Effusive-constrictive pericarditis

Novel role of cardiovascular MRI to contextualise tuberculous pericardial inflammation and oedema as predictors of constrictive pericarditis

Tuberculosis (TB) and human immunodeficiency virus/acquired immunodeficiency syndrome have reached epidemic proportions, particularly affecting vulnerable populations in low- and middle-income countries of sub-Saharan Africa. TB pericarditis is the commonest cardiac manifestation of TB and is the leading cause of constrictive pericarditis, a reversible (by surgical pericardiectomy) cause of diastolic heart failure in endemic areas. Unpacking the complex mechanisms underpinning constrictive haemodynamics in TB pericarditis has proven challenging, leaving various basic and clinical research questions unanswered. Subsequently, risk stratification strategies for constrictive outcomes have remained unsatisfactory. Unique pericardial tissue characteristics, as identified on cardiovascular magnetic resonance imaging, enable us to stage and quantify pericardial inflammation and may assist in identifying patients at higher risk of tissue remodelling and pericardial constriction, as well as predict the degree of disease reversibility, tailor medical therapy, and determine the ideal timing for surgical pericardiectomy.

Surviving the Storm: Cardiac Tamponade and Effusive Constrictive Pericarditis Complicated by Pericardial Decompression Syndrome Induced by COVID-19 Infection in the Setting of Newly Diagnosed Acute Myeloid Leukemia (AML)

Coronavirus disease 2019 (COVID-19)-induced pericarditis and pericardial myocarditis are common entities; however, the development of pericardial effusion post-COVID-19 infection has only been reported in about 5% of cases. Rapid and acute progression to pericardial tamponade is uncommon, and progression to effusive constrictive pericarditis (ECP) and pericardial decompression syndrome (PDS) is an even rarer phenomenon. We describe these phenomena in this report to raise awareness and aid clinicians in the early diagnosis and management of these conditions. We report a case of a 45-year-old female with a past medical history of recent COVID-19 infection, uncontrolled diabetes mellitus, and hypertension who presented with severe chest pain, which was determined to be acute pericarditis post-COVID-19 infection. The patient developed a large pericardial effusion leading to cardiac tamponade within one day of initial presentation. Urgent pericardiocentesis was performed but was complicated by rapid decompensation of the patient, which has been assumed to be ECP following pericardiocentesis and PDS.  Close monitoring of acute pericarditis with pericardial effusion is required in these patients for the early detection of cardiac tamponade, which requires urgent pericardiocentesis. Judicious post-pericardiocentesis follow-up is also required for the early diagnosis of conditions such as ECP and PDS. These cases are generally managed symptomatically, but in cases of severe ECP syndrome, pericardial stripping may be required.

Semiquantitative 18F-FDG PET/CT in monitoring glucocorticoid response of immunoglobulin G4-related effusive constrictive pericarditis: a case report

BACKGROUND

Immunoglobulin G4 (IgG4)-related effusive constrictive pericarditis (ECP) is a rare manifestation of IgG4-related disease (IgG4-RD). It can lead to persistent pericardial fibrosis, resulting in cardiac tamponade, diastolic dysfunction, and heart failure. Glucocorticoids are the primary treatment for effectively reducing inflammation and preventing fibrosis. However, guidelines for monitoring treatment response are lacking and tapering glucocorticoid therapy for specific target organs remains a challenge. Recent studies on IgG4-RD have demonstrated that semiquantitative measurements of fluorine-18 fluorodeoxyglucose (18F-FDG) uptake in the main involved organs in positron emission tomography/computed tomography (PET/CT) scanning are correlated to disease activity. We present a case of IgG4-related ECP to demonstrate the usefulness of 18F-FDG PET/CT for diagnosing and treatment follow-up of IgG4-related ECP.

