Pericardial disease

Pharmacotherapy update of acute idiopathic pericarditis

Idiopathic (viral) pericarditis is the most common form of pericardial disease in the Western world. Despite the combination of colchicine and nonsteroidal antiinflammatory drugs (NSAIDs) plus aspirin (ASA), considered first-line therapy, the incidence of recurrent pericarditis is ~20-30%. In addition, secondary recurrence without optimal first-line therapy is ~50%. This is due to the many clinical challenges, such as inappropriate NSAID/ASA duration of therapy, the use of corticosteroid therapy, contraindications or intolerances to therapy, adverse effects, and issues related to adherence. This review describes contemporary pharmacotherapeutic management of idiopathic (viral) pericarditis, with a particular emphasis on the role of colchicine. Emerging therapies and management strategies, such as high-sensitivity C-reactive protein-guided therapy and novel immunotherapies, are also reviewed. Ultimately, understanding appropriate treatment will assist the clinician in helping decrease the risk of recurrent, incessant, and refractory pericarditis.

Pericardial Effusion and Adenosine Deaminase False Positivity Due to Parvovirus B19

This case is presented to highlight that one of the causes for massive exudative pericardial effusion in a child may be parvovirus B19, and adenosine deaminase can be falsely positive in such patients.

Pericarditis and pericardial effusions in the military patient

The pericardium is the thin double-walled sac encapsulating the heart which has a number of important physiological roles including fixing the heart in the mediastinum, protecting it from cross-organ infection (eg, lung) and lubricating cardiac contraction. The pericardium is associated with several disease syndromes that occasionally affect the military population. These include acute and recurrent pericarditis, pericardial effusion and tamponade, which may result from a large number of different aetiological agents. Pericardial diseases have a wide range of clinical manifestations and the diagnosis of pericardial diseases can be a challenge. This article reviews the anatomy and pathophysiology of pericarditis and pericardial effusions before outlining their clinical features, recommended investigations and management options. Particular emphasis is placed on the impact of these diseases for patients in a military occupational environment.

Pericardiectomy is Associated with Improvement in Longitudinal Displacement of Left Ventricular Free Wall Due to Increased Counterclockwise Septal-to-Lateral Rotational Displacement

BACKGROUND

Pericardiectomy is an effective intervention for constrictive pericarditis. Speckle-tracking echocardiography can provide quantitative information not only about longitudinal strain (LS) but about longitudinal displacement (LD) and septal-to-lateral rotational displacement (SLRD). The aim of this study was to investigate whether pericardiectomy improves myocardial mechanics using speckle-tracking analysis.

METHODS

Eighty-three patients with constrictive pericarditis who underwent echocardiography were retrospectively assessed (mean age, 58 ± 12 years; 72 men; 50 idiopathic, 20 postoperative, four viral, three radiation, and six others) and compared with 20 healthy volunteers. LD and SLRD were measured from the apical four-chamber view and global LS from three apical views.

RESULTS

LD was less in the constrictive pericarditis group compared with control subjects (P < .001). Only lateral LS was significantly less than that of control subjects (P < .001), but septal LS was similar (P = .48). In pre- and post-pericardial surgery comparisons (n = 27), values of septal and lateral LD were almost identical (mean, 13.6 ± 4.7 vs 13.3 ± 5.4 mm; P = .70) before pericardiectomy, but septal LD decreased (mean, 9.3 ± 3.5 mm; P < .001) and lateral LD increased (mean, 16.8 ± 4.7 mm; P = .0106) after the surgery, even though the difference in LS between the septal and lateral walls decreased (from 5.6 ± 5.3% to 2.5 ± 4.2%, P = .008). Systolic whole-heart swinging motion significantly increased to a counterclockwise direction after surgery (mean SLRD, -0.8 ± 3.3° vs 2.1 ± 3.0°; P = .001). Although the change in SLRD after pericardiectomy was not different between patients with decreases and increases in New York Heart Association class, SLRD change was significantly greater in patients who received fewer diuretics after surgery (mean, 4.00 ± 0.91 vs 0.27 ± 1.47; P = .027).

CONCLUSIONS

After surgical removal of the pericardium, LD of the septal and lateral walls became significantly different, and counterclockwise SLRD increased, reflecting loss of pericardial support.

