Progress in Pediatric Cardiology 50 (2018) 39–45

Contents lists available at ScienceDirect

Progress in Pediatric Cardiology

journal homepage: www.elsevier.com/locate/ppedcard

Cardiac MRI in evaluation and management of pediatric pericarditis T

a,⁎ b b c b
Shankar Baskar , Jorge Betancor , Kunal Patel , Malek El Yaman , Paul C. Cremer ,
Andrew S. Zeftd, Allan L. Kleinb
a
The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
b
Department of Cardiovascular Imaging, Center for the Diagnosis and Treatment of Pericardial Disease, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH,
United States
c
Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, OH, United States
d
Center for Pediatric Rheumatology, Cleveland Clinic Children's, Cleveland, OH, United States

A R T I C LE I N FO A B S T R A C T

Keywords: Background: Evaluation of pediatric pericarditis depends on the physical examination, electrocardiography and
Pericarditis echocardiography. However, a multimodality imaging approach which includes cardiac magnetic resonance
Pediatrics imaging (MRI) has been adopted in the adult population. The use of such an approach in the pediatric population
Magnetic resonance imaging has not been studied well.
Cardiac imaging
Objective: The present study was intended to describe a single institution's experience with the use of cardiac
Constrictive pericarditis
MRI in the evaluation of pericarditis in the pediatric population.
Study Design: A retrospective review of patients who had a cardiac MRI before the age of 21 years, between 2005
and 2014, to evaluate for pericardial pathology including pericarditis, constrictive pericarditis, recurrent peri-
carditis and pericardial effusion was performed. Patients were excluded if the cardiac MRI was done for eva-
luation of pathologies other than those related to the pericardium. Patients with predominant myocarditis were
also excluded. The cardiac MRI and the echocardiograms were reviewed by a single blinded investigator.
Results: Twenty-one patients satisfied the inclusion criteria. The study population were predominantly male
(81%) older adolescents (mean age: 17 ± 3 years). The major indications for cardiac MRI included evaluation of
myocardial involvement in acute pericarditis, modulation of therapy in recurrent pericarditis and confirmation
of constriction. Cardiac MRI was comparable to echocardiogram in detecting constrictive physiology and was
useful in determining the presence of active pericardial inflammation. Systemic inflammatory diseases de-
monstrated higher values on quantification of late gadolinium enhancement.
Conclusion: We have reported on a relatively large series of pediatric patients with pericarditis evaluated by
cardiac MRI. Cardiac MRI may be a useful adjunct to conventional imaging in selected pediatric patients with
pericarditis.

1. Introduction
Pericarditis is characterized by inflammation of the pericardium. It
can be acute, incessant, recurrent or chronic and can be complicated by
pericardial effusion leading to cardiac tamponade or constrictive peri-
carditis [1–3]. Similar to adults, pericarditis in childhood can be sec-
ondary to infectious or non-infectious causes (rheumatologic, meta-
bolic, neoplastic or post-surgical) or can be idiopathic and can lead to
complications [3–6]. Evaluation of pediatric pericarditis depends on the
physical examination, electrocardiography and echocardiography.
However, a multi-modality imaging approach, which includes cardiac
magnetic resonance imaging (MRI) has been adopted in the adult po-
pulation [1,3,7]. Reports on the use of cardiac MRI for the evaluation of
pediatric pericarditis have been limited to case reports. The present
study was intended to describe our single institution's experience with
the use of cardiac MRI in the evaluation of pericarditis in the pediatric
population.
2. Patients and methods
This was a retrospective, single institutional study. Patients with
ICD-9 codes for pericarditis, constrictive pericarditis, recurrent/chronic

Abbreviations: ASE, American Society of Echocardiography; MRI, magnetic resonance imaging; EACVI, European Association of Cardio Vascular Imaging
⁎
Corresponding author at: Pediatric Cardiology Fellow, The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH 45229,
United States.
E-mail address: shankarbaskar@gmail.com (S. Baskar).