CASE PRESENTATION

Herein, a 66-year-old woman diagnosed with IgG4-related ECP presented with breathlessness, leg swelling, rales, and fever. Laboratory tests revealed markedly elevated levels of C-reactive protein, and transthoracic echocardiography revealed constrictive physiology with effusion. High IgG4 levels suggested an immune-related pathogenesis, while viral and malignant causes were excluded. Subsequent pericardial biopsy revealed lymphocyte and plasma cell infiltration in the pericardium, confirming the diagnosis of IgG4-related ECP. 18F-FDG PET/CT revealed increased uptake of 18F-FDG in the pericardium, indicating isolated cardiac involvement of IgG4-RD. Treatment with prednisolone and colchicine led to a rapid improvement in the patient's condition within a few weeks. Follow-up imaging with 18F-FDG PET/CT after 3 months revealed reduced inflammation and improved constrictive physiology on echocardiography, leading to successful tapering of the prednisolone dose and discontinuation of colchicine.

CONCLUSION

The rarity of IgG4-related ECP and possibility of multiorgan involvement in IgG4-RD necessitates a comprehensive diagnostic approach and personalized management. This case report highlights the usefulness of 18F-FDG PET/CT in the diagnosis and treatment follow-up of isolated pericardial involvement in IgG4-RD.

Partial pericardiectomy for refractory acute tuberculous pericarditis: A case report

INTRODUCTION

Tuberculosis is an infectious disease that usually manifests in the lungs but can also affect other organs, including the cardiovascular system. In this article, we present a rare case of purulent pericarditis caused by Mycobacterium tuberculosis.

PRESENTATION OF CASE

A 67-year-old man was admitted to the emergency department with a large pericardial effusion with evidence of cardiac tamponade caused by acute pericarditis. The patient underwent surgical pericardial drainage, and a total volume of 500 mL of purulent fluid was collected with a positive culture for Mycobacterium tuberculosis. Despite antituberculous drugs, the patient presented with clinical worsening and recurrence of large pericardial effusion. Therefore, he was submitted to a second intervention by full median sternotomy to drain the pericardial effusion and perform a surgical pericardial debridement associated with a partial pericardiectomy. After the procedure, he improved clinically and was discharged after 24 days of hospitalization.

DISCUSSION

Pericardiectomy is recommended for patients with refractory tuberculous pericarditis after four to eight weeks of antituberculous treatment. We decided not to wait that long to perform an open surgical partial pericardiectomy and debridement with a median sternotomy approach. We believe that this more aggressive surgical approach would be more efficient to combat the infection, which was causing progressive deterioration of patient's clinical condition and early recurrence of significant pericardial effusion.

CONCLUSION

Open partial pericardiectomy with surgical debridement could be an efficient approach for treatment of a refractory acute tuberculous pericarditis.

Characteristics and Clinical Outcomes of Cancer Patients Who Developed Constrictive Physiology after Pericardiocentesis

BACKGROUND AND OBJECTIVES

This study aimed to identify the characteristics and clinical outcomes of cancer patients who developed constrictive physiology (CP) after percutaneous pericardiocentesis.

METHODS

One-hundred thirty-three cancer patients who underwent pericardiocentesis were divided into 2 groups according to follow-up echocardiography (CP vs. non-CP). The clinical history, imaging findings, and laboratory results, and overall survival were compared.

RESULTS

CP developed in 49 (36.8%) patients after pericardiocentesis. The CP group had a more frequent history of radiation therapy. Pericardial enhancement and malignant masses abutting the pericardium were more frequently observed in the CP group. Fever and ST segment elevation were more frequent in the CP group, with higher C-reactive protein levels (6.6±4.3mg/dL vs. 3.3±2.5mg/dL, p<0.001). Pericardial fluid leukocytes counts were significantly higher, and positive cytology was more frequent in the CP group. In baseline echocardiography before pericardiocentesis, medial e' velocity was significantly higher in the CP group (8.6±2.1cm/s vs. 6.5±2.3cm/s, p<0.001), and respirophasic ventricular septal shift, prominent expiratory hepatic venous flow reversal, pericardial adhesion, and loculated pericardial fluid were also more frequent. The risk of all-cause death was significantly high in the CP group (hazard ratio, 1.53; 95% confidence interval,1.10-2.13; p=0.005).

CONCLUSIONS

CP frequently develops after pericardiocentesis, and it is associated with poor survival in cancer patients. Several clinical signs, imaging, and laboratory findings suggestive of pericardial inflammation and/or direct malignant pericardial invasion are frequently observed and could be used as predictors of CP development.