Anterior parasternal approach for creation of a pericardial window

INTRODUCTION

The optimal method for creation of a pericardial window (PW) is still controversial and it remains a surgical challenge, mainly in obese patients. The aim of this study was to evaluate the efficacy and safety of a novel approach that has not been described previously, for creation of a PW in patients with symptomatic, chronic, large pericardial effusion.

METHODS

We retrospectively analysed the records of 30 patients (14 men, 16 women) who underwent a PW procedure between 2001 and 2011. The mean age was 63 years (standard deviation [SD]: 17 years, median: 60 years, range: 27-90 years) and the mean body mass index was 34 kg/m(2) (SD: 2 kg/m(2)). The operation was performed through a curvilinear parasternal approach, 6-8 cm in length, followed by a mini-thoracotomy between ribs 4 and 5. Discharged patients were followed up clinically.

RESULTS

The mean operative time was 73 minutes (SD: 21 minutes) and a median of 658 ml (range: 300-1,500 ml) of fluid was evacuated. The main aetiologies were idiopathic in 17 patients (57%) and malignant in 9 (30%). Seven patients (23%) died in hospital owing to underlying malignancy. Postoperative complications included mild renal failure (20%), respiratory failure (20%), pneumonia (13%), atrial fibrillation (10%) and atelectasis (6%). There were no wound infections. The median length of stay following the procedure was 8 days. In a median follow-up period of 3.8 years, 16 patients with non-malignant effusion were free of recurrence of pericardial effusion.

CONCLUSIONS

The anterior parasternal approach for creation of a PW is simple, safe and efficacious, and results in long-term symptomatic improvement, specifically in patients with non-malignant effusions. This approach may be more appealing in obese patients.

At the Heart of the Matter

Echocardiography is an excellent method for evaluating cardiac morphology and dynamic function. It has a long history of innovative thinking mixed with some degree of serendipity. Its early applications were as a tool to evaluate the mitral valve, left ventricular characteristics, and pericardial effusion. Today it has evolved into a robust modality that allows for a very wide range cardiac interrogation, able to evaluate the valves, chambers, myocardium, and pericardium. The practice of echocardiography also is often separate from that of general or vascular sonography. The objective of this article is to provide the non–cardiac sonographer with an overview and appreciation of the basic principles and practices of echocardiography. It is not meant as a guide to scanning but rather, as a vehicle to spark the interest and imagination of the reader.

Mechanics of pericardial effusion: A simulation study

Pericardial effusion is a pathological accumulation of fluid within pericardial cavity, which may compress heart chambers with hemodynamic impairment. We sought to determine the mechanics underlying the physiology of the hemodynamic impairment due to pericardial effusion using patient-specific computational modeling. Computational models of left ventricle and right ventricle were based on magnetic resonance images obtained from patients with pericardial effusion and controls. Myocardial material parameters were adjusted, so that volumes of ventricular chambers and pericardial effusion agreed with magnetic resonance imaging data. End-diastolic and end-systolic pressure–volume relationships as well as stroke volume were determined to evaluate impaired cardiac function of biventricular model. Distributions of myocardial fiber stresses and their regional variation along left ventricular wall were compared between patient groups. Both end-diastolic and end-systolic pressure–volume relationships shifted to the left for patients with pericardial effusion, with right ventricle diastolic filling particularly restricted. Left ventricle function as estimated by Starling curve was reduced by pericardial effusion. End-systolic fiber stress of left ventricle was significantly reduced as compared to that found for healthy patients. Myocardial stress was found increased at interventricular septum when compared to that exerted at lateral wall of left ventricle. Right ventricular myocardial stress was reduced as a consequence of the pressure equalization between right ventricle and pericardial effusion. Diastolic right ventricle collapse in patients with pericardial effusion is related to higher myocardial fiber stress on interventricular septum and to an extensible pericardium reducing motion of ventricular chambers, with right ventricle particularly restrained. These findings likely portend progression of pericardial effusion to cardiac tamponade.

