the cardiac structures, including assessment of valvular function, right and left ventricular ejection fractions, myocardial tissue characterization, and evaluation of the pericardium. Cardiac MRI can provide this information non-invasively, and therefore transesophageal echocardiography would not be required unless cardiac MRI could not be obtained or was technically not feasible. Catheter pulmonary angiography could provide evaluation of right heart function, which may play a role in this patient given the enlargement of the right heart seen on CT. Furthermore, right heart catheterization certainly plays a role in the evaluation of the functional consequences of pericardial disease, but obtaining catheter pulmonary angiography at this point is premature. As notes previously, both 18FDG-PET and 68Ga-citrate scintigraphy would not prove useful for the assessment of this patient.
Cardiac MRI (Figure 3) was performed; representative images are shown below.
Figure 3. Axial double inversion recovery “black blood” images (A and B), short axis (C) and 4 chamber (D) segmented T1-weighted inversion recovery delayed enhancement images, and free breathing MR echo (E) images show pericardial thickening before intravenous contrast administration (arrowheads, A and B) with extensive pericardial thickening on delayed contrast enhanced imaging (arrows in C and D). Small bilateral pleural effusions (*) are present. The free-breathing MR echo images show leftward motion of the interventricular septum (double arrowhead, E), representing the “septal bounce” characteristic of right ventricular pressures transiently exceeding left ventricular pressures in the setting of pericardial constriction.
The patient was treated for constrictive pericarditis with ibuprofen, prednisone, and colchicine. A repeat cardiac MRI (Figure 4) showed resolution of the pericardial thickening and enhancement, with normalization of interventricular septal motion.
Figure 4: Axial double inversion recovery “black blood” images (A and B), short axis (C) and 4 chamber (D) segmented T1-weighted inversion recovery delayed enhancement images, and free breathing MR echo (E) images show resolution of the previously thickened pericardium (arrowheads in A and B show the normal pericardium now appearing as a thin, black line). The previously seen extensive pericardial enhancement has resolved (the arrows in C and D show the thin black line representing the pericardium, outlined on either side by bright, hyperintense fat. The functional MR echo images show normalization of the interventricular septal position, now bowing rightward (double arrowheads, E). Note resolution of the previously seen bilateral pleural effusions.
The patients symptoms resolved and his inflammatory biomarkers returned to normal levels as well. Repeat chest radiography (Figure 5) showed normalization of heart size and resolution of pleural effusions.
Figure 5: Frontal chest radiograph performed following treatment for constrictive pericarditis shows normalization of heart size and resolution of bilateral pleural effusions.
Diagnosis: Constrictive pericarditis
References