A rare cause of effusive-constrictive pericarditis

Effusive–constrictive pericarditis (ECP) is an uncommon diagnosis, frequently missed due to its heterogeneous presentation, but a potentially reversible cause of heart failure. A 62‐year‐old Caucasian male presented with remittent right heart failure and mild–moderate pericardial effusion. Following an initial diagnosis of idiopathic pericarditis, indomethacin was started, but the patient shortly relapsed, presenting with severe pericardial effusion and signs of cardiac tamponade, requiring pericardiocentesis. ECP was diagnosed on cardiac catheterization. Cardiac computed tomography showed non‐calcified, mildly thickened and inflamed parietal pericardium. Pericardiectomy was performed with symptoms remission. On histological examination of pericardium, chronic non‐necrotizing granulomatous inflammation was noted. Polymerase chain reaction assay was positive for non‐tuberculous mycobacteria. This case represents a rare finding of ECP with unusual presentation due to atypical mycobacteriosis in a non‐immunocompromised patient and in a non‐endemic area. Pericardiectomy can be an effective option in cases unresponsive to anti‐inflammatory treatment, even in the absence of significant pericardial thickening or calcification.

Effusive-constrictive pericarditis secondary to pneumopericardium associated with gastropericardial fistula

A 66-year-old man with a history of gastric pull-up reconstruction for oesophageal cancer was hospitalized because of prolonged chest pain. Chest X-ray demonstrated pneumopericardium. Computed tomography revealed ulceration and abscess in the gastric conduit adjacent to the heart, suggesting gastropericardial fistula. As the patient did not show tamponade physiology, he was conservatively treated with antibiotics. The pneumopericardium diminished; however, he developed effusive-constrictive pericarditis with overt heart failure symptoms. Because pericardiocentesis failed to relieve the symptoms, pericardiectomy was performed. Intraoperative exploration revealed remarkably thickened pericardium and epicardium constituting multiple layers with purulent effusion. Epicardiectomy as well as pericardiectomy were required to achieve the effective reduction of central venous pressure. Perforation of the gastric conduit into the pericardial cavity was identified and repaired. Histopathology demonstrated thickened pericardium composed of hyalinized stroma, collagenous bundles, and infiltration of inflammatory cells. Streptococcus anginosus and Candida tropicalis were identified by culture of the resected tissue.

Effusive-Constrictive Pericarditis in a Young Active Duty Male

Effusive-constrictive pericarditis (ECP) is a rare clinical entity resulting from accumulating pericardial fluid within a stiff, non-compliant pericardium. There are a number of etiologies for ECP, which include malignancy, radiation, post-surgical causes, infectious, and collagen disorders. Clinically, ECP often presents as right-sided heart failure, or in advanced cases, cardiac tamponade. Symptoms may persist despite treatment with pericardiocentesis, and may warrant consideration for pericardiectomy for more definitive management. Invasive hemodynamic evaluation with cardiac catheterization remains the gold standard for diagnosis of ECP; however, echocardiography can provide a definitive diagnosis with high sensitivity and specificity. Echocardiographic features suggestive of ECP include ventricular septal motion abnormalities, such as interdependence, accentuated longitudinal motion of the heart, and altered respirophasic ventricular filling. While these features have been well established and can lead to the diagnosis of ECP, they are rarely observed in clinical practice. We present a case of ECP in a 25-year-old active duty male with a history of chest wall myoepithelial carcinoma who clearly demonstrated such echocardiographic findings of ECP.

Breaking hearts and taking names: A case of sarcoidosis related effusive-constrictive pericarditis

INTRODUCTION

Pericardial involvement of sarcoidosis is a rare cause for acute heart failure, and usually occurs as a result of the development of a pericardial effusion leading to cardiac tamponade. Even rarer still, is the manifestation of constrictive pericarditis. We report a case of sarcoidosis with lung, pleural, and pericardial involvement with effusive-constrictive pericarditis leading to cardiac tamponade.