Invasive hemodynamics of constrictive pericarditis

Cardiac catheterization and hemodynamic study is the gold standard for the diagnosis of pericardial constriction. Careful interpretation of the hemodynamic data is essential to differentiate it from other diseases with restrictive physiology. In this hemodynamic review we shall briefly discuss the physiologic basis of various hemodynamic changes seen in a patient with constrictive pericarditis.

Role of a 12-lead electrocardiogram in the diagnosis of cardiac tamponade as diagnosed by transthoracic echocardiography in patients with malignant pericardial effusion

BACKGROUND

Few studies have looked at the utility of the 12-lead electrocardiogram (ECG) in diagnosing cardiac tamponade in malignant pericardial effusion (PE). The aim of this study was to determine the sensitivity (Se), specificity (Sp), positive predictive value (PPV), and negative predictive value (NPV) of 12-lead ECG in diagnosing cardiac tamponade in PE.

HYPOTHESIS

Abnormalities on a 12 lead ECG can be used to diagnose or exclude cardiac tamponade in patients with malignant PE.

METHODS

Using echocardiography as the gold standard for diagnosis of cardiac tamponade, we determined the Se, Sp, PPV, and NPV for individual and combinations of the 3 ECG abnormalities (low-voltage complexes, electrical alternans, and sinus tachycardia).

RESULTS

For PEs of all sizes, the Se, Sp, PPV, and NPV for detecting cardiac tamponade were: low-voltage complexes (56%, 74%, 81%, 46%), electrical alternans (23%, 98%, 95%, 39%), and sinus tachycardia (76%, 60%, 79%, 56%), respectively. Presence of all 3 and any of the 3 ECG abnormalities had a Se, Sp, PPV, and NPV of 8%, 100%, 100%, 36% and 89%, 47%, 77%, 69%, respectively, for cardiac tamponade. The odds ratios for cardiac tamponade in PE were 3.7 (95% confidence interval [CI]: 1.65-8.30) for low-voltage complexes, 12.3 (95% CI: 1.58-95.17) for electrical alternans, and 4.9 (95% CI: 2.22-10.80) for sinus tachycardia. Presence of any of 3 ECG abnormalities had an odds ratio of 7.3 (95% CI: 2.9-18.1) for cardiac tamponade.

CONCLUSIONS

In malignant PE, combination of ECG abnormalities can supplement clinical examination in the diagnosis of echocardiographic cardiac tamponade. Due to its low NPV, 12-lead ECG cannot be used as a screening tool to exclude cardiac tamponade with malignant PE.

Interleukin-1 as a common denominator from autoinflammatory to autoimmune disorders: premises, perils, and perspectives

A complex web of dynamic relationships between innate and adaptive immunity is now evident for many autoinflammatory and autoimmune disorders, the first deriving from abnormal activation of innate immune system without any conventional danger triggers and the latter from self-/non-self-discrimination loss of tolerance, and systemic inflammation. Due to clinical and pathophysiologic similarities giving a crucial role to the multifunctional cytokine interleukin-1, the concept of autoinflammation has been expanded to include nonhereditary collagen-like diseases, idiopathic inflammatory diseases, and metabolic diseases. As more patients are reported to have clinical features of autoinflammation and autoimmunity, the boundary between these two pathologic ends is becoming blurred. An overview of monogenic autoinflammatory disorders, PFAPA syndrome, rheumatoid arthritis, type 2 diabetes mellitus, uveitis, pericarditis, Behçet's disease, gout, Sjögren's syndrome, interstitial lung diseases, and Still's disease is presented to highlight the fundamental points that interleukin-1 displays in the cryptic interplay between innate and adaptive immune systems.

MR imaging evaluation of pericardial constriction

Abnormal thickening or rigidity of the pericardium may compromise normal cardiac function. This condition is known as pericardial constriction, or constrictive pericarditis. Several imaging modalities are used to evaluate the pericardium, including MR, computed tomography, and echocardiography, which can all play a complementary role aiding diagnosis. This article focuses on MR imaging and its role in the detection and evaluation of pericardial constriction. MR imaging has many advantages compared with other modalities including precise delineation of the pericardial thickness, evaluation of ventricular function, detection of wall motion abnormalities, and provision of information about common (and potentially harmful) sequelae of pericardial constriction.

