Multimodality Imaging for the Assessment of Pericardial Diseases

Pericarditis recurrence is associated with milder electrocardiographic, echocardiographic, and laboratory findings

Recurrent pericarditis (RP) complicates approximately 30% of acute pericarditis (AP) cases. We sought to compare the prevalence and severity of objective findings seen in patients with RP. A retrospective single-center study during 2010-2019, including 765 patients diagnosed with AP. Clinical, electrocardiographic, echocardiographic, and laboratory findings were extracted from the local electronic health records. Recurrence during follow-up was documented in 134 patients (17.5%), with a median time to recurrence of 101 (± 59-251) days. The median age was 60 years (IQR 45-72), 68% were male. Most patients were defined as having idiopathic\viral pericarditis (64%). The clinical manifestation during the recurrent event of pericarditis was less prominent or attenuated when compared to the initial event-ECG signs (ST elevation 12% vs. 26%; p = 0.006, Knuckle sign 13% vs. 33%; p < 0.001, ST larger in lead L2 than L3 4% vs. 19%; p < 0.001), pericardial effusion moderate and above (11% vs. 30%; p = 0.02), and inflammatory markers (mean peak CRP levels 66 mg/l vs. 97 mg/l; p < 0.001). Similar results were seen in the subgroup of patients defined as having idiopathic\viral pericarditis. Up to 20% of patients who did not have ECG signs or a significant pericardial effusion in their 1st event demonstrated these findings during the recurrence, though still to a lesser extent compared with those who had these signs in their 1st event. The objective findings of AP are less pronounced during recurrent events. Future studies should focus on the role of advanced biomarkers and imaging in defining true RP events.

Transient pericardial constriction: A not so rare entity

Constrictive pericarditis is a rare, potentially treatable, cause of heart failure with preserved ejection fraction that is characterized by insidious onset, challenging diagnosis and dismal prognosis, even following complete surgical pericardiectomy, particularly in advanced disease stages. In recent years it has been proposed that transient pericardial constriction may occur, with an even rarer frequency, during early phases of acute pericarditis and may resolve following specific treatment without progressing to the chronic, irreversible form. We recently observed two cases of well-documented transient pericardial constriction. In the present work we describe these two cases and provide a review on this rare condition, that, if unrecognized and left untreated, may lead to irreversible constrictive pericarditis.

Prevalence of Pericardial Late Gadolinium Enhancement in Patients After Cardiac Surgery: Clinical and Histological Correlations

BACKGROUND

Pericardial late gadolinium enhancement (LGE) is usually associated with active pericarditis, but it is not infrequently found in patients after cardiac surgery even a long time after the intervention. The clinical relevance of this finding and its histological correlates are unknown. We sought to determine the prevalence of chronic pericardial LGE in patients after cardiac surgery.

METHODS

All consecutive patients with previous cardiac surgery, who were referred to cardiovascular magnetic resonance between January 2017 and December 2021 were enrolled in the study. Cardiovascular magnetic resonance examination protocol was adapted to clinical indication but always included standard LGE acquisitions. Two independent observers blinded to clinical data assessed the presence of pericardial enhancement on LGE sequences. Fifteen patients underwent cardiac reintervention and pericardial biopsies were obtained. The primary study end point was to assess the prevalence of pericardial enhancement after cardiac surgery and identify possible determinants. The secondary end point was to correlate pericardial enhancement with clinical symptoms and histopathology.

RESULTS

Two hundred four patients were included in the study. The median time between surgery and cardiovascular magnetic resonance was 160 months (35-226 months). Pericardial LGE was observed in 90 patients (44%). All patients were asymptomatic, and no specific treatment for pericarditis was started. All patients remained asymptomatic at a 1-year clinical follow-up. Pericardial LGE was significantly correlated with the number of previous surgeries (P=0.03). Pericardial fibrosis was detected in all 15 pericardial biopsy specimens; pericardial LGE was present in 7 patients (47%) who underwent biopsy. Histological signs of low-grade inflammation were detected in 6 patients (40%) with severe, circumferential pericardial LGE but in no patient without pericardial enhancement.