https://doi.org/10.1016/j.ppedcard.2018.05.003
Received 17 January 2018; Received in revised form 20 April 2018; Accepted 2 May 2018
1058-9813/ © 2018 Elsevier B.V. All rights reserved.
S. Baskar et al. Progress in Pediatric Cardiology 50 (2018) 39–45

pericarditis and pericardial effusion, who had cardiac MRI at the 2.3. Statistical data analysis
Cleveland Clinic before the age of 21 years, between 2005 and 2014,
were included in the study. Patients were excluded if the cardiac MRI After quantification, late gadolinium enhancement was compared
was done for evaluation of pathologies other than those related to the after grouping patients by diagnosis (acute pericarditis/myoper-
pericardium. Patients were also excluded if there was evidence of icarditis, effusive-constrictive pericarditis and recurrent pericarditis),
predominant myocarditis, which was defined as the presence of ven- etiology (viral/idiopathic and systemic) and course (resolved and re-
tricular dysfunction demonstrated by echocardiogram or cardiac MRI. current). Statistics was performed using SPSS 22 (IBM Corp. Released
Patients with ventricular dysfunction were excluded since the man- 2013. Armonk, NY: IBM Corp).
agement and evaluation of such patients with predominant myocarditis
differs from those with pericarditis [8]. This study was approved by the 3. Results
Cleveland Clinic institutional review board and need for informed
consent was waived. The study protocol conforms to the ethical A total of 66 patients were initially identified based on the inclusion
guidelines of the 1975 Declaration of Helsinki as reflected in a priori criteria. After exclusion of patients who had cardiac MRI done for
approval by the institution's human research committee. pathologies other than those involving the pericardium and those with
predominant myocarditis, 21 patients were included in the study. The
majority of patients were male (80%) who were predominantly diag-
2.1. Definitions nosed in adolescence (mean age: 16.8 ± 2.8 years) with a mean age at
cardiac MRI of 17.5 years (SD: 3 years). Four patients were diagnosed
Acute pericarditis was diagnosed if 2 or more of the following were with acute pericarditis/myopericarditis, 11 with recurrent pericarditis
present for < 3 months, 1. typical chest pain, 2. pericardial rub, 3. ty- and 6 with constrictive pericarditis/effusive-constrictive pericarditis.
pical ECG changes, and 4. new or worsening pericardial effusion [1]. (Table 1). Patients were subdivided into groups based on the pericardial
Myopericarditis was diagnosed in the presence of elevated troponin pathologic process at the time of first cardiac MRI and their char-
along with evidence of pericarditis and in the absence of ventricular acteristics with course are described below.
dysfunction by echocardiogram or cardiac MRI. Recurrent pericarditis
was defined as recurrence of pericarditis after an asymptomatic period
of ≥6 weeks. Constrictive pericardial physiology was suspected in the 3.1. Blinded review of cardiac MRI and echocardiogram
presence of respirophasic echocardiographic changes that included in-
spiratory ventricular septal motion towards the right ventricle (septal Cardiac MRI was useful in detecting pericardial inflammation evi-