CASE PRESENTATION

A 34-year-old Caucasian man presented for evaluation of a history of worsening exertional dyspnea, edema, and weight loss. A high-resolution chest computed tomography showed diffuse pulmonary nodules with upper lobe predominance and in a perilymphatic distribution; large right pleural effusion; and large pericardial effusion with pericardial thickening. A transthoracic echocardiogram demonstrated early tamponade physiology for which a pericardial drain was placed. After removal of the drain he developed cardiogenic shock from cardiac tamponade attributed to the reaccumulation of a pericardial effusion and urgent pericardial window was performed. Serial echocardiography was concerning for organization and localization of the pericardial fluid. Cardiac magnetic resonance imaging demonstrated a significant reduction in pericardial slippage between the parietal and visceral layers around the heart collectively suggestive of constrictive pericarditis. Confirmation of effusive-constrictive pericarditis was noted on right heart catheterization. He then underwent pericardiectomy, which on histopathologic evaluation demonstrated non-necrotizing granulomas, thus confirming pericardial involvement of sarcoidosis.

CONCLUSIONS

We report a case demonstrating unique manifestations of sarcoidosis; effusive-constrictive pericarditis presenting with acute congestive heart failure.

Acute Transient Effusive-Constrictive Pericarditis

A 52-year-old female developed acute idiopathic pericarditis, which was complicated with tamponade. Constrictive physiology persisted after pericardiocentesis, and effusive-constrictive pericarditis (ECP) was diagnosed. Constrictive physiology improved in 10 days with anti-inflammatory therapy. This case was remarkable because it showed that ECP may present in an acute and reversible form. (Level of Difficulty: Beginner.)

Effusive-Constrictive Pericarditis: Doppler Findings

PURPOSE OF REVIEW

To review the echo-Doppler findings in effusive-constrictive pericarditis (ECP). ECP corresponds to the coexistence of a hemodynamically significant pericardial effusion and markedly reduced compliance of the pericardium, manifested by constrictive physiology post-pericardiocentesis.

RECENT FINDINGS

We summarize herein the recent observations regarding the prevalence of ECP based on echocardiography as well as the pre- and post-pericardiocentesis echo-Doppler features of ECP. ECP diagnosed by echocardiography was seen in approximately 15% of patients with ECP pre- and post-pericardiocentesis echo-Doppler findings sharing features with both cardiac tamponade and constrictive pericarditis. ECP post-pericardiocentesis is common but its natural history in the current era might be better than previously reported. Further studies and (particularly simultaneous echocardiography-cardiac catheterization) are still critically needed to better understand the underlying hemodynamics of ECP. Moreover, it remains to be determined whether pre- and post-pericardiocentesis echo-Doppler findings can be used to prognosticate or to guide therapy of those undergoing pericardiocentesis.

[Management of pericarditis and pericardial effusion, constrictive and effusive-constrictive pericarditis]

This CME review takes stock of the progress in the etiology, pathophysiology, diagnostics and treatment of pericarditis and pericardial effusion brought about by the publication of the 2nd European Society of Cardiology (ESC) guidelines on the management of pericardial diseases in 2015. It also emphasizes special forms, which have received less attention in the past, such as therapy-refractory (incessant), effusive-constrictive and constrictive pericarditis and the treatment of acute and recurrent pericarditis with colchicine. After the diagnosis of pericarditis with or without effusion has been made, the first step is to clarify its etiology, which affects the clinical symptoms, course, treatment and the prognosis. In this aspect the requirements of the guidelines and the reality of an etiological classification of pericardial diseases diverge in many cases. The diagnosis of "idiopathic" acute or recurrent pericarditis is still much too often the result of insufficient efforts to find the cause. Too often only malignant and bacterial forms are excluded. If the etiology is known local intrapericardial treatment with the already inserted pigtail catheter from the diagnostic pericardial puncture can be carried out with few systemic side effects. The 2015 ESC guidelines recommend colchicine as first line treatment in all forms of pericarditis except for neoplastic pericardial effusion. It accelerates healing and reduces the frequency of recurrence of pericarditis but cannot eliminate recurrence completely. The best treatment and prevention of recurrence is the eradication of the underlying etiological cause.

