American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with pericardial disease: endorsed by the Society for Cardiovascular Magnetic Resonance and Society of Cardiovascular Computed Tomography

Diagnosis, Risk Stratification, and Treatment of Pericarditis: A Review

Importance

Pericarditis accounts for up to 5% of emergency department visits for nonischemic chest pain in North America and Western Europe. With appropriate treatment, 70% to 85% of these patients have a benign course. In acute pericarditis, the development of constrictive pericarditis (<0.5%) and pericardial tamponade (<3%) can be life-threatening.

Observations

Acute pericarditis is diagnosed with presence of 2 or more of the following: sharp, pleuritic chest pain that worsens when supine (≈90%); new widespread electrocardiographic ST-segment elevation and PR depression (≈25%-50%); a new or increased pericardial effusion that is most often small (≈60%); or a pericardial friction rub (<30%). In North America and Western Europe, the most common causes of acute pericarditis are idiopathic or viral, followed by pericarditis after cardiac procedures or operations. Tuberculosis is the most common cause in endemic areas and is treated with antituberculosis therapy, with corticosteroids considered for associated constrictive pericarditis. Treatment of acute idiopathic and pericarditis after cardiac procedures or operations involves use of high-dose nonsteroidal anti-inflammatory drugs (NSAIDs), with doses tapered once chest pain has resolved and C-reactive protein level has normalized, typically over several weeks. These patients should receive a 3-month course of colchicine to relieve symptoms and reduce the risk of recurrence (37.5% vs 16.7%; absolute risk reduction, 20.8%). With a first recurrence of pericarditis, colchicine should be continued for at least 6 months. Corticosteroids are often used if pericarditis does not improve with NSAIDs and colchicine. In certain patients with multiple recurrences, which can occur for several years, interleukin 1 (IL-1) blockers have demonstrated efficacy and may be preferred to corticosteroids.

Conclusions

Acute pericarditis is a common cause of nonischemic chest pain. Tuberculosis is the leading cause of pericarditis in endemic areas and is treated with antitubercular therapy. In North America and Western Europe, pericarditis is typically idiopathic, develops after a viral infection, or develops following cardiac procedures or surgery. Treatment with NSAIDs and colchicine leads to a favorable prognosis in most patients, although 15% to 30% of patients develop recurrence. Patients with multiple recurrent pericarditis can have a disease duration of several years or more, are often treated with corticosteroids, and IL-1 blockers may be used for selected patients as steroid-sparing therapy.

Post cardiac arrest left ventricular ejection fraction associated with survival to discharge

Background

Post cardiac arrest left ventricular ejection fraction (LVEF) is routinely assessed, but the implications of this are unknown. This study aimed to assess the association between post cardiac arrest LVEF and survival to hospital discharge.

Methods

In this retrospective cohort study, all in-hospital and out of hospital cardiac arrests at our tertiary care center between January 2012 and September 2015 were included. Baseline demographics, clinical data, characteristics of the arrest, and interventions performed were collected. Earliest post cardiac arrest echocardiograms were reviewed with LVEF documented. The primary outcome was survival to discharge.

Results

A total of 736 patients were included in the analysis (mean age 58 years, 44% female). 15% were out of hospital cardiac arrest (24% shockable rhythm). After adjusting for covariates, patients with LVEF < 30% had 36% lower odds of surviving to hospital discharge than those with LVEF ≥ 52% (p = 0.014). Shockable initial rhythm and targeted temperature management were associated with improved survival.

Conclusion

After a cardiac arrest, an initial LVEF < 30% is associated with significantly lower odds of survival to hospital discharge.

Predicting Long-Term Clinical Outcomes of Patients With Recurrent Pericarditis

BACKGROUND

Recurrent pericarditis (RP) is a complex condition associated with significant morbidity. Prior studies have evaluated which variables are associated with clinical remission. However, there is currently no established risk-stratification model for predicting outcomes in these patients.

OBJECTIVES

We developed a risk stratification model that can predict long-term outcomes in patients with RP and enable identification of patients with characteristics that portend poor outcomes.

METHODS

We retrospectively studied a total of 365 consecutive patients with RP from 2012 to 2019. The primary outcome was clinical remission (CR), defined as cessation of all anti-inflammatory therapy with complete resolution of symptoms. Five machine learning survival models were used to calculate the likelihood of CR within 5 years and stratify patients into high-risk, intermediate-risk, and low-risk groups.