CONCLUSIONS

Pericardial LGE is a frequent finding even several years after cardiac surgery. Its histological correlate is a chronic subclinical post-pericardiotomy inflammation.

Constrictive Pericarditis: An Update on Noninvasive Multimodal Diagnosis

Constrictive pericarditis (CP) is a rare condition that can affect the pericardium after every pericardial disease process and has been described even after SARS-CoV-2 infection or vaccine. In CP, the affected pericardium, usually the inner layer, is noncompliant, constraining the heart to a fixed maximum volume and impairing the diastolic function. This leads to several clinical features, that, however, can be pleomorphic. In its difficult diagnostic workup, noninvasive multimodal imaging plays a central role, providing important morphological and functional data, like the enhanced ventricular interdependence and the dissociation between intrathoracic and intracardiac pressures. An early and proper diagnosis is crucial to set an appropriate therapy, changing the prognosis of patients affected by CP. In this review, we cover in detail the main elements of each imaging technique, after a reminder of pathophysiology useful for understanding the diagnostic findings.

Advanced Cardiac Imaging and Women's Chest Pain: A Question of Gender

Awareness of gender differences in cardiovascular disease (CVD) has increased: both the different impact of traditional cardiovascular risk factors on women and the existence of sex-specific risk factors have been demonstrated. Therefore, it is essential to recognize typical aspects of ischemic heart disease (IHD) in women, who usually show a lower prevalence of obstructive coronary artery disease (CAD) as a cause of acute coronary syndrome (ACS). It is also important to know how to recognize pathologies that can cause acute chest pain with a higher incidence in women, such as spontaneous coronary artery dissection (SCAD) and myocardial infarction with non-obstructive coronary arteries (MINOCA). Coronary computed tomography angiography (CCTA) and cardiac magnetic resonance imaging (CMR) gained a pivotal role in the context of cardiac emergencies. Thus, the aim of our review is to investigate the most frequent scenarios in women with acute chest pain and how advanced cardiac imaging can help in the management and diagnosis of ACS.

Pericardial Diseases in Pregnancy

Pericardial effusion is the most common manifestation of pericardial diseases during pregnancy. This effusion is benign, mild, or moderate, well tolerated, with spontaneous resolution after delivery; no specific treatment is required. Acute pericarditis is the second most common condition, usually requiring medical therapy during pregnancy. Cardiac tamponade and constrictive pericarditis are rare in pregnancy. Pre-pregnancy counselling is essential in women of childbearing age with recurrent pericarditis to plan pregnancy in a phase of disease quiescence and to review therapy. High-dose aspirin or nonselective nonsteroidal anti-inflammatory drugs, such as ibuprofen and indomethacin, can be used up to the 20th week of gestation. Low-dose prednisone (2.5-10 mg/d) can be administered throughout pregnancy. All of these medications, apart from high-dose aspirin, may be used during lactation. Colchicine is compatible with pregnancy and breastfeeding, and it can be continued throughout pregnancy to prevent recurrences. Appropriate follow-up with a multidisciplinary team with experience in the field is recommended throughout pregnancy to ensure good maternal and fetal outcomes.

Cardiac magnetic resonance imaging of pericardial diseases: a comprehensive guide

Cardiac magnetic resonance (CMR) imaging has been established as a valuable diagnostic tool in the assessment of pericardial diseases by providing information on cardiac anatomy and function, surrounding extra-cardiac structures, pericardial thickening and effusion, characterization of pericardial effusion, and the presence of active pericardial inflammation from the same scan. In addition, CMR imaging has excellent diagnostic accuracy for the non-invasive detection of constrictive physiology evading the need for invasive catheterization in most instances. Growing evidence in the field suggests that pericardial enhancement on CMR is not only diagnostic of pericarditis but also has prognostic value for pericarditis recurrence, although such evidence is derived from small patient cohorts. CMR findings could also be used to guide treatment de-escalation or up-titration in recurrent pericarditis and selecting patients most likely to benefit from novel treatments such as anakinra and rilonacept. This article is an overview of the CMR applications in pericardial syndromes as a primer for reporting physicians. We sought to provide a summary of the clinical protocols used and an interpretation of the major CMR findings in the setting of pericardial diseases. We also discuss points that are less well clear and delineate the strengths and weak points of CMR in pericardial diseases.