Effusive-Constrictive Pericarditis

Effusive-constrictive pericarditis (ECP) corresponds to the coexistence of a hemodynamically significant pericardial effusion and decreased pericardial compliance. The hallmark of ECP is the persistence of elevated right atrial pressure postpericardiocentesis. The prevalence of ECP seems higher in tuberculous pericarditis and lower in idiopathic cases. The diagnosis of ECP is traditionally based on invasive hemodynamics but the presence of echocardiographic features of constrictive pericarditis post-pericardiocentesisis can also identify ECP. Data on the prognosis and optimal treatment of ECP are still limited. Anti-inflammatory agents should be the first line of treatment. Pericardiectomy should be reserved for refractory cases.

Restrictive Cardiomyopathy or Constrictive Pericarditis: An Unresolved Conundrum

Cardiomyopathy may have a variety of causes and may lead to significant morbidity. Often, there is no "perfect" treatment. New investigative techniques may add insight but retain the possibility of uncertainty. The distinction between restrictive cardiomyopathy and pericardial constriction may be challenging, particularly when considering the incidence of these entities. This distinction may significantly impact patient management and this is becoming increasingly important in the context of donor organ austerity. We present a case of a 17-year-old male to illustrate the overlap highlighting this debate and our subsequent management.

Effusive-Constrictive Pericarditis After Pericardiocentesis: Incidence, Associated Findings, and Natural History

OBJECTIVES

This study sought to investigate the incidence, associated findings, and natural history of effusive-constrictive pericarditis (ECP) after pericardiocentesis.

BACKGROUND

ECP is characterized by the coexistence of tense pericardial effusion and constriction of the heart by the visceral pericardium. Echocardiography is currently the main diagnostic tool in the assessment of pericardial disease, but limited data have been published on the incidence and prognosis of ECP diagnosed by echo-Doppler.

METHODS

A total of 205 consecutive patients undergoing pericardiocentesis at Mayo Clinic, Rochester, Minnesota, were divided into 2 groups (ECP and non-ECP) based on the presence or absence of post-centesis echocardiographic findings of constrictive pericarditis. Clinical, laboratory, and imaging characteristics were compared.

RESULTS

ECP was subsequently diagnosed in 33 patients (16%) after pericardiocentesis. Overt clinical cardiac tamponade was present in 52% of ECP patients and 36% of non-ECP patients (p = 0.08). Post-procedure hemopericardium was more frequent in the ECP group (33% vs. 13%; p = 0.003), and a higher percentage of neutrophils and lower percentage of monocytes were noted on pericardial fluid analysis in those patients. Clinical and laboratory findings were otherwise similar. Baseline early diastolic mitral septal annular velocity was significantly higher in the ECP group. Before pericardiocentesis, respiratory variation of mitral inflow velocity, expiratory diastolic flow reversal of hepatic vein, and respirophasic septal shift were significantly more frequent in the ECP group. Fibrinous or loculated effusions were also more frequently observed in the ECP group. Four deaths occurred in the ECP group; all 4 patients had known malignancies. During median follow-up of 3.8 years (interquartile range: 0.5 to 8.3 years), only 2 patients required pericardiectomy for persistent constrictive features and symptoms.

CONCLUSIONS

In a large cohort of unselected patients undergoing pericardiocentesis, 16% were found to have ECP. Pre-centesis echocardiographic findings might identify such patients. Long-term prognosis in those patients remains good, and pericardiectomy was rarely required.

Transient Constrictive Pericarditis: Current Diagnostic and Therapeutic Strategies

Transient constrictive pericarditis is increasingly recognized as a distinct sub-type of constrictive pericarditis. The underlying pathophysiology typically relates to impaired pericardial distensibility, associated with acute or sub-acute inflammation, rather than the fibrosis or calcification often seen in chronic pericardial constriction. Accordingly, patients may present clinically with concomitant features of pericarditis and constrictive physiology. Non-invasive multimodality imaging is advocated for diagnosis of transient constrictive pericarditis. Echocardiography remains the mainstay for initial evaluation of the dynamic features of constriction. However, cardiac magnetic resonance imaging can provide complimentary functional information, with the addition of dedicated sequences to assess for active pericardial edema and inflammation. Although transient pericardial constriction can spontaneously resolve, institution of anti-inflammatory therapy may hasten resolution or even prevent progression to chronic pericardial constriction. Non-steroidal anti-inflammatory agents remain the initial treatment of choice, with subsequent consideration of colchicine, steroids, and other immune-modulating agents in more refractory cases.

