Circulation. 2007;115:e191-e193
doi: 10.1161/CIRCULATIONAHA.106.635433
(Circulation. 2007;115:e191-e193.)
© 2007 American Heart Association, Inc.
Images in Cardiovascular Medicine |
Constrictive Pericarditis Diagnosed by Cardiac Magnetic Resonance Imaging in a Pacemaker Patient
J. Ronald Mikolich, MD;
Edward T. Martin, MD
From the Section of Cardiology, Northeastern Ohio Universities College of Medicine, Youngstown, Ohio (J.R.M.), and the Oklahoma Heart Institute, University of Oklahoma–Tulsa, Tulsa, Okla (E.T.M.).
Correspondence to Edward T. Martin, MD, Director, Cardiovascular Magnetic Resonance, Oklahoma Heart Institute, 9228 S. Mingo Rd, Tulsa, OK 74133. E-mail martin{at}oklahomaheart.com
A 71-year-old male was referred for evaluation of 6 months of progressively worsening dyspnea on exertion and peripheral edema, mainly of the legs. During the symptomatic period, he had undergone 3 thoracentesis procedures, each draining more than 1500 mL of transudative fluid. His functional impairment was so severe that he contemplated suicide. His cardiac history was significant for syncope attributable to sinus node dysfunction 19 years earlier, requiring implantation of an atrioventricular pacing system. Because of atrial lead fracture, a second atrial lead had been placed 1 month before the onset of the dyspnea and leg edema. Physical examination revealed diminished breath sounds over both lung fields and moderate (2+) edema of both lower extremities to the level of the knee.
The 12-lead ECG demonstrated normal sinus rhythm at 79 bpm with low-voltage and diffuse ST and T-wave abnormalities (Figure 1). A chest x-ray revealed a dual-chamber permanent cardiac pacemaker, 2 retained leads, and bilateral pleural effusions (Figure 2). Transthoracic and transesophageal echocardiography and invasive cardiac catheterization failed to establish the cause of the patient’s symptoms or define a treatment plan. Multislice computed tomography revealed a thickened pericardium (Figure 3). To establish a definitive diagnosis, a pacemaker cardiac magnetic resonance imaging (MRI) study was performed according to published protocol.1
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Figure 1. Twelve-lead ECG shows normal sinus rhythm with low-voltage QRS and diffuse ST and T-wave abnormalities.
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Figure 2. Postero-anterior chest x-ray shows a dual-chamber permanent pacemaker, 2 retained leads, and bilateral pleural effusions, left greater than right.
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Figure 3. Multislice computed tomography 4-chamber axial view shows circumferential thickening of the pericardium. Artifacts from the pacer wires are seen within the right atrium. Bilateral pleural effusions are also seen.
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The MRI showed normal left and right ventricular systolic function, with marked pericardial thickening and adherence of the pericardium to the myocardium over the right and left ventricular apices and along the left lateral wall of the left ventricle (Figure 4). Adherence was confirmed by myocardial tagging (Figure 5). Phase–velocity mapping of the mitral inflow tract was consistent with impaired diastolic filling of the left ventricle (Figure 6). Additionally, an MRI signal-void artifact was noted in the area of the right atrial appendage extending superiorly in the pericardial space along the right lateral wall of the aorta (Figure 7). This finding suggests perforation of the lead into the pericardial space, but because of the magnitude of the lead artifact, lead tip position could not be absolutely located. The patient tolerated the cardiac MRI procedure without clinical sequelae. Pulse-generator function remained unaffected.
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Figure 4. Magnetic resonance imaging 4-chamber view shows a large area of pericardial–myocardial adherence seen from the right-ventricle (RV) apex and extending to the lateral segment of the left ventricle. A septal "bounce," characteristic of pericardial constriction, is also evident. Bilateral pleural effusions and pacemaker lead artifact (black areas) in the right heart chambers are also seen. See Movie I. LV indicates left ventricle; LA, left atrium.
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Figure 5. Tagging confirmed adherence and immobility of the pericardial–myocardial interface. See Movie II.
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Figure 6. Graph of the phase–velocity map of the mitral inflow shows E-to-A wave reversal consistent with impaired diastolic filling. Systolic flow below the zero line represents mitral regurgitation (MR).
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Figure 7. Using an axial imaging plane, pacemaker lead signal-void artifacts are evident in the superior vena cava as expected. Further signal-void artifact is also noted along the right lateral wall of the aorta, in the pericardial space, suggesting perforation. See Movie III. Asc Ao indicates ascending aorta; Des Ao, descending aorta; and MPA, main pulmonary artery.
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Constrictive pericarditis was confirmed at surgery, and a pericardiectomy was performed. Because of the extensive fibrosis around the myocardium, pacemaker lead perforation could not be visually identified. Normal pacemaker function was confirmed in the hospital before surgery. After surgery, the patient had complete resolution of his symptoms and returned to full functional status.
Cardiac MRI has been shown to be useful in the diagnosis of constrictive pericarditis.2,3 Because MRI has been thought to be an absolute contraindication for patients with pacemakers, it usually is not considered as a useful test in this patient population. However, recent studies have suggested that MRI in pacemaker patients may represent only a relative contraindication if previously established protocols are followed.1,4 Patients with retained postsurgical pacing wires have also safely undergone MRI.5 The unique anatomic orientation, soft-tissue characterization, and spatial resolution of MRI make it ideal for evaluation of pericardial disease. In this particular case, an accurate diagnosis was not made by other modalities, necessitating consideration of a cardiac MRI study. Although caution is appropriate, wider use of MRI for pacemaker patients may be justified and necessary to provide optimal patient care.
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Disclosures
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Dr Martin has received honoraria from GE Medical Systems and
the Guidant Corporation. Dr Mikolich has received honoraria
from GE Medical Systems.
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Footnotes
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The online-only Data Supplement, consisting of Movies I through III, is available with this article at http://circ.ahajournals.org/cgi/content/full/115/7/e191/DC1.
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References
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1. Martin ET, Coman JA, Shellock FG, Pulling CC, Fair R, Jenkins K. Magnetic resonance imaging and cardiac pacemaker safety at 1.5 tesla.
J Am Coll Cardiol. 2004; 43: 1315–1324.
[Abstract/Free Full Text]2. Kovanlikaya A, Burke LP, Nelson MD, Wood J. Characterizing chronic pericarditis using steady-state free-precession cine MR imaging. Am J Roentgenol. 2002; 179: 475–476.[Free Full Text]
3. Kojima S, Yamada N, Goto Y. Diagnosis of constrictive pericarditis by tagged cine magnetic resonance imaging. N Engl J Med. 1999; 341: 373–374.[Free Full Text]
4. Martin ET. Can cardiac pacemakers and magnetic resonance imaging systems co-exist? Eur Heart J. 2005; 26: 325–327.[Free Full Text]
5. Hartnell GG, Spence L, Hughes LA, Cohen MC, Saouaf R, Buff B. Safety of MR imaging in patients who have retained metallic materials after cardiac surgery. Am J Roentgenol. 1997; 168: 1157–1159.[Abstract/Free Full Text]
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Disclosures
References