Cardiac tamponade

Cardiac tamponade is a medical emergency caused by the progressive accumulation of pericardial fluid (effusion), blood, pus or air in the pericardium, compressing the heart chambers and leading to haemodynamic compromise, circulatory shock, cardiac arrest and death. Pericardial diseases of any aetiology as well as complications of interventional and surgical procedures or chest trauma can cause cardiac tamponade. Tamponade can be precipitated in patients with pericardial effusion by dehydration or exposure to certain medications, particularly vasodilators or intravenous diuretics. Key clinical findings in patients with cardiac tamponade are hypotension, increased jugular venous pressure and distant heart sounds (Beck triad). Dyspnoea can progress to orthopnoea (with no rales on lung auscultation) accompanied by weakness, fatigue, tachycardia and oliguria. In tamponade caused by acute pericarditis, the patient can experience fever and typical chest pain increasing on inspiration and radiating to the trapezius ridge. Generally, cardiac tamponade is a clinical diagnosis that can be confirmed using various imaging modalities, principally echocardiography. Cardiac tamponade is preferably resolved by echocardiography-guided pericardiocentesis. In patients who have recently undergone cardiac surgery and in those with neoplastic infiltration, effusive-constrictive pericarditis, or loculated effusions, fluoroscopic guidance can increase the feasibility and safety of the procedure. Surgical management is indicated in patients with aortic dissection, chest trauma, bleeding or purulent infection that cannot be controlled percutaneously. After pericardiocentesis or pericardiotomy, NSAIDs and colchicine can be considered to prevent recurrence and effusive-constrictive pericarditis.

Multimodality Cardiac Imaging in Patients with Systemic Lupus Erythematosus

Systemic lupus erythematous (SLE) is an autoimmune disease with a wide range of cardiovascular complications. The main manifestations include diseases of the coronary arteries, valves, pericardium, and myocardium. Multimodality cardiovascular imaging techniques are critical for evaluating the extent of cardiac manifestations in SLE patients, which can provide valuable prognostic information. However, their utility has previously not been well defined. This review provides a state-of-the-art update on the cardiovascular manifestations of lupus, as well as the role of multimodality cardiac imaging in guiding management of patients with SLE.

Pericardiectomy and Pericardial Window for the Treatment of Pericardial Disease in the Contemporary Era

PURPOSE OF REVIEW

To summarize the contemporary practice of pericardiectomy and pericardial window. We discuss the indications, preoperative planning, procedural aspects, postprocedural management, and outcomes of each procedure.

RECENT FINDINGS

Surgical approaches for the treatment of pericardial disease have been around even before the emergence of cardiopulmonary bypass. Since the forthcoming of cardiopulmonary bypass, there have been significant changes in the epidemiology and diagnostic approach of pericardial diseases as well as advancements in the surgical techniques and perioperative management used in the care of these patients. Pericardiectomy has an average mortality of almost 7% and is typically performed in patients with advanced symptoms from constrictive pericarditis and relatively few comorbidities. Pericardial window is a safe procedure for the treatment of pericardial effusion that can be performed with different approaches.

The role of multi-modality cardiovascular imaging in a patient presenting with acute liver failure secondary to constrictive pericarditis: a case report

Background

Constrictive pericarditis is a rare cause of heart failure which often presents a diagnostic challenge to clinicians.