Subacute effusive-constrictive pericarditis: Echocardiography-guided diagnosis and management

A 49-year-old man presented with flu-like symptoms of two weeks. Electrocardiogram showed diffuse ST elevation. Blood samples revealed severe renal failure and moderate inflammatory results. Echocardiogram showed large pericardial effusion, dilated inferior vena cava, but no right ventricular collapse. The patient underwent hemodialysis, after which he developed clinical signs of cardiac tamponade with echocardiographic features of collapse of the right ventricle. Pericardial drainage was then performed revealing purulent fluid of 800 ml. Streptococcus agalactiae was found in the cultures of urine, blood, and pericardial fluid. Despite removal of the pericardial fluid, echocardiogram failed to show any improvement in dilated inferior vena cava and estimated right atrial pressure remained elevated. Thus, a diagnosis of subacute effusive-constrictive pericarditis was made. Following antibiotic treatment for purulent pericarditis, early pericardiectomy was performed under transesophageal echocardiographic monitoring which successfully guided surgeons to careful removal of thick and adhesive visceral pericardium as well as an additional Waffle procedure resulting in significant clinical and hemodynamic improvement. Echo-guided approach is most practical in establishing the diagnosis of effusive-constrictive pericarditis and also most helpful in obtaining successful surgical results. <Learning objective: Diagnosis of effusive-constrictive pericarditis is difficult and is not often made because of mixtures of clinical findings associated with effusion/tamponade and constriction. Echo-guided approach is most practical in establishing the diagnosis by detecting absence of normalization in dilatation of the inferior vena cava after pericardial drainage. Also, since careful removal of visceral pericardium is mandatory, transesophageal echocardiographic monitoring during pericardiectomy plays an essential role in obtaining successful surgical results.>.

Redefining Effusive-Constrictive Pericarditis with Echocardiography

Background

Effusive-constrictive pericarditis (ECP) is traditionally diagnosed by using the expensive and invasive technique of direct pressure measurements in the pericardial space and the right atrium. The aim of this study was to assess the diagnostic role of echocardiography in tuberculous ECP.

Methods

Intrapericardial and right atrial pressures were measured pre- and post-pericardiocentesis, and right ventricular and left ventricular pressures were measured post-pericardiocentesis in patients with tuberculous pericardial effusions. Echocardiography was performed post-pericardiocentesis. Traditional, pressure-based diagnostic criteria were compared with post-pericardiocentesis systolic discordance and echocardiographic evidence of constriction.

Results

Thirty-two patients with tuberculous pericardial disease were included. Sixteen had ventricular discordance (invasively measured), 16 had ECP as measured by intrapericardial and right atrial invasive pressure measurements and 17 had ECP determined echocardiographically. The sensitivity and specificity of pressure-guided measurements (compared with discordance) for the diagnosis of ECP were both 56%. The positive and negative predictive values were both 56%. The sensitivity of echocardiography (compared with discordance) for the diagnosis of ECP was 81% and the specificity 75%, while the positive and the negative predictive values were 76% and 80%, respectively.

Conclusion

Echocardiography shows a better diagnostic performance than invasive, pressure-based measurements for the diagnosis of ECP when both these techniques are compared with the gold standard of invasively measured systolic discordance.

[Progress or regress or both? ESC guidelines on pericardial diseases 2015]

Eleven years after the publication of the first guidelines worldwide on pericardial diseases by the European Society of Cardiology (ESC), the international expert group of the ESC has updated the original document of 28 pages with 275 references. The final version of the new guidelines is more voluminous with 44 pages of recommendations but only 233 references. A continuing medical education (CME) certified update of the 2004 guidelines was published in the journal Herz volume 7/2014. In comparison to 2004 the 2015 guidelines have remained virtually unchanged in the sections detailing diagnostics, differential diagnosis, pathology and pathophysiology. Substantial progress has been made in magnetic resonance imaging (MRI) of pericarditis and epicarditis and in the practically universal recommendation of colchicine for all forms of pericarditis and pericardial effusion, whether acute, chronic or recurrent. This can truly be called progress; however, little has changed since 2004 even in tertiary referral centers or universities with respect to the etiological classification of acute or recurrent forms of pericarditis or pericardial effusion. By classifying pericardial syndromes much too often as idiopathic when a malignant or bacterial cause has been excluded, the underlying cause is often overlooked. Standstill in diagnosis is in the end regress because we too often lag behind our actual diagnostic and interventional possibilities.

