The Role of Multimodality Imaging in the Management of Pericardial Disease

Received November 12, 2009; accepted March 19, 2010. Pericardial pathology is commonly encountered in clinical practice and may present either as an isolated process or in association with other systemic disorders. Recognizing pericardial pathology can be relatively straightforward, particularly if the clinical manifestation is typical (eg, the patient with acute pericarditis and an audible friction rub reporting retrosternal pain, exacerbated by inspiration or in the supine position) or when an associated disease process gives a direct clue to the diagnosis (eg, the finding of a complex pericardial effusion in a patient with a known malignancy). In these situations, the diagnostic pathway can be limited to a relatively small sequence of tests to basically confirm the initial clinical suspicion.1However, pericardial disease can also result in nonspecific symptoms and equivocal physical findings. When the initial tests of choice turn out to be nondiagnostic or the course of the disease is prolonged, pericardial disease may cause considerable diagnostic dilemmas. Furthermore, established diagnostic techniques may not visualize the full extent of the pericardial disease process. In such difficult clinical situations, an integrated multimodality imaging approach may provide incremental value. Unfortunately, current guidelines do not address the role of a multimodality approach in the difficult to manage pericardial patient.1 This review will therefore discuss the potential role of different imaging modalities in the diagnosis and management of pericardial disorders, with a specific focus on what constitutes a rational multimodality imaging approach.The 3 imaging modalities most commonly used for evaluation of pericardial disease are echocardiography, cardiac computed tomography (CT), and cardiac MRI (CMR). The main indications and limitation for each test are summarized in Table 1. Echocardiography remains the initial imaging method of choice for the majority of patients with pericardial disease, but in many clinical scenarios, a transthoracic echocardiogram (TTE) …