RESULTS

Among the cohort, the mean age was 46 ± 15 years, and 205 (56%) were women. CR was achieved in 118 (32%) patients. The final model included steroid dependency, total number of recurrences, pericardial late gadolinium enhancement, age, etiology, sex, ejection fraction, and heart rate as the most important parameters. The model predicted the outcome with a C-index of 0.800 on the test set and exhibited a significant ability in stratification of patients into low-risk, intermediate-risk, and high-risk groups (log-rank test; P < 0.0001).

CONCLUSIONS

We developed a novel risk-stratification model for predicting CR in RP. Our model can also aid in stratifying patients, with high discriminative ability. The use of an explainable machine learning model can aid physicians in making individualized treatment decision in RP patients.

Left atrial compression syndrome secondary to coronary artery perforation: Pathophysiology, diagnosis, and management strategies

Coronary perforation (CP) poses a significant risk of morbidity and mortality, particularly, in patients with a history of cardiac surgery. The occurrence of loculated pericardial effusion presents distinctive challenges in these postcardiac surgical patients. This study delves into the complexities arising from the formation of loculated pericardial effusions subsequent to CP, with a specific focus on the loculated effusion in the posterior wall leading to left atrial compression syndrome. This analysis is dedicated to elucidating pathophysiology diagnostic and treatment strategies tailored for addressing left atrium compression syndrome, providing invaluable insights into the intricacies of diagnosing, treating, and managing this entity in the postcardiac surgical patient.

Congenital Absence of Pericardium: The Swinging Heart

Congenital absence of the pericardium (CAP) is an unusual condition discovered, in most cases, incidentally but can potentially lead to fatal complications, including severe arrhythmias and sudden death. Recently, the use of modern imaging technologies has increased the diagnosis of CAP, providing important findings for risk stratification. Nevertheless, there is not yet consensus regarding therapeutic decisions, and the management of patients with CAP remains challenging. In this paper, we discuss the pathophysiological implication of CAP, review the current literature and explain the role of multimodality imaging tools for its diagnosis, management and treatment.

Position Statement on Cardiac Computed Tomography Following Left Atrial Appendage Occlusion

Left atrial appendage occlusion (LAAO) is rapidly growing as valid stroke prevention therapy in atrial fibrillation. Cardiac imaging plays an instrumental role in preprocedural planning, procedural execution, and postprocedural follow-up. Recently, cardiac computed tomography (CCT) has made significant advancements, resulting in increasing use both preprocedurally and in outpatient follow-up. It provides a noninvasive, high-resolution alternative to the current standard, transesophageal echocardiography, and may display advantages in both the detection and characterization of device-specific complications, such as peridevice leak and device-related thrombosis. The implementation of CCT in the follow-up after LAAO has identified new findings such as hypoattenuated thickening on the atrial device surface and left atrial appendage contrast patency, which are not readily assessable on transesophageal echocardiography. Currently, there is a lack of standardization for acquisition and interpretation of images and consensus on definitions of essential findings on CCT in the postprocedural phase. This paper intends to provide a practical and standardized approach to both acquisition and interpretation of CCT after LAAO based on a comprehensive review of the literature and expert consensus among European and North American interventional and imaging specialists.

Pericardial Diseases and Best Practices for Pericardiectomy: JACC State-of-the-Art Review

Remarkable advances have occurred in the understanding of the pathophysiology of pericardial diseases and the role of multimodality imaging in this field. Medical therapy and surgical options for pericardial diseases have also evolved substantially. Pericardiectomy is indicated for chronic or irreversible constrictive pericarditis, refractory recurrent pericarditis despite optimal medical therapy, or partial agenesis of the pericardium with a complication (eg, herniation). A multidisciplinary evaluation before pericardiectomy is essential for optimal patient outcomes. Overall, given the good outcomes reported, radical pericardiectomy on cardiopulmonary bypass, if feasible, is the preferred approach. Due to patient complexity, as well as the technical aspects of the surgery, pericardiectomy should be performed at high-volume centers that have the required expertise. The current review highlights the essential features of this multidisciplinary approach from diagnosis to recovery in patients undergoing pericardiectomy.