bounce) on 2D and/or an abnormal filling pattern of the left ventricular dent by the presence of late gadolinium enhancement, when there was
and right ventricular in diastole (> 25% fall in mitral inflow velocity no evidence of pericarditis on the echocardiogram. Of the 21 patients in
and > 40% increase in tricuspid velocity in the first beat after in-
spiration) on Doppler echocardiography. The presence of diastolic
septal bounce with flattening of the interventricular septum during
inspiration and diastolic restraint were considered supportive of a Table 1
constrictive physiology on cardiac MRI [1]. Effusive-constrictive peri- Patient characteristics (n = 21).
carditis was diagnosed based on the presence of pericardial effusion and
Demographics No./percent
constrictive physiology.
Male 17 (81%)
Age at diagnosis (mean ± SD, years) 17 ±3
Age at index CMR (mean ± SD, years) 17 ±3
2.2. Imaging and data collection
Referred patients 12 (62%)
Presenting complaints
All patients had comprehensive echocardiograms with re- Chest pain 9 (43%)
spirometers based on guidelines for patients with pericardial diseases Evaluation of recurrent pericarditis 9 (43%)
[1]. Cardiac MRI was performed on a 1.5 T MRI scanner (Achieva XR, Other1 4 (19%)
Examination
Philips Medical Systems, Best, Netherlands), using commercially Normal 13 (62%)
available software, electrocardiographic triggering and dedicated Pericardial rub 4 (19%)
phased-array receiver coils as previously described [9]. Late gadolinium Elevated JVP 2 (10%)
enhancement images were obtained in long- and short-axis orienta- Other 2 2 (10%)
Laboratory evaluation
tions, 10 min after the intravenous injection of gadolinium
Elevated CRP 11/20 (55%)
(0.1–0.2 mmol/kg body weight) while using a phase-sensitive inversion Elevated WSR 8/20 (40%)
recovery technique, along with selection of inversion time for optimal Elevated troponins 2/14 (14%)
nulling of the myocardium. We used an 8 mm thickness slice with 2 mm ECG
gap. Electronic patient records were reviewed for presenting com- Normal 10 (48%)
ST-segment changes 4 (19%)
plaints, past history, clinical examination, laboratory tests for in- T-wave changes 4 (19%)
flammatory markers and myocardial injury (troponin) and electro- ST-segment and T-wave changes 1 (5%)
cardiogram (ECG). The echocardiogram and the cardiac MRI were Diagnosis after index CMR
independently reviewed by one of the investigator (K.P) who was Acute pericarditis 2 (10%)
Acute myopericarditis 2 (10%)
blinded to the final reported results and the patient's clinical informa-
Recurrent pericarditis 11 (52%)
tion. Late gadolinium enhancement was quantified using CMR42 soft- Constrictive pericarditis 3 (14%)
ware (Circle Cardiovascular Imaging Inc., Calgary, Canada) by a single Effusive-constrictive pericarditis 3 (14%)
validated observer (P.C.C) for patients with quantifiable evidence of Etiology
pericardial Late gadolinium enhancement as previously explained [10]. Idiopathic/viral 16 (76%)
Rheumatologic 3 (14%)
In brief, manual contouring of the pericardium was performed on short- Others3 2 (10%)
axis late gadolinium enhancement images, and signals > 6 SD from the
normal myocardium was quantified. 1. Shortness of breath, ascites, syncope and evaluation of constrictive peri-
carditis; 2. Tachycardia, hepatomegaly; 3. Others - trauma, histoplasmosis.