Case summary

We describe the case of a 62-year-old male who presented to our institution with symptoms and signs suggestive of acute liver failure. Abdominal imaging demonstrated congestive hepatopathy. Clinical suspicion despite a 'normal' echocardiogram and sub-threshold NT-proBNP led to multi-modality cardiovascular imaging investigations to determine the cause of the heart failure syndrome. His cardiovascular magnetic resonance scan confirmed ventricular interdependence and extensive late enhancement in the pericardium with associated pericardial effusion. An 18F-fluorodeoxyglucose-positron emission tomography scan confirmed active pericardial inflammation. Cardiac computed tomography showed minimal pericardial calcification. Following confirming the diagnosis of effusive-constrictive pericarditis with evidence of active pericardial inflammation on imaging, a discussion within the Heart multidisciplinary team concluded that a trial of medical therapy with steroids is justifiable to avoid high-risk pericardiectomy. The patient was successfully treated with a combination of ibuprofen, colchicine, and prednisolone resulting in clinical improvement and remission of his symptoms. The imaging investigations were repeated 6 months later and confirmed radiological remission and medical therapy was discontinued.

Discussion

We stress the importance of multi-modality cardiovascular imaging in the diagnosis of constrictive pericarditis and also emphasize its role in identifying the subset of patients who may respond to medical therapy, therefore reducing the risk of high need surgical pericardiectomy.

Parametric mapping CMR for the measurement of inflammatory reactions of the pericardium

Objectives

Although cardiovascular magnetic resonance (CMR) is increasingly used to diagnose pericardial inflammation, imaging can still be challenging using conventional CMR techniques. Parametric mapping (T1/T2 mapping) techniques have emerged as novel methods to quantify focal and global changes of the myocardium without contrast agent. The aim of the present study was to implement parametric mapping to facilitate diagnostic decision-making in pericardial inflammation.

Methods

Twenty patients with pericardial inflammation underwent CMR (1.5T system) including T1-weighted/T2-weighted imaging, T1/T2 mapping and late gadolinium enhancement. T1/T2 mapping was performed in end-diastole covering three short-axis slices. Diagnosis of pericardial inflammation was made according to recent guidelines. T1/T2 measurements were pursued by manually drawing regions of interest (ROIs) in the thickened, diseased pericardium carefully avoiding contamination by other cardiac structures. Parametric values were correlated to further markers of pericardial inflammation, such as pericardial thickening and inflammatory parameters.

Results

On average, the pericardium displayed a thickness of 4.8±1.0 mm. Mean T1 value was 1363.0±227.1 ms and T2 value was 123.3±52.6 ms, which were above patient’s myocardial values (myocardial T1: 998.7±81.0 ms, p<0.001, median 1014.46 ms; T2: 68.0±28.9 m, p<0.001) and the values of a group of four patients with chronic pericarditis (T1: 953.0±16.7 ms; T2: 63.2±10.1 ms). T1 and T2 showed a correlation to the extent of the thickened pericardium (R=0.64, p=0.002 for T1, R=0.72, p=0.005 for T2). There was no correlation of pericardial T1/T2 to blood markers of inflammation, myocardial injury (C reactive protein, troponin, creatine kinase) or further CMR parameters.

Conclusions

In patients with pericardial inflammation, parametric mapping showed elevated T1 and T2 values. Parametric mapping may help to facilitate diagnosis of pericardial inflammation if conventional parameters such as pericardial hyperintensity in T1-weighted or T2-weighted imaging or contrast agent uptake are heterogeneous.

Acute Pericarditis: Update

Purpose of Review

Since 2015, when ESC guidelines for the diagnosis and management of pericardial diseases were published, ongoing research has enhanced the current state of knowledge on acute pericarditis. This review is an update on the latest developments in this field.

Recent Findings

In recurrent acute pericarditis, autoinflammation has been included among causative mechanisms restricting the vague diagnoses of “idiopathic” pericarditis. Cardiac magnetic resonance that detects ongoing pericardial inflammation may guide treatment in difficult-to-treat patients. Development of risk scores may assist identification of patients at high risk for complicated pericarditis, who should be closely monitored and aggressively treated. Treatment with IL-1 inhibitors has been proven efficacious in recurrent forms with a good safety profile. Finally, acute pericarditis has recently attracted great interest as it has been reported among side effects post COVID-19 vaccination and may also complicate SARS-CoV-2 infection.