Bacteriologic profile of pericardial infections after cardiac surgery: study in an Iranian cardiovascular tertiary care center

BACKGROUND

Bacterial pericarditis is an important cause of post-surgery mortality and morbidity. This can be a preventable complication and the involved pathogens vary according to the time and location.

OBJECTIVES

The aim of this study was to investigate the bacteriologic profile in patients with pericardial infections after cardiac surgery in the largest tertiary care center for cardiovascular diseases in Iran. The results can be applied for prevention, diagnosis, and treatment of similar patients in Iran.

PATIENTS AND METHODS

This prospective study was performed in Rajaie Cardiovascular Medical and Research Center (RCMRC), the largest tertiary care center for cardiovascular disease in Iran from March 2011 to March 2012. Patients who had undergone cardiac surgery with cardiopulmonary bypass and showed suggestive sign and symptoms of pericardial infections were registered and samples from their pericardial fluids were obtained to perform standard bacteriologic and antibiogram tests.

RESULTS

A total of 158 patients were registered. Bacteriologic findings were positive in 30 patients (19%). Staphylococcus epidermidis was the most frequent isolated organism, which was found in 22 patients (73.3%) with eight of them being methicillin-resistant strains.

CONCLUSIONS

The bacteriologic profile in our patient is specific to our own community. Knowledge about this profile can help us to improve prevention, diagnosis, and treatment of the affected patients.

Noninvasive imaging of cardiovascular injury related to the treatment of cancer

The introduction of multiple treatments for cancer, including chemotherapeutic agents and radiation therapy, has significantly reduced cancer-related morbidity and mortality. However, these therapies can promote a variety of toxicities, among the most severe being the ones involving the cardiovascular system. Currently, for many surviving cancer patients, cardiovascular (CV) events represent the primary cause of morbidity and mortality. Recent data suggest that CV injury occurs early during cancer treatment, creating a substrate for subsequent cardiovascular events. Researchers have investigated the utility of noninvasive imaging strategies to detect the presence of CV injury during and after completion of cancer treatment because it starts early during cancer therapy, often preceding the development of chemotherapy or cancer therapeutics related cardiac dysfunction. In this State-of-the-Art Paper, we review the utility of current clinical and investigative CV noninvasive modalities for the identification and characterization of cancer treatment-related CV toxicity.

Constrictive pericarditis--a curable diastolic heart failure

Constrictive pericarditis can result from a stiff pericardium that prevents satisfactory diastolic filling. The distinction between constrictive pericarditis and other causes of heart failure, such as restrictive cardiomyopathy, is important because pericardiectomy can cure constrictive pericarditis. Diagnosis of constrictive pericarditis is based on characteristic haemodynamic and anatomical features determined using echocardiography, cardiac catheterization, cardiac MRI, and CT. The Mayo Clinic echocardiography and cardiac catheterization haemodynamic diagnostic criteria for constrictive pericarditis are based on the unique features of ventricular interdependence and dissociation of intrathoracic and intracardiac pressures seen when the pericardium is constricted. A complete pericardiectomy can restore satisfactory diastolic filling by removing the constrictive pericardium in patients with constrictive pericarditis. However, if inflammation of the pericardium is the predominant constrictive mechanism, anti-inflammatory therapy might alleviate this transient condition without a need for surgery. Early diagnosis of constrictive pericarditis is, therefore, of paramount clinical importance. An improved understanding of how constrictive pericarditis develops after an initiating event is critical to prevent this diastolic heart failure. In this Review, we discuss the aetiology, pathophysiology, and diagnosis of constrictive pericarditis, with a specific emphasis on how to differentiate this disease from conditions with similar clinical presentations.

Severe constrictive pericarditis after parvovirus B19 and human herpes virus 6 infection in a 9-year-old girl

We report on a 9-year-old girl who developed signs of congestive heart failure with significant ascites due to constrictive pericarditis. Cardiac catheterization was performed to establish the diagnosis and to rule out restrictive cardiomyopathy. Endomyocardial biopsies were positive for activated macrophages and small-vessel disease, but no viral genomes were detected. Open pericardectomy was performed and histopathologic examination of the resected thickened pericardium showed extensive fibrosis and hyaline degeneration. A combined infection with parvovirus B19 (PVB19) and human herpes virus 6 (HHV6; subtype B) was proven within the resected pericardium. We suggest that local HHV6-induced immunosuppression enhanced the PVB19 infection, thus resulting in chronic infection and leading to constrictive pericarditis.