40
S. Baskar et al. Progress in Pediatric Cardiology 50 (2018) 39–45

Table 2
Characteristics of patients with acute pericarditis.
Diagnosis after index Age at CMR Time since onset of Troponin Echocardiography Index CMR LGE quantification Indication of Course
CMR (years) pericarditis (cm3) index MRI

1 Acute myopericarditis 19 3 days Elevated Small PEff Small PEff, pericardial 108 A Resolved
and myocardial LGE
2 Acute myopericarditis 20 1 month Elevated Small PEff Moderate PEff, 17 A Resolved
pericardial LGE
3 Acute pericarditis 17 2 years Normal Normal Pericardial LGE 65 B, C Resolved
4 Acute pericarditis 17 2 days Normal Normal Pericardial LGE 74 D Resolved

Abbreviations: LGE, Late gadolinium enhancement; PE, Pericardial effusion; A, Clinical evidence of myocarditis; B, Failure to respond to anti-inflammatory therapy;
C, Atypical clinical presentation; D, Suspicion of constrictive pericarditis.

Fig. 1. Serial cardiac MRI in a 17-year-old patient who had initially presented for evaluation of persistent symptoms due to acute pericarditis. A: Index cardiac MRI
using late gadolinium enhancement technique demonstrating active inflammation involving most of the pericardium (red arrow). B: Cardiac MRI of the same patient
after 3 months of therapy with colchicine and steroids demonstrating resolution of inflammation (red arrow).(For interpretation of the references to color in this
figure legend, the reader is referred to the web version of this article.)

the study, 9 patients (43%) had a normal echocardiogram with the
cardiac MRI demonstrating evidence of pericardial inflammation by
late gadolinium enhancement. Seven of these patients had recurrent
pericarditis and 2 patients with acute pericarditis and the etiology was
viral/idiopathic in all patients. Cardiac MRI was comparable to echo-
cardiogram in detecting constrictive physiology.
3.2. Acute pericarditis
There were 4 patients with acute pericarditis, of whom 2 had
myocardial involvement in the form of myopericarditis (Table 2). No
specific etiology was found in any of the patients, and pericarditis was
considered to be idiopathic in nature. Patient 3 had a cardiac MRI due
to atypical presentation with exercise limitation and persistent chest
pain 2 weeks after an episode of clinically diagnosed acute pericarditis.
He had an otherwise normal cardiac evaluation including echocardio-
gram. Cardiac MRI revealed minimal enhancement of the pericardium
at the base of the ventricles consistent with pericardial inflammation
episode. Cardiac MRI was obtained in patient 4 due to concerns for
constrictive physiology, which demonstrated late gadolinium en-
hancement of the pericardium without any constrictive physiology
(Fig. 1). Our independent review of the echocardiogram did not reveal
any evidence of constrictive physiology.
3.3. Recurrent pericarditis
There were 11 patients with recurrent pericarditis at the time of
their first cardiac MRI (Table 3), which was done at an average of 1 year
from the time of initial diagnosis of pericarditis (Fig. 2). No specific
etiology had been found in the majority of recurrent pericarditis pa-
tients (9 patients, 82%), and they were deemed to have idiopathic or
viral pericarditis. The etiology in the other 2 patients were histo-
plasmosis and anti-phospholipid syndrome. Monitoring for the presence
and severity of pericardial inflammation in order to modulate man-
agement was the main indication for the index cardiac MRI. Based on
the cardiac MRI results along with the clinical presentation, 8 of these
patients (73%) had their anti-inflammatory medications modified. Ad-
dition of prednisone to the treatment regimen or changes in the dosing
of the prednisone were the most frequent therapeutic change.
3.4. Constrictive pericarditis/effusive-constrictive pericarditis
A total of 6 patients demonstrated constrictive physiology on car-
diac MRI, and 3 of these had effusive-constrictive pericarditis (Table 4).
All the three patients with isolated constrictive pericarditis underwent
pericardial resection. Two patients with effusive-constrictive peri-
carditis were found to have connective tissue disease and had evidence

41
S. Baskar et al. Progress in Pediatric Cardiology 50 (2018) 39–45

APLAS, Anti-phospholipid antibody syndrome; LGE, Later gadolinium enhancement; PEff, Pericardial effusion; D, Suspicion of constrictive pericarditis; E, Monitor the presence or severity of inflammation to modulate
of complex pericardial effusions with constrictive physiology on the
Indication for CMR
cardiac MRI. Following the cardiac MRI, additional anti-inflammatory
agents were recommended (steroids or azathioprine) for all 3 of the
E,D patients with effusive-constrictive pericarditis.

3.5. Late gadolinium enhancement quantifications

E

E
E
E
E
E
E
E
E
E
LGE quantification (cm3)

Late gadolinium enhancement quantification was performed in 16

patients, with a median late gadolinium enhancement of 65 cm3 (IQR:
25.3–111.8) (Fig. 3). There was a trend towards higher late gadolinium
enhancement among patients with effusive-constrictive pericarditis
(p = 0.026) and among patients with systemic diseases (p < 0.0001).
Late gadolinium enhancement was not performed in 5 patients, because
148