Summary

Recent advancements in acute pericarditis have contributed to a better understanding of the disease allowing a tailored to the individual patient approach. However, there are still unsolved questions that require further research.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11886-022-01710-8.

ACR Appropriateness Criteria® Dyspnea-Suspected Cardiac Origin (Ischemia Already Excluded): 2021 Update

Dyspnea is the symptom of perceived breathing discomfort and is commonly encountered in a variety of clinical settings. Cardiac etiologies of dyspnea are an important consideration; among these, valvular heart disease (Variant 1), arrhythmia (Variant 2), and pericardial disease (Variant 3) are reviewed in this document. Imaging plays an important role in the clinical assessment of these suspected abnormalities, with usually appropriate procedures including resting transthoracic echocardiography in all three variants, radiography for Variants 1 and 3, MRI heart function and morphology in Variants 2 and 3, and CT heart function and morphology with intravenous contrast for Variant 3. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Pericardial Involvement in Sarcoidosis

Pericardial disease secondary to sarcoidosis is a rare clinical entity with no observational studies in previous research. Therefore, we evaluated reported cases of pericarditis because of sarcoidosis to further understand its diagnosis and management. We performed a systematic review of previous research until December 16, 2020 in MEDLINE, Embase, Scopus, Cochrane Central Register of Controlled Trials, and Web of Science. Case reports and case series demonstrating pericardial involvement in sarcoidosis were included. Fourteen reports with a total of 27 patients were identified. Dyspnea (82%) was the most common presentation, with the lungs being the primary site of sarcoidosis in most patients (77%). The most frequently encountered pericardial manifestations were pericardial effusion (89%), constrictive pericarditis and cardiac tamponade (48%). Management of these patients included use of corticosteroids (82%), colchicine (11%), and nonsteroidal anti-inflammatory agents (7%). Similar to the general population, the most common intervention in these patients was pericardiocentesis (59%), pericardial window (30%), and pericardiectomy (19%). Overall, the majority of this population (70%) achieved clinical improvement during median follow-up time of 8 months. In conclusion, the prevalence and incidence of sarcoid-induced pericarditial disease remain unclear. Clinical manifestations of pericardial involvement are variable, though many patients present with asymptomatic pericardial effusions. No consensus exists on the treatment of this special population, but corticosteroids and combination therapies are considered first-line therapies because of their efficacy in suppressing pericardial inflammation and underlying sarcoidosis. Patients with refractory cases of pericarditis may also benefit therapeutically from the addition of nonsteroidal anti-inflammatory agents, colchicine, and/or biologics.

Is the heart involved or not? The diagnostic value of cardiovascular magnetic resonance imaging in the assessment of non-cardiac malignancies and metastatic cardiac tumours

Cardiovascular magnetic resonance (CMR) is a radiation-free, high-spatial resolution technique which provides dynamic assessment of the heart and pericardial tissue. This is particularly useful for the evaluation and characterisation of non-cardiac tumours close to the pericardium for the exclusion of cardiovascular infiltration, and also for the assessment of the extent of myocardial invasion of cardiac metastases. This information can help make key decisions on further management in oncology multidisciplinary meetings. The CMR evaluation and main types of sequences acquired are detailed in this case series to illustrate the application of CMR in the assessment of non-cardiac malignancies and its importance in guiding management.

Established and Emerging Techniques for Pericardial Imaging with Cardiac Magnetic Resonance

PURPOSE OF REVIEW

Pericardial diseases include a wide range of pathologies and their diagnosis can often be challenging. The goal of this review is to describe the established and emerging CMR imaging techniques used in the assessment of common pericardial diseases and explain the role of pericardial characterization in their diagnosis and management.