Computed tomography and magnetic resonance imaging evaluation of pericardial disease

Pericardial diseases are commonly encountered in clinical practice and may present as an isolated process or in association with various systemic conditions. Traditionally transthoracic echocardiography (TTE) has been the method of choice for the evaluation of suspected pericardial disease but increasingly computed tomography (CT) and magnetic resonance imaging (MRI) are also being used as part of a rational multi-modality imaging approach tailored to the specific clinical scenario. This paper reviews the role of CT and MRI across the spectrum of pericardial diseases.

[Diagnostics and therapy of pericarditis and pericardial effusion]

This article describes the diagnostics, differential diagnostics, multimodal imaging, medicinal and invasive diagnostic therapy of acute and chronic pericarditis, constrictive pericarditis, pericardial effusion and cardiac tamponade under etiological aspects and on the basis of the guidelines of the European Society of Cardiology (ESC). The starting point of the decision tree is the symptomatic patient with echocardiographic evidence of pericardial effusion. The principle feature of the diagnostics is the etiopathogenetic allocation of the pericardial disease which influences the clinical picture, course therapy and prognosis. Infectious pericarditis (e.g. viral, bacterial and tuberculous) is differentiated from sterile autoreactive pericarditis and from neoplastic pericardial effusion by the cytology of the effusion and immunohistological and molecular investigations of the pericardial and epicardial biopsies. Pericardioscopy plays an important role in the recognition of suspicious areas. In many cases intrapericardial administration of cisplatin for neoplastic pericardial effusion and instillation of triamcinolone for autoreactive pericarditis prevent recurrence just as a treatment of several months with colchicine.

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.

Isolated shortness of breath in a woman with a history of Hodgkin lymphoma

BACKGROUND

Isolated shortness of breath in the patient with a history of a malignancy creates a diagnostic challenge and serves as a source of anxiety. Although cancer recurrence is typically the first concern of the patient and the clinician, toxicities of anticancer therapies must also be considered.

METHODS

A case of a 49-year-old woman with a distant history of Hodgkin lymphoma with 2 months of progressive dyspnea is presented and discussed.

RESULTS

Although the patient was found to have bilateral pleural and pericardial effusions that were concerning for a recurrence of malignancy, analysis and cytology of fluids were negative for cancer. Instead a diagnosis of effusive-constrictive pericarditis secondary to radiation therapy was made.

CONCLUSION

When treating a patient with a history of malignancy who presents with dyspnea, it is important to consider the downstream effects related to cancer treatments, even decades later, to guide specific therapies and to assuage the patient's fears.

Immortalization protocols used in cell culture models of human breast morphogenesis

Defining the key players in normal breast differentiation is instrumental to understanding how morphogenesis becomes defective during breast cancer progression. During the past 2 decades much effort has been devoted to the development of technologies for purification and expansion of primary human breast cells in culture and optimizing a relevant microenvironment, which may help to define the niche that regulates breast differentiation and morphogenesis. In contrast to the general property of cancer, normal human cells have a finite lifespan. After a defined number of population doublings, normal cells enter an irreversible proliferation-arrested state referred to as replicative senescence. To overcome this obstacle for continuous long-term studies, replicative senescence can be bypassed by treatment of cells with chemical agents such as benzopyrene, by radiation or by transfection with viral oncogenes or the gene for human telomerase (human telomerase reverse transcriptase, hTERT). A drawback of some of these protocols is a concurrent introduction of chromosomal changes, which sometimes leads to a transformed phenotype and selection of a subpopulation, which may not be representative of the tissue of origin. In recent years, we have sought to establish immortalized primary breast cells, which retain crucial characteristics of their original in situ tissue pattern. This review discusses various approaches to immortalization of breast-derived epithelial and stromal cells and the application of such cell lines for studies on human breast morphogenesis.