Efficacy and safety of colchicine for treatment of multiple recurrences of pericarditis (CORP-2): a multicentre, double-blind, placebo-controlled, randomised trial

BACKGROUND

Colchicine is effective for the treatment of acute pericarditis and first recurrences. However, conclusive data are lacking for the efficacy and safety of colchicine for treatment of multiple recurrences of pericarditis.

METHODS

We did this multicentre, double-blind trial at four general hospitals in northern Italy. Adult patients with multiple recurrences of pericarditis (≥two) were randomly assigned (1:1) to placebo or colchicine (0·5 mg twice daily for 6 months for patients weighing more than 70 kg or 0·5 mg once daily for patients weighing 70 kg or less) in addition to conventional anti-inflammatory treatment with aspirin, ibuprofen, or indometacin. Permuted block randomisation (size four) was done with a central computer-based automated sequence. Patients and all investigators were masked to treatment allocation. The primary outcome was recurrent pericarditis in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NCT00235079.

FINDINGS

240 patients were enrolled and 120 were assigned to each group. The proportion of patients who had recurrent pericarditis was 26 (21·6%) of 120 in the colchicine group and 51 (42·5%) of 120 in the placebo group (relative risk 0·49; 95% CI 0·24-0·65; p=0·0009; number needed to treat 5). Adverse effects and discontinuation of study drug occurred in much the same proportions in each group. The most common adverse events were gastrointestinal intolerance (nine patients in the colchicine group vs nine in the placebo group) and hepatotoxicity (three vs one). No serious adverse events were reported.

INTERPRETATION

Colchicine added to conventional anti-inflammatory treatment significantly reduced the rate of subsequent recurrences of pericarditis in patients with multiple recurrences. Taken together with results from other randomised controlled trials, these findings suggest that colchicine should be probably regarded as a first-line treatment for either acute or recurrent pericarditis in the absence of contraindications or specific indications.

FUNDING

Azienda Sanitaria 3 of Torino (now ASLTO2).

Advanced ultrasound procedures

Ultrasound guidance has become the standard of care for many bedside procedures, owing to its portability, ease of use, and significant reduction in complications. This article serves as an introduction to the use of ultrasonography in several advanced procedures, including pericardiocentesis, thoracentesis, paracentesis, lumbar puncture, regional anesthesia, and peritonsillar abscess drainage.

Tuberculous pericarditis with and without HIV

The human immunodeficiency virus (HIV) has altered the epidemiology, clinical manifestations, treatment considerations and natural history of tuberculous (TB) pericarditis with significant implications for clinicians. The caseload of TB pericarditis has risen sharply in TB endemic areas of the world where co-infection with HIV is common. Furthermore, TB is the cause in greater than 85 % of cases of pericardial effusion in HIV-infected cohorts. In the absence of HIV, the morbidity of TB pericarditis is primarily related to the ferocity of the immune response to TB antigens within the pericardium. In patients with HIV, because TB pericarditis more often occurs as part of a disseminated process, the infection itself has a greater impact on the morbidity and mortality. HIV-associated TB pericarditis is a more aggressive disease with a greater degree of myocardial involvement. Patients have larger pericardial effusions with more frequent hemodynamic compromise and more significant ST segment changes in the electrocardiogram. HIV alters the natural history and outcomes of TB pericarditis. Immunocompromised participants appear less likely to develop constrictive pericarditis and have a significantly higher mortality compared with their immunocompetent counterparts. Finally co-infection with HIV has resulted in a number of areas of uncertainty. The mechanisms of myocardial dysfunction are unclear, new methods of improving the yield of TB culture and establishing a rapid bacterial diagnosis remain a major challenge, the optimal duration of anti-TB therapy has yet to be established, and the role of corticosteroids has yet to be resolved.