RECENT FINDINGS

CMR is indicated in cases of diagnostic uncertainty and for a comprehensive evaluation of the pericardium and its impact on the heart. This includes assessment of pericardial anatomy and associated cardiac hemodynamics, quantification and characterization of an effusion, disease staging, tissue characterization, guiding management, and even prognostication in some diseases of the pericardium. An emerging technique, pericardial characterization, utilizes various sequences to diagnose and stage pericardial inflammation, act as a biomarker in recurrent pericarditis, and guide management in inflammatory pericardial conditions. Beyond imaging, it has ushered in an era of tailored therapy for patients with pericardial diseases. Future directions should aim at exploring the role of tissue characterization in various pericardial diseases.

Review of pericardial disease on computed tomography

Echocardiography has long been the mainstay in the evaluation of cardiac and pericardial disease. As computed tomography (CT) has advanced, it has become a valuable partner in the imaging of the pericardium. The advantages of CT include a larger field of view, multiplanar reconstruction and increased discrimination between various soft tissues and fluids. CT is less operator dependent and can more easily, and reproducibly, image areas of the pericardium for which echocardiography has poor windows such as the right pericardium. The introduction of EKG gating has decreased cardiac motion artifact and can allow functional evaluation although echocardiography remains the primary source of real-time imaging of cardiac and valve motion. It is essential for the skilled cardiac imager to understand the strengths and weaknesses of CT and its role in the definition and assessment of pericardial disease.

New Approaches to Management of Pericardial Effusions

Purpose of Review

Pericardial effusion is a challenging pericardial syndrome and a cause of serious concern for physicians and patients due to its potential progression to life-threatening cardiac tamponade. In this review, we summarize the contemporary evidence of the etiology; diagnostic work-up, with particular emphasis on the contribution of multimodality imaging; therapeutic options; and short- and long-term outcomes of these patients.

Recent Findings

In recent years, an important piece of information has contributed to put together several missing parts of the puzzle of pericardial effusion. The most recent 2015 guidelines of the European Society of Cardiology for the diagnosis and management of pericardial diseases are a valuable aid for a tailored approach to this condition. Actually, current guidelines suggest a 4-step treatment algorithm depending on the presence or absence of hemodynamic impairment; the elevation of inflammatory markers; the presence of a known or first-diagnosed underlying condition, possibly related to pericardial effusion; and finally the duration and size of the effusion. In contrast to earlier perceptions, based on the most recent evidence, it seems that in the subgroup of asymptomatic patients with large (> 2-cm end-diastolic diameter), chronic (> 3 months) C-reactive protein negative, idiopathic (without an apparent cause) pericardial effusion, a conservative approach is the most reasonable option.

Summary

At present there is an increasing interest in the pericardial syndromes in general and pericardial effusions in specific, which has consistently expanded our knowledge in this “hazy landscape.” Apart from general recommendations applied to all cases, an individualized, etiologically driven treatment is of paramount importance.

Pericardial Diseases in COVID19: a Contemporary Review

PURPOSE OF REVIEW

Coronavirus disease 2019 (COVID19) involves the heart, including pericardium. This article reviews the possible pathophysiological mechanisms in pericardial involvement in COVID19 and pericardial manifestations of COVID19. It also summarizes the patients with pericarditis secondary to COVID19 and outlines the contemporary treatment strategies in this patient population.

RECENT FINDINGS

A high degree of suspicion is required to identify the pericardial involvement in COVID19 patients. It is proposed that an underlying hyperinflammatory reaction in COVID19 leads to pericardial inflammation. Acute pericarditis with or without myocardial involvement is diagnosed on clinical presentation, serum inflammatory markers, electrocardiogram, and echocardiogram. Multimodality imaging may also have an additional diagnostic value. Patients are usually managed medically, but some patients develop a life-threatening pericardial tamponade necessitating pericardial drainage. Pericardial involvement is an important clinical manifestation of COVID19 requiring a proper workup. Timely diagnosis and a specific management plan based on the presentation and concomitant organ involvement usually lead to a complete recovery.