Acute Pericarditis Triggered by Severe Thyrotoxicosis

Acute pericarditis is a common inflammatory disorder with several causes including infection, malignancy, acute myocardial infarction, and autoimmune disease. Acute pericarditis can rarely present in the setting of thyrotoxicosis. A 65-year-old man with a past medical history of HIV, diastolic dysfunction, and prediabetes presented with positional chest pain, respiratory distress, and altered mentation. He was found down on the ground in a lethargic state and was last seen normally five days before the presentation. On presentation, he was tachycardic and tachypneic, requiring supplemental oxygenation with a nonrebreather mask to maintain adequate oxygen saturation. Initial electrocardiogram (EKG) demonstrated diffuse ST-elevations with early repolarization, consistent with acute pericarditis. Laboratory diagnostics revealed elevated lactic acid, leukocytosis, acute kidney injury, undetectable thyroid stimulating hormone, and elevations in T3, T4, C-reactive protein, brain natriuretic peptide, and creatinine kinase. Given the patient's complex presentation involving thyrotoxicosis and pericarditis, a multidisciplinary team discussion was pursued involving critical care, cardiology, and endocrinology. He was started on intravenous methylprednisolone (subsequently transitioned to prednisone), methimazole, and metoprolol. Colchicine was subsequently added for the management of pericarditis and prednisone was continued (given concomitant thyroid disease) with a plan for tapering them off, per cardiology and endocrinology recommendations. A transthoracic echocardiogram revealed a small pericardial effusion. Anticoagulation was not initiated given the potential risk of developing a hemorrhagic pericardial effusion. Thyroid ultrasound was nonsuggestive of Graves' disease. Thyrotoxicosis may present with a constellation of symptoms, including acute pericarditis. Timely recognition with EKG and echocardiography can aid in prompt management.

Pericardial Disease in Cardiac Amyloidosis: A Comprehensive Review

In patients with cardiac amyloidosis, pericardial involvement is common, with up to half of patients presenting with pericardial effusions. The pathophysiological mechanisms of pericardial pathology in cardiac amyloidosis include chronic elevations in right-sided filling pressures, myocardial and pericardial inflammation due to cytotoxic effects of amyloid deposits, and renal involvement with subsequent uremia and hypoalbuminemia. The pericardial effusions are typically small; however, several cases of life-threatening cardiac tamponade with hemorrhagic effusions have been described as a presenting clinical scenario. Constrictive pericarditis can also occur due to amyloidosis and its identification presents a clinical challenge in patients with cardiac amyloidosis who concurrently manifest signs of restrictive cardiomyopathy. Multimodality imaging, including echocardiography, cardiac computed tomography, and cardiac magnetic resonance imaging, is useful in the evaluation and management of this patient population. The recognition of pericardial effusion is important in the risk stratification of patients with cardiac amyloidosis as its presence confers a poor prognosis. However, specific treatment aimed at the effusions themselves is seldom indicated. Cardiac tamponade and constrictive pericarditis may necessitate pericardiocentesis and pericardiectomy, respectively.

Asymptomatic Chronic Large Pericardial Effusions: To Drain or to Observe?

Pericardial effusions, especially large ones, have traditionally been regarded with concern by clinicians due to the sometimes unpredictable development of life-threatening cardiac tamponade. In the European Society of Cardiology Guidelines on pericardial diseases, the simplified algorithm for pericardial effusion triage and management recommends pericardial drainage in cases of cardiac tamponade and/or suspicion of bacterial or neoplastic etiology. In the presence of acute pericarditis, empiric anti-inflammatory treatment should be given, while when a specific indication known to be associated with pericardial effusion is found, then treatment of the underlying cause is indicated. Notably, the most challenging subgroup of patients includes those with large, asymptomatic, C-reactive-protein-negative, idiopathic effusions. In the latter subjects, pericardial drainage is proposed in cases of chronic effusions (lasting more than three months). However, this recommendation is based on scant data stemming from small-sized non-randomized studies. Nevertheless, recent evidence in a larger cohort of patients pointed out that a watchful waiting strategy is a safe option in terms of complication-free survival. This review summarizes the contemporary evidence on this challenging topic and provides recommendations for tailoring individual patient treatments.