123
NA

NA
29

14

47
26
65
10
68

of the suboptimal nature of the study for quantification (n = 4) or be-

cause gadolinium was not administered (n = 1).
Moderate PEff, pericardial LGE
Pericardial LGE, moderate PEff

Small PEff and pericardial LGE

Pericardial LGE, small PEff

4. Discussion

We have described a series of pediatric patients at our institution

Pericardial LGE

Pericardial LGE

Pericardial LGE
Pericardial LGE
Pericardial LGE
Pericardial LGE
pericardial LGE

who underwent cardiac MRI for evaluation and management of peri-

carditis. This is the first comprehensive description of the use of cardiac
MRI in the evaluation of pediatric pericarditis in a case series.
CMR

Modulation of treatment in recurrent pericarditis and evaluation of

constrictive physiology and myocardial involvement were the main
Thickened pericardium, small PEff

indications for cardiac MRI. Cardiac MRI frequently demonstrated

pericardial late gadolinium enhancement indicating active pericardial
inflammation in selected patients, who had a normal echocardiogram.
Cardiac MRI was comparable to echocardiogram in demonstrating
constrictive physiology. There was a higher degree of late gadolinium
Echocardiography

enhancement in patients with systemic disease and recurrent peri-

Moderate PEff

Moderate PEff

carditis.
Trivial PEff

The patients included in our study were older at the time of initial
Normal

Normal

Normal

Normal
Normal
Normal
Normal

diagnosis than those reported in other pediatric pericarditis series and

multi-institutional studies [1,3]. This could be secondary to a more
severe disease course necessitating further evaluation in older adoles-
Viral/Idiopathic

Viral/Idiopathic
Viral/Idiopathic
Viral/Idiopathic

Viral/Idiopathic
Viral/Idiopathic
Viral/Idiopathic
Viral/Idiopathic
Viral/Idiopathic
Histoplasmosis

cents and young adults. Males were predominant which is similar to

prior studies, the explanation of which is unclear [6]. Prior cardiac
Etiology

APLAS

surgery had been noted to be a significant risk factor for pericarditis in

prior studies; however in the present study, there were no patients with
prior cardiac surgery [11]. This could be due to the older age of the
Time since onset of pericarditis (years)

patients and a more diagnostic complexity in a subset of idiopathic/

viral pericarditis necessitating further evaluation by cardiac MRI.
Cardiac MRI demonstrates enhancement of thickened pericardium
on T1-weighted images and/or late gadolinium enhancement, with a
sensitivity of 94 to 100% in detecting pericardial inflammation among
patients with acute pericarditis [1]. Increased signal in pericardial
tissue on T2W STIR images correlates with pathologic findings of
edema, neovascularization, and/or granulation tissue [12,13]. Among
patients with acute pericarditis, myocardial involvement was a
common indication for cardiac MRI. The European Association of
Characteristics of patients with recurrent pericarditis.

0.5

0.5
1
2
1
1
1
1
1
2
1

Cardio Vascular Imaging (EACVI) recommends cardiac MRI in patients

with acute pericarditis in the context of myocarditis [7]. Findings on
Age at CMR (years)

cardiac MRI in myocarditis include increased T1 and T2 signal intensity

consistent with edema and myocardial enhancement with gadolinium
administration indicative of hyperemia and necrosis, in addition to
global and regional ventricular wall motion abnormalities associated
with myocarditis. Cardiac MRI is also useful in the evaluation of ele-
14
16
18
18
18
20
20
20
21
19
8

vated troponins in pediatric patients with chest pain that can be seen in
Diagnosis after index CMR

coronary anomalies, coronary vasospasm and arrhythmias in addition

to myopericarditis or myocarditis [14]. In pericardial disease, the sys-
pericarditis
pericarditis
pericarditis
pericarditis
pericarditis
pericarditis
pericarditis
pericarditis
pericarditis
pericarditis
pericarditis