Diagnosis and treatment of effusive-constrictive pericarditis: a case report

Background

Effusive–constrictive pericarditis (ECP) is a rare syndrome involving pericardial effusion and concomitant constrictive pericarditis. The hallmark is a persistently elevated right atrial pressure of >10 mmHg or reduction of less than 50% from baseline despite pericardiocentesis. Aetiologies include radiation, infection, malignancy, and autoimmune disease.

Case summary

A 71-year-old man with a history of atrial fibrillation, obesity, hypertension, obstructive sleep apnoea, managed with continuous positive airway pressure presented with acute pericarditis complicated by pericardial effusion leading to cardiac tamponade. He was diagnosed with ECP after pericardiocentesis and was managed surgically with a pericardial window.

Discussion

Early detected cases of ECP can be managed by medical therapy. Therapeutic interventions include pericardiocentesis, balloon pericardiostomy, and pericardiectomy. This report describes a case of new-onset congestive heart failure secondary to ECP.

Management of acute and recurrent pericarditis in pregnancy

This review summarizes the currently available evidence on the management of acute and recurrent pericarditis during pregnancy, focusing on the safety of diagnostic procedures and treatment options for the mother and foetus. Family planning should be addressed in women with recurrent pericarditis of reproductive age and adjustment of therapy should be considered before a planned pregnancy. The treatment of pericarditis in pregnancy is similar to that for non-pregnant women but considers current knowledge on drug safety during pregnancy and lactation. The largest case series on this topic described 21 pregnancies with idiopathic recurrent pericarditis. Pregnancy should be planned in a phase of disease quiescence. Non-steroidal anti-inflammatory drugs can be used at high dosages until the 20th week of gestation (except low-dose aspirin 100 mg/die). Colchicine is allowed until gravindex positivity; after this period, administration of this drug during pregnancy and lactation should be discussed with the mother if its use is important to control recurrent pericarditis. Prednisone is safe if used at low-medium doses (2,5 - 10 mg/die). General outcomes of pregnancy in patients with pericarditis are good when the mothers are followed by a multidisciplinary team with experience in the field.

Cardiac tamponade: an educational review

Cardiac tamponade is a pericardial syndrome characterised by an impairment of the diastolic filling of the ventricles causing reduction of cardiac output, usually producing signs and symptoms of cardiac arrest, if untreated. The main causes of cardiac tamponade include percutaneous cardiac interventions, malignacies, infectious/inflammatory causes, mechanical complications of myocardial infarction and aortic dissection. The diagnosis of cardiac tamponade is a clinical diagnosis based on a suggestive history and clinical presentation with worsening dyspnoea, distended jugular veins, muffled heart sounds and pulsus paradoxus, and should be confirmed by echocardiography. Cardiac tamponade is a life-threatening syndrome that requires urgent treatment by pericardiocentesis. Pericardiocentesis is an interventional technique to drain pericardial fluid by a percutaneous route. The standard technique for pericardiocentesis is guided by echocardiography or fluoroscopy under local anaesthesia. Pericardiocentesis should be performed by experienced operators and carries a variable risk of complications, mainly cardiac chamber puncture, arrhythmias (ventricular arrhythmias suggest puncture of the ventricle), coronary artery puncture or haemothorax, pneumothorax, pneumopericardium and hepatic injury. The prognosis of cardiac tamponade is essentially related to aetiology. Cardiac tamponade in patients with cancer and metastatic involvement of the pericardium has a bad short-term prognosis because it is a sign of advanced cancer, on the contrary, patients with cardiac tamponade and a final diagnosis of idiopathic pericarditis generally have a good long-term prognosis.