Prognostic Utility of Pericardial Effusion in the General Population: Findings From the STAAB Cohort Study

BACKGROUND

The incidental finding of a pericardial effusion (PE) poses a challenge in clinical care. PE is associated with malignant conditions or severe cardiac disease but may also be observed in healthy individuals. This study explored the prevalence, determinants, course, and prognostic relevance of PE in a population-based cohort.

METHODS AND RESULTS

The STAAB (Characteristics and Course of Heart Failure Stages A/B and Determinants of Progression) cohort study recruited a representative sample of the population of Würzburg, aged 30 to 79 years. Participants underwent quality-controlled transthoracic echocardiography including the dedicated evaluation of the pericardial space. Of 4965 individuals included at baseline (mean age, 55±12 years; 52% women), 134 (2.7%) exhibited an incidentally diagnosed PE (median diameter, 2.7 mm; quartiles, 2.0-4.1 mm). In multivariable logistic regression, lower body mass index and higher NT-proBNP (N-terminal pro-B-type natriuretic peptide) levels were associated with PE at baseline, whereas inflammation, malignancy, and rheumatoid disease were not. Among the 3901 participants attending the follow-up examination after a median time of 34 (30-41) months, PE was found in 60 individuals (1.5%; n=18 new PE, n=42 persistent PE). Within the follow-up period, 37 participants died and 93 participants reported a newly diagnosed malignancy. The presence of PE did not predict all-cause death or the development of new malignancy.

CONCLUSIONS

Incidental PE was detected in about 3% of individuals, with the vast majority measuring <10 mm and completely resolving. PE was not associated with inflammation markers, death, incident heart failure, or malignancy. Our findings corroborate the view of current guidelines that a small PE in asymptomatic individuals can be considered an innocent phenomenon and does not require extensive short-term monitoring.

Pericardial effusion in patients with chronic kidney disease: A two-center study

BACKGROUND AND AIMS

Pericardial effusion (PE) is a prevalent form of pericardial involvement in chronic kidney disease (CKD). This study aims to investigate the clinical and laboratory features associated with PE severity in patients with CKD.

METHODS

In this cross-sectional study, we examined the medical records of patients admitted to tertiary hospitals with International Classification of Diseases 10th Revision (ICD-10) codes associated with CKD and PE. We included 112 CKD patients in stage 4 and 5 non-dialysis (ND) with PE for assessing the clinical and laboratory features of severity.

RESULTS

Patients were divided into two categories based on the severity of PE. Seventy-two patients had mild and 40 had moderate and severe PE. Univariate analysis of demographic and laboratory features on the date of admission demonstrated that chest pain, dyspnea, serum albumin, and neutrophil-to-lymphocyte ratio (NLR) are associated with the severity of PE. The univariate analysis on the date of echocardiography showed significantly higher white blood cell count (WBC), neutrophil count (percentage and absolute count), and NLR, along with significantly lower lymphocyte percentage and serum albumin among patients with moderate and severe PE. In the multivariable analysis of laboratory features, on admission hypoalbuminemia (p-value = 0.014, OR = 4.03, CI: 1.32-12.25) and NLR greater than 5.5 (p-value = 0.015, OR = 4.22, CI: 1.32-13.50) were significantly associated with moderate and severe PE. In a parallel matter, at the time of echocardiography hypoalbuminemia (p-value = 0.004, OR = 5.38, CI: 1.74-16.65) and neutrophilia (p-value = 0.005, OR = 7.94, CI: 1.89-33.44) were significantly associated with moderate and severe PE.

CONCLUSION

Despite advancements in the diagnosis and treatment of CKD, PE is still a concerning issue in these patients. This study revealed that hypoalbuminemia, neutrophilia, and NLR greater than 5.5 could be predictive factors of moderate and severe PE in CKD patients with PE. Further prospective study with larger sample size is needed to confirm these results.

2024 CSANZ Position Statement on Indications, Assessment and Monitoring of Structural and Valvular Heart Disease With Transthoracic Echocardiography in Adults

Transthoracic echocardiography (TTE) is the most widely available and utilised imaging modality for the screening, diagnosis, and serial monitoring of all abnormalities related to cardiac structure or function. The primary objectives of this document are to provide (1) a guiding framework for treating clinicians of the acceptable indications for the initial and serial TTE assessments of the commonly encountered cardiovascular conditions in adults, and (2) the minimum required standard for TTE examinations and reporting for imaging service providers. The main areas covered within this Position Statement pertain to the TTE assessment of the left and right ventricles, valvular heart diseases, pericardial diseases, aortic diseases, infective endocarditis, cardiac masses, pulmonary hypertension, and cardiovascular diseases associated with cancer treatments or cardio-oncology. Facilitating the optimal use and performance of high quality TTEs will prevent the over or under-utilisation of this resource and unnecessary downstream testing due to suboptimal or incomplete studies.

