Pericardial Diseases

Pericardial disorders are often seen in clinical practice. Due to potential problems in differential diagnosis and the absence of particular signs in first-line imaging modalities, their diagnosis and treatment are neither prompt nor straightforward. Pericardial diseases include inflammation (pericarditis), constriction, effusion, tamponade, while pericardial cysts, masses, and pericardial agenesis are rarer. Pericardial evaluation is a domain of echocardiography which allows, in most cases, to comprehensively explore both morphological changes (membranes thickening, calcifications, effusions) and their functional impact on diastolic filling. Cardiovascular magnetic resonance (CMR) has emerged as one of the most versatile imaging modalities to image the pericardium. CMR is able to blend anatomy, physiology, and tissue characterization to obtain the most precise diagnosis possible for even the most challenging pericardial disorders. The normal pericardium appears as a thin hypointense line (1–2 mm thick), surrounded by hyperintense mediastinal and epicardial fat on T1-weighted imaging. Similarly to myocardial diseases, pericardial tissue characterization is usually accomplished by using cine steady-state free precession (SSFP) imaging, dark-blood T1-weighted, T2-weighted, and short-tau inversion-recovery (STIR) fast spin-echo (FSE) imaging, first pass perfusion, and late T1-weighted contrast-enhanced imaging (LGE). Phase contrast sequences allow evaluation of ventricular in-and out-flow patterns; real-time cine sequences track beat-to-beat cardiac movements. Acute, chronic, recurring, and constrictive pericarditis, as well as pericarditis-related consequences, pericardial masses, and congenital pericardial abnormalities, are often seen in clinical practice and are associated with a high incidence of morbidity and death. Due to the difficulty of diagnosis, CMR imaging is a necessary tool to confirm the diagnosis and elucidate the underlying pathophysiology. This chapter aims to provide an up-to-date view on the numerous potentials of CMR imaging in pericardial disease, highlighting the significance of CMR in guiding diagnosis, prognosis, and treatment tailoring via the use of clinical examples.