Multimodality imaging in pericardial diseases

With a rapidly growing spectrum, non-specific symptoms and overlapping etiologies, pericardial diseases can represent a real diagnostic challenge. Consequently, multimodality imaging has taken a front seat in the diagnosis and management of these conditions. Cardiac CT offers an excellent anatomical characterization of pericardial thickening, fat stranding and/or presence of calcifications. and is also the preferred modality to assess extra-cardiac structures. Active pericardial inflammation, edema and fibrosis comprise pericardial characterization using CMR and allows for a precise diagnosis, disease staging and patient specific tailoring of therapies. PET scan still occupies a very modest role in the evaluation of pericardial diseases, but might help discriminating malignant pericardial effusion and extra-pulmonary tuberculous. More than ever, clinicians need to master how these modalities complement each other while avoiding unnecessary cost and to translate this knowledge into a more customized patient's care approach. The aim of this review is to recognize the role of multimodality imaging in the investigation of various pericardial diseases, assess how these modalities can impact the clinical course and treatment of these affections and finally elucidate their role in the patient's prognostication.

Contemporary management of pericardial effusion

Pericardial effusion is a relatively common clinical condition with a variety of clinical manifestations ranging from incidentally discovered asymptomatic cases to life-threatening cardiac tamponade. The etiology encompasses idiopathic cases and forms secondary to different conditions, including autoimmune diseases, malignancies, metabolic disorders, etc. While medical therapy should be offered to patients with elevation of inflammatory markers, in specific forms treatment should be appropriate to the underlying disorder. In cases with hemodynamic compromise pericardial drainage either with pericardiocentesis or pericardial "window" is indicated for therapeutic and diagnostic purposes. In the remainder, factors like comorbidities, size and location of the pericardial effusion will influence the clinical decision making. In asymptomatic or minimally symptomatic chronic large idiopathic pericardial effusions, according to recent evidence, a conservative approach with watchful waiting seems the most reasonable option. The prognosis of pericardial effusions largely depends on the underlying etiologies. Metastatic spread to the pericardium has an ominous prognosis whereas large to moderate effusions have been often associated with known or newly discovered specific underlying causes. Chronic small idiopathic effusions have an excellent prognosis and do not require specific monitoring. Large chronic idiopathic effusions in clinically stable patients require a 3 to 6-month assessment ideally in a specialized unit.

Echocardiographic assessment in cardiogenic shock

Echocardiography is the most helpful diagnostic modality in cardiogenic shock, the management of which still remains challenging despite advances in therapeutic options. The presence of cardiogenic shock portends high mortality rates. Therefore, rapid recognition, identification of the underlying cause, and evaluation of the severity of hemodynamic dysfunction are vital for correct management. Whether the cause of shock is unknown, suspected, or established, echocardiography is utilized in its diagnosis and management as well as to monitor progress. It is recommended as the modality of first choice. No other investigative bedside tool can offer comparable diagnostic capability, allowing for exact targeting of the underlying cardiac and hemodynamic problems. Echocardiography can promptly provide an impression of the etiology of shock and the potential line of treatment. Normal left ventricular and right ventricular systolic function, normal cardiac chamber dimensions, absence of any significant valvular pathology, and absence of any pericardial effusion virtually rule out a cardiac cause of shock. This review discusses the role of echocardiography as a decision-making tool in the evaluation and management of cardiogenic shock.

Update on diagnosis and management of neoplastic pericardial disease

INTRODUCTION

Pericardial neoplasms are uncommon, mostly due to secondary involvement of the pericardium by extracardiac tumors. Clinical presentation is nonspecific, frequently leading to a delayed diagnosis. Moreover, both benign and malignant pericardial tumors may be associated with myocardial infiltration and mechanical compression of cardiac chambers, possibly precipitating clinical conditions. Pericardial tumors are indeed a diagnostic and therapeutic clinical challenge.

AREAS COVERED

This review aims to provide an overview of the main clinical characteristics of pericardial tumors, along with their management in clinical practice.

EXPERT COMMENTARY

Multimodality imaging (echocardiography, chest X-ray, CT, CMR, and PET) enable full characterization of pericardial neoplasms. An individualized strategy should be developed by a multidisciplinary team including cardiologists, oncologists, radiologists, and cardiac surgeons.