A randomized trial of colchicine for acute pericarditis

BACKGROUND

Colchicine is effective for the treatment of recurrent pericarditis. However, conclusive data are lacking regarding the use of colchicine during a first attack of acute pericarditis and in the prevention of recurrent symptoms.

METHODS

In a multicenter, double-blind trial, eligible adults with acute pericarditis were randomly assigned to receive either colchicine (at a dose of 0.5 mg twice daily for 3 months for patients weighing >70 kg or 0.5 mg once daily for patients weighing ≤70 kg) or placebo in addition to conventional antiinflammatory therapy with aspirin or ibuprofen. The primary study outcome was incessant or recurrent pericarditis.

RESULTS

A total of 240 patients were enrolled, and 120 were randomly assigned to each of the two study groups. The primary outcome occurred in 20 patients (16.7%) in the colchicine group and 45 patients (37.5%) in the placebo group (relative risk reduction in the colchicine group, 0.56; 95% confidence interval, 0.30 to 0.72; number needed to treat, 4; P<0.001). Colchicine reduced the rate of symptom persistence at 72 hours (19.2% vs. 40.0%, P=0.001), the number of recurrences per patient (0.21 vs. 0.52, P=0.001), and the hospitalization rate (5.0% vs. 14.2%, P=0.02). Colchicine also improved the remission rate at 1 week (85.0% vs. 58.3%, P<0.001). Overall adverse effects and rates of study-drug discontinuation were similar in the two study groups. No serious adverse events were observed.

CONCLUSIONS

In patients with acute pericarditis, colchicine, when added to conventional antiinflammatory therapy, significantly reduced the rate of incessant or recurrent pericarditis. (Funded by former Azienda Sanitaria Locale 3 of Turin [now Azienda Sanitaria Locale 2] and Acarpia; ICAP ClinicalTrials.gov number, NCT00128453.).

Management of pericarditis and myocarditis: could heart-rate-reducing drugs hold a promise?

Rest is usually recommended in acute pericarditis and acute myocarditis. Given that myocarditis often leads to hospitalization, this task seems easy to carry out in hospital practice; however, it could be a real challenge at home in daily life. Heart rate-lowering treatments (mainly beta-blockers) are usually recommended in case of acute myocarditis, especially in case of heart failure or arrhythmias, but level of proof remains weak. Calcium channel inhibitors and digoxin are sometimes proposed, albeit in limited situations. It is possible that rest or even heart rate-lowering treatments could help to manage these patients by preventing heart failure as well as by limiting "mechanical inflammation" and controlling arrhythmias, especially life-threatening ones. Whether heart rate has an effect on inflammation remains unclear. Several questions remain unsolved, such as the duration of such treatments, especially in light of new heart rate-lowering treatments, such as ivabradine. In this review, we discuss rest and heart-rate lowering medications for the treatment of pericarditis and myocarditis. We also highlight some work in experimental models that indicates the beneficial effects of such treatments for these conditions. Finally, we suggest certain experimental avenues, through the use of animal models and clinical studies, which could lead to improved management of these patients.

Pericardial disease: value of CT and MR imaging

The pericardium represents an important focus of morbidity and mortality in patients with cardiovascular disease. Fortunately, in recent years knowledge regarding this enigmatic part of the heart and the diagnosis of related diseases has substantially advanced. To a large extent, this can be attributed to the availability of several noninvasive cardiac imaging modalities. Transthoracic echocardiography, which combines structural and physiologic assessment, is the first-line technique for examination of patients suspected of having or known to have pericardial disease; however, cardiac computed tomography (CT) and magnetic resonance (MR) imaging are becoming increasingly popular for the study of this part of the heart. Modern multidetector CT scanners merge acquisition speed and high spatial and contrast resolution, with volumetric scanning to provide excellent anatomic detail of the pericardium. Multidetector CT is by far the modality of choice for depiction of pericardial calcifications. MR imaging is probably the best imaging modality for the acquisition of a comprehensive view of the pericardial abnormalities. MR imaging combines cardiac and pericardial anatomic assessment with tissue characterization and appraisal of the effects of pericardial abnormalities on cardiac performance. This review aims to elucidate the role of the pericardium and its interaction with the remainder of the heart in normal and pathologic conditions. It focuses on the rapidly evolving insights regarding pericardial disease provided by modern imaging modalities, not infrequently necessitating reconsideration of evidence that has thus far been taken for granted.