tolic function can be preserved compared with restrictive cardiomyo-

pathy. However the myocardial mechanics with strain imaging can
show abnormalities in regional strain in constrictive pericarditis despite
Recurrent
Recurrent
Recurrent
Recurrent
Recurrent
Recurrent
Recurrent
Recurrent
Recurrent
Recurrent
Recurrent

having normal function due to peri-myocardial tethering, that might

therapy.
Table 3

improve after pericardiectomy [15]. The management of pericarditis

may be complicated in the setting of LV systolic function and may imply

42
S. Baskar et al.
Fig. 2. Index cardiac MRI of patient with recurrent pericarditis demonstrating A: circumferential active inflammation by late gadolinium enhancement technique
(red arrow) B: T2-weighted short-tau inversion recovery imaging demonstrating active inflammation (red arrow).(For interpretation of the references to color in this
figure legend, the reader is referred to the web version of this article.)
evidence of peri-myocarditis. If the LV systolic function is reduced a
heart failure regimen may be initiated. For those patients with normal
LV systolic function, treatment is done with standard anti-inflammatory
therapy [3].
Recurrent pericarditis is rare in children and can have an un-
predictable course [6,11]. The present report included patients pre-
dominantly with idiopathic recurrent pericarditis with a minority
having associated systemic diseases. Pericardial enhancement in car-
diac MRI can provide supportive evidence and may be useful in ruling
out pericardial inflammation in patients with recurrent pericarditis
presenting with atypical chest pain [1]. Cardiac MRI guided therapy for
recurrent pericarditis has been shown to decrease recurrences and ex-
posure to steroids [13,16].
In constrictive pericarditis, the pericardium becomes thickened and
inelastic, limiting the diastolic filling of the ventricles. Cardiac MRI
demonstrates thickening of the pericardium, enhancement of peri-
cardium in some patients, hemodynamic and respirophasic alterations,
and pericardial-myocardial adherence on myocardial tagging. Based on
the increased thickness and presence of inflammation of pericardium,
Cardiac MRI can be useful in differentiating restrictive cardiomyopathy
from constrictive pericarditis [1,7]. Both the ASE and EACVI consider
cardiac MRI to be useful in the evaluation of patients with an echo-
cardiogram suspicious for constrictive pericarditis and for follow-up of
these patients and prior to undergoing surgical pericardial intervention.
Similar to constrictive pericarditis, in effusive-constrictive pericarditis
cardiac MRI is considered helpful in confirming diagnosis when sus-
pected by echocardiogram and for follow-up. Cardiac MRI may be
useful in better delineating pericardial thickness in the face of peri-
cardial effusion. Since the management of constrictive pericarditis may
include surgical intervention, prompt identification of constrictive
pericarditis is important in patients with an inconclusive echocardio-
gram.
Late gadolinium enhancement quantification is a novel method of
objectively defining the degree of inflammation [10,13]. Although we
have very limited number of patients, we identified a trend to have
higher late gadolinium enhancement among patients with systemic
diseases such as SLE. However, there was no significant correlation
between inflammatory markers and LGE quantification. This is likely
43
Progress in Pediatric Cardiology 50 (2018) 39–45
secondary to the limited numbers, since previous work has shown
modest correlation [17]. Recent studies have also demonstrated that
pericardial late gadolinium enhancement might predict reversibility of
constriction by anti-inflammatory medications, however further studies
are warranted [18].
Although studies directly comparing cardiac MRI and echocardio-
gram in the diagnosis of pericardial pathology are lacking, there is
strong evidence for the role of cardiac MRI in the detecting pericardial
pathology. Similar to the ASE and EACVI guidelines on the multi-
modality imaging of pericarditis in adults, we found that cardiac MRI
was used in cases with suspected myocarditis, modulating therapy in
recurrent pericarditis and confirming constrictive pericarditis. Our in-
dependent review of the prior studies, demonstrate that half of the
patients with active inflammation of the pericardium might have a
normal echocardiogram and would be detected by late gadolinium
enhancement on cardiac MRI. As expected, cardiac MRI and echo-
cardiogram were comparable in detecting constrictive physiology.
5. Study limitations
This study has some notable limitations, which includes a relatively
small and heterogeneous group of patients, biases associated with a
retrospectively collected data on clinical characteristics and treatment.
There might also be a selection bias due to the most severely affected
patient being referred for cardiac MRI and the absence of specific in-
dications in the pediatric population resulting in referral for cardiac
MRI based on the physician preference. A small sample size, sig-
nificantly decreases the accuracy of the statistical analysis associated
with late gadolinium enhancement quantification. Finally, we did not
report on the T2 weighted STIR images on pericardial edema, since the
brightness of images could be influenced by concomitant pericardial
effusion. However, future prospective studies should assess the value of
both edema (T2 STIR), inflammation (LGE) and its quantification as an
incremental value in the prognosis of these patients.
6. Conclusion
We have reported on a relatively large case series of pediatric
S. Baskar et al. Progress in Pediatric Cardiology 50 (2018) 39–45