Risk Prediction, Diagnosis and Management of a Breast Cancer Patient with Treatment-Related Cardiovascular Toxicity: An Essential Overview

Breast cancer is amongst the most common invasive cancers in adults. There are established relationships between anti-cancer treatments for breast cancer and cardiovascular side effects. In recent years, novel anti-cancer treatments have been established, as well as the availability of multi-modal cardiac imaging and the sophistication of treatment for cardiac disease. This review provides an in-depth overview regarding the interface of breast cancer and cancer therapy-related cardiovascular toxicity. Specifically, it reviews the pathophysiology of breast cancer, the method of action in therapy-related cardiovascular toxicity from anti-cancer treatment, the use of echocardiography, cardiac CT, MRI, or nuclear medicine as diagnostics, and the current evidence-based treatments available. It is intended to be an all-encompassing review for clinicians caring for patients in this situation.

Cardiac Tamponade and Pericardiocentesis: Recognition, Standard Techniques, and Modern Advancements

Pericardiocentesis is an important diagnostic and therapeutic procedure. In the setting of cardiac tamponade, pericardiocentesis can rapidly improve hemodynamics, and in cases of diagnostic uncertainty, pericardiocentesis allows for fluid analysis to aid in diagnosis. In contemporary practice, the widespread availability of ultrasonography has made echocardiographic guidance the standard of care. Additional tools such as micropuncture technique, live ultrasonographic guidance, and adjunctive tools including fluoroscopy continue to advance and enhance procedural efficiency and safety. When performed by experienced operators, pericardiocentesis is a safe, effective, and potentially life-saving procedure.

Acute and Complicated Inflammatory Pericarditis: A Guide to Contemporary Practice

Inflammatory disease of the pericardium represents a relatively common presentation, especially among the young. For the most part, inflammatory pericardial disease can be expeditiously and effectively managed without significant sequelae. However, some individuals present with severe and recurrent illness, representing significant therapeutic challenges. During the past decade, there have been great strides made in developing an evidence-based approach to management of inflammatory pericardial disease, the result of which has been the development of (1) a systematic, protocoled approach to initial care; (2) targeted therapeutics; and (3) specialized, collaborative, and integrated care pathways. Herein we present a review of the current state of the art as it pertains to the diagnostic evaluation and therapeutic considerations in inflammatory pericardial disease with a focus on acute and complicated pericarditis.

Post-cardiac injury syndrome and pericardial effusion recurrence after pericardial effusion drainage in chronic idiopathic pericardial effusion

INTRODUCTION

The management of even large pericardial effusions in asymptomatic patients is still a matter of debate. Aim of the present study is to explore, in a multicenter setting, the rate of post-cardiac injury syndromes (PCIS) and pericardial effusion recurrence after pericardial effusion drainage procedure.

MATERIAL AND METHODS

This is a multicenter international retrospective study including a consecutive cohort of patients diagnosed with large, chronic and idiopathic pericardial effusions, prospectively evaluated from January 2003 to December 2021 who underwent a clinically indicated pericardial drainage procedure. Two separate end-points were recorded: 1) recurrence of pericardial effusion after drainage without any sign of pericardial inflammation 2) occurrence of PCIS, defined as the new onset of pericarditis 1 to 6 weeks after pericardial intervention.

RESULTS

124 patients were enrolled (50 % female, mean age 64 years old). A mean follow-up of 29.6 ± 25.6 months was obtained in 110 patients (88 %). 110 patients were treated with pericardiocentesis (89 %), 25 with pleuro-pericardial windows (20 %), and 1 with pericardiectomy (1 %). PCIS occurred in 21 out of 124 patients followed for at least 6 weeks (16.9%). Recurrence of pericardial effusion after drainage without any sign of pericardial inflammation occurred in 68 out of 110 patients at a longer follow-up (61.8 %). At multivariate analysis only inflammatory cells in pericardial fluid was associated with PCIS and pericardiocentesis with pericardial effusion recurrency.