SUPPLEMENTAL MATERIAL

http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.13121059/-/DC1.

A massive occult pericardial effusion in an athletic young male

We present a case of a 27-year-old Royal Marine with a massive pericardial effusion, presenting with minimal clinical findings, suggesting that high levels of physical fitness may effectively mask the normal symptoms of this potentially life-threatening condition.

An unusual cause of dysphagia: pericardial effusion after implantable cardioverter-defibrillator placement

BACKGROUND

Dysphagia is a known complication of pericardial effusions. Most cases of pericardial effusions are idiopathic, infectious, and neoplastic, but can also occur after cardiac procedures.

OBJECTIVE

To report the case of a patient who developed dysphagia from a sub-acute pericardial effusion caused by the placement of an implantable cardioverter-defibrillator (ICD).

CASE REPORT

A 62-year-old woman presented to the Emergency Department (ED) with a 2-day history of dysphagia. Imaging revealed a large pericardial effusion compressing the esophagus from the mid-thoracic level to the gastroesophageal junction. Ten days prior, a dual-chamber ICD with small-diameter active fixation leads was placed in the patient. There had been no apparent complications from the procedure, however, over this 10-day period she developed a sub-acute pericardial effusion from an incidental perforation during ICD lead placement that led to the extrinsic compression of the esophagus and her presenting symptom of dysphagia. The patient underwent pericardiocentesis for the pericardial effusion and she was discharged in stable condition.

CONCLUSION

This case report highlights the importance of recognizing a non-cardiac complaint such as dysphagia as the primary symptom of a critical cardiac condition. With an increase in cardiac procedures anticipated, clinicians should consider the possibility of a pericardial effusion as a cause of dysphagia, especially for those patients with recent cardiac procedures.

Pericardial effusion and pericardiocentesis: role of echocardiography

Pericardial effusion can develop from any pericardial disease, including pericarditis and several systemic disorders, such as malignancies, pulmonary tuberculosis, chronic renal failure, thyroid diseases, and autoimmune diseases. The causes of large pericardial effusion requiring invasive pericardiocentesis may vary according to the time, country, and hospital. Transthoracic echocardiography is the most important tool for diagnosis, grading, the pericardiocentesis procedure, and follow up of pericardial effusion. Cardiac tamponade is a kind of cardiogenic shock and medical emergency. Clinicians should understand the tamponade physiology, especially because it can develop without large pericardial effusion. In addition, clinicians should correlate the echocardiographic findings of tamponade, such as right ventricular collapse, right atrial collapse, and respiratory variation of mitral and tricuspid flow, with clinical signs of clinical tamponade, such as hypotension or pulsus paradoxus. Percutaneous pericardiocentesis has been the most useful procedure in many cases of large pericardial effusion, cardiac tamponade, or pericardial effusion of unknown etiology. The procedure should be performed with the guidance of echocardiography.

Cardiac calcification in acute intermittent porphyria

Aetiology of pericardial calcifications can be multifactorial. Tuberculosis has been reported as the most common cause. Other known causes include uraemia, asbestosis, post-traumatic or postoperative. We report a rare case of pericardial calcification seen in a patient with established acute intermittent porphyria. A direct causal relationship cannot be established between porphyria and pericardial calcification, but it may be due to deposition of the porphyrin in the pericardium.

Management of pericardial effusion

Pericardial effusion is a common finding in clinical practice either as incidental finding or manifestation of a systemic or cardiac disease. The spectrum of pericardial effusions ranges from mild asymptomatic effusions to cardiac tamponade. The aetiology is varied (infectious, neoplastic, autoimmune, metabolic, and drug-related), being tuberculosis the leading cause of pericardial effusions in developing countries and all over the world, while concurrent HIV infection may have an important promoting role in this setting. Management is guided by the haemodynamic impact, size, presence of inflammation (i.e. pericarditis), associated medical conditions, and the aetiology whenever possible. Pericardiocentesis is mandatory for cardiac tamponade and when a bacterial or neoplastic aetiology is suspected. Pericardial biopsy is generally reserved for cases with recurrent cardiac tamponade or persistence without a defined aetiology, especially when a bacterial or neoplastic aetiology is suspected and cannot be assessed by other conventional and less invasive means. A true isolated effusion may not require a specific treatment if the patient is asymptomatic, but large ones are at risk of progression to cardiac tamponade (up to one third). Pericardiocentesis alone may be curative for large effusions, but recurrences are also common and pericardiectomy or less invasive options (i.e. pericardial window) should be considered with recurrent cardiac tamponade or symptomatic pericardial effusion (either circumferential or loculated). The aim of this paper was to summarize and critically evaluate current knowledge on the management of pericardial effusion.