B, Failure to respond to anti-inflammatory therapy; D, Suspicion of constrictive pericarditis; F, to distinguish constriction from restriction; G, Evaluation of presence of inflammation in effusive-constrictive pericarditis;
Indication of index

D, G

D, G
B, G
MRI

D, F

D
Viral/Idiopathic

Viral/Idiopathic

Viral/Idiopathic
MCTD/SLE
Etiology

Trauma

overlap
SLE
Follow-up

Recurrent
Improved

Improved

Improved

Improved

Improved

Fig. 3. Patient with pericardial late gadolinium enhancement and effusion. On

short axis, first the pericardium has been outlined (within the red and green
tracings), with the normal septal myocardium outlined as a reference region
(blue tracing). Quantitative signal > 6 standard deviations above normal
myocardium is colored yellow.(For interpretation of the references to color in
this figure legend, the reader is referred to the web version of this article.)
Procedures

Pericardial

Pericardial

Pericardial
resection

resection

resection
NA

NA

NA

patients who underwent cardiac MRI for evaluation for pericarditis.

Although our study was not designed to provide evidence based
LGE quantification (cm3)

guidelines for the use of cardiac MRI in pediatric pericarditis, we have

shown that cardiac MRI can be a clinically useful adjunct to conven-
tional evaluation of pediatric pericarditis in certain situations. Future
studies are needed to validate these findings and to assess the cost-
effectiveness of cardiac MRI in pediatric pericarditis.
123

274
NA

NA

NA
23

Funding source
Complex PEff, pericardial thickening, constrictive

None.
Complex PEff, pericardial LGE, constrictive
Pericardial thickening, Pericardial LGE,

Pericardial thickening, pericardial LGE

Complex PEff, constrictive physiology

Conflict of interest
physiology, LGE - not performed

Baskar S: None, Betancor J: None, Kunal P: None, Yaman ME: None,

Cremer PC: None, Zeft AS: None, Klein AL: None.
Constrictive physiology
constrictive physiology

References

[1] Klein AL, Abbara S, Agler DA, et al. American society of echocardiography clinical
physiology

recommendations for multimodality cardiovascular imaging of patients with peri-

cardial disease: endorsed by the society for cardiovascular magnetic resonance and
CMR

MCTD: Mixed connective tissue disease; SLE: Systemic lupus erythematosus.

society of cardiovascular computed tomography. J Am Soc Echocardiogr

2013;26:965–1012. (e15).
[2] Troughton RW, Asher CR, Klein AL. Pericarditis. Lancet (London, England)
2004;363:717–27.
[3] Authors/Task Force M, Adler Y, Charron P, et al. 2015 ESC guidelines for the di-
Complex PEff, constrictive

Complex PEff, constrictive

Complex Peff, constrictive

agnosis and management of pericardial diseases: the task force for the diagnosis and
Constrictive physiology

Constrictive physiology

Constrictive physiology

management of pericardial diseases of the European society of cardiology (ESC)

endorsed by: the European association for cardio-thoracic surgery (EACTS). Eur
Echocardiogram
Characteristics of patients with constrictive pericarditis.