Pericardial disease--anatomy and function

Imaging of patients with suspected or known pericardial disease remains challenging. Echocardiography is the first-line investigation for pericardial disease but it has specific limitations in terms of its abilities to visualise the pericardium fully and to identify extracardiac pathology. Cardiac cross-sectional imaging by both MRI and CT has developed significantly and now has an important role in the investigation of pericardial disease. This article examines the appearances of both healthy and diseased pericardium using CT and MRI. The typical imaging findings across a wide range of conditions are illustrated and the roles of CT and MRI are reviewed. The relative merits and weaknesses of each modality are explored and the specific functional techniques that are available are introduced.

Management of pericarditis in women

The risk of developing pericarditis is similar in men and women. However, systemic autoimmune diseases are more common in women and may determine an increased risk of recurrences and complications. Specific management issues for women with pericarditis include pregnancy and lactation. Relatively few data have been published on pericardial involvement during pregnancy, and major concerns of clinicians are related to management issues, especially medical treatment. Nowadays, the general outcomes of these pregnancies can be similar to that expected in the general population when carefully followed by dedicated multidisciplinary teams. The aim of this article is to review the management of pericarditis with a focus on gender-specific issues.

Could heart rate play a role in pericardial inflammation?

PURPOSE AND MEDICAL HYPOTHESIS: Rest is usually recommended in acute pericarditis, as it could help to lower heart rate (HR) and contribute to limit "mechanical inflammation". Whether HR on admission could be correlated and perhaps participate to inflammation has not been reported.

METHODS

Between March 2007 and February 2010, we conducted a retrospective study on all patients admitted to our center for acute pericarditis. Diagnosis criteria included two of the following ones: typical chest pain, friction rub, pericardial effusion on cardiac echography, or typical electrocardiogram (ECG) findings. Primary endpoint was biology: CRP on admission, on days 1, 2, 3, and especially peak.

RESULTS

We included 73 patients. Median age was 38 years (interquartiles 28-51) and median hospitalization duration was 2.0 days (1.5-3.0). Median heart rate was 88.0 beats per minute (bpm) on admission (interquartiles 76.0-100.0) and 72.0 on discharge (65.0-80.0). Heart rate on admission was significantly correlated with CRP peak (p<0.001), independently of temperature on admission, hospitalization duration and age. Recurrences occurred within 1 month in 32% of patients. Heart rate on hospital discharge was correlated with recurrence, independently of age.

CONCLUSION

In acute pericarditis, heart rate on admission is independently correlated with CRP levels and heart rate on discharge seems to be independently correlated to recurrence. This could suggest a link between heart rate and pericardial inflammation.

Constrictive pericarditis with a calcified pericardial band at the level of left ventricle causing mid-ventricular obstruction

An adolescent presented with insidious onset and gradually progressive distension of abdomen associated with bilateral ankle swelling of few months duration. He had one episode of prolonged low-grade self-limiting febrile illness during childhood but had not consulted to doctor and never had been diagnosed as case of tuberculosis or acute pericarditis. A detail clinical evaluation showed raised central venous pressure, ascites and ankle oedema. Systemic examination was not much informative except ejection systolic murmur in third left intercostal space. Echocardiography and CT scan heart showed localised thickened pericardium with calcific band around the left ventricle at mid ventricle level. The band around the heart caused the heart to have a 'dumbbell' appearance with ballooning in apical area and a rare mid-ventricular obstruction in the left. A diagnosis of chronic constrictive pericarditis with calcific band was made and the patient was referred to another centre for cardiac surgery.