Heart J 2015;36:2921–64.
[4] Roodpeyma S, Sadeghian N. Acute pericarditis in childhood: a 10-year experience.
physiology

physiology

physiology

Pediatr Cardiol 2000;21:363–7.

[5] Nadas AS, Levy JM. Pericarditis in children. Am J Cardiol 1961;7:109–17.
[6] Raatikka M, Pelkonen PM, Karjalainen J, Jokinen EV. Recurrent pericarditis in
children and adolescents: report of 15 cases. J Am Coll Cardiol 2003;42:759–64.
[7] Cosyns B, Plein S, Nihoyanopoulos P, et al. European association of cardiovascular
imaging (EACVI) position paper: multimodality imaging in pericardial disease. Eur
Diagnosis after index

Effusive-constrictive

Effusive-constrictive

Effusive-constrictive

Heart J Cardiovasc Imaging 2015;16:12–31.

[8] Di Filippo S. Improving outcomes of acute myocarditis in children. Expert Rev
Cardiovasc Ther 2016;14:117–25.
Constrictive

Constrictive

Constrictive
pericarditis

pericarditis

pericarditis

[9] Zurick AO, Bolen MA, Kwon DH, et al. Pericardial delayed hyperenhancement with
CMR imaging in patients with constrictive pericarditis undergoing surgical peri-
cardiectomy: a case series with histopathological correlation. JACC Cardiovasc
MRI

Imaging 2011;4:1180–91.
[10] Cremer PC, Tariq MU, Karwa A, et al. Quantitative assessment of pericardial de-
layed hyperenhancement predicts clinical improvement in patients with con-
strictive pericarditis treated with anti-inflammatory therapy. Circ Cardiovasc ima-
Age at CMR

ging 2015;8. http://dx.doi.org/10.1161/CIRCIMAGING.114.003125.

[11] Shakti D, Hehn R, Gauvreau K, Sundel RP, Newburger JW. Idiopathic pericarditis
(years)
Table 4

and pericardial effusion in children: contemporary epidemiology and management.

14

15

18

12

18

19

J Am Heart Assoc 2014;3:e001483.

44
S. Baskar et al.
[12] Zurick 3rd AO, Klein AL. Effusive-constrictive pericarditis. J Am Coll Cardiol
2010;56:86.
[13] Cremer PC, Kumar A, Kontzias A, et al. Complicated pericarditis: understanding risk
factors and pathophysiology to inform imaging and treatment. J Am Coll Cardiol
2016;68:2311–28.
[14] Schwartz MC, Wellen S, Rome JJ, Ravishankar C, Natarajan S. Chest pain with
elevated troponin assay in adolescents. Cardiol Young 2013;23:353–60.
[15] Kusunose K, Dahiya A, Popovic ZB, et al. Biventricular mechanics in constrictive
pericarditis comparison with restrictive cardiomyopathy and impact of peri-
cardiectomy. Circ Cardiovasc Imaging 2013;6:399–406.
45
Progress in Pediatric Cardiology 50 (2018) 39–45
[16] Alraies MC, AlJaroudi W, Yarmohammadi H, et al. Usefulness of cardiac magnetic
resonance-guided management in patients with recurrent pericarditis. Am J Cardiol
2015;115:542–7.
[17] Kumar A, Sato K, Yzeiraj E, et al. Quantitative pericardial delayed
Hyperenhancement informs clinical course in recurrent pericarditis. JACC
Cardiovasc Imaging 2017;10:1337–46.
[18] Feng D, Glockner J, Kim K, et al. Cardiac magnetic resonance imaging pericardial
late gadolinium enhancement and elevated inflammatory markers can predict the
reversibility of constrictive pericarditis after antiinflammatory medical therapy: a
pilot study. Circulation 2011;124:1830–7.