CONCLUSION

Our data support the need of caution with the use of pericardiocentesis in asymptomatic patients with large pericardial effusion as it is often associated with pericardial effusion recurrence. Of interest the presence of inflammatory cells in the pericardial fluid is associated with PCIS after pericardial drainage procedures.

The Postoperative Paradoxical Septum (POPS): A Comprehensive Review on Physio-Pathological Mechanisms

The interventricular septum (IVS) is a core myocardial structure involved in biventricular coupling and performance. Physiologically, during systole, it moves symmetrically toward the center of the left ventricle (LV) and opposite during diastole. Several pathological conditions produce a reversal or paradoxical septal motion, such as after uncomplicated cardiac surgery (CS). The postoperative paradoxical septum (POPS) was observed in a high rate of cases, representing a unicum in the panorama of paradoxical septa as it does not induce significant ventricular morpho-functional alterations nor negative clinical impact. Although it was previously considered a postoperative event, evidence suggests that it might also appear during surgery and gradually resolve over time. The mechanism behind this phenomenon is still debated. In this article, we will provide a comprehensive review of the various theories generated over the past fifty years to explain its pathological basis. Finally, we will attempt to give a heuristic interpretation of the biventricular postoperative motion pattern based on the switch of the ventricular anchor points.

Complete Congenital Absence of the Left Pericardium in Elderly Patient: A Case Report

Congenital pericardial absence is an uncommon heart condition that is usually undiagnosed due to a lack of symptoms and awareness. In this case study, we present a 72-year-old patient who initially presented for medical evaluation due to unexplained weight loss, a displaced cardiac apex, and poor echocardiographic windows. An extracardiac tumor was suspected at first, but it was later determined that the patient had a congenital complete absence of the left pericardium. This case illustrates the possibility for benign pathology to present abnormally and details the clinical features, imaging findings, and management of congenital absence of the pericardium.

Blood or Fat? Differentiating Hemopericardium versus Epicardial Fat Using Focused Cardiac Ultrasound

Basic point-of-care ultrasound of the heart-also known as Focused Cardiac Ultrasound (FoCUS)-has emerged as a powerful bedside tool to narrow the differential diagnosis of causes of hypotension. The list of causes of hypotension that a FoCUS provider is expected to be able to recognize includes a compressive pericardial effusion due to hemopericardium (blood in the pericardial sac). But hemopericardium can be difficult to distinguish from a more common condition that is not immediately life-threatening: epicardial fat. This paper reviews illustrative images of both epicardial fat and hemopericardium to provide practice guidance to the FoCUS user on how to differentiate these two phenomena.

Is pulmonary hypertension protective against cardiac tamponade? A systematic review

The presence of pulmonary hypertension (PH) may affect whether cardiac tamponade physiology develops from a pericardial effusion. Specifically, the increased intracardiac pressure and right ventricular hypertrophy associated with PH would seemingly increase the intrapericardial pressure threshold at which the right-sided chambers collapse. In this systematic review, we examined the impact of PH on the incidence, in-hospital and long-term mortality, and echocardiographic findings of patients with cardiac tamponade. Using the PRISMA guideline, a systematic search was conducted in PubMed, Academic Search Premier, Web of Science, Google Scholar, and the Cochrane Database for studies investigating PH and cardiac tamponade. The Newcastle-Ottawa Scale was used to analyze the quality of returned studies. Primary outcomes included the incidence of cardiac tamponade, as well as in-hospital and long-term mortality rates. Secondary outcomes were the presence or absence of echocardiographic findings of cardiac tamponade in patients with PH. Forty-three studies (9 cohort studies and 34 case reports) with 1054 patients were included. The incidence of cardiac tamponade was significantly higher in patients with PH compared to those without PH, 2.0% (95% CI 1.2-3.2%) vs. 0.05% (95% CI 0.05-0.05%), p < 0.0001, OR 40.76 (95% CI 24.8-66.9). The incidence of tamponade in patients with a known pericardial effusion was similar in those with and without PH, 20.3% (95% CI 12.0-32.3%) and 20.9% (95% CI 18.0-24.1%), p = 0.9267, OR 0.97 (95% CI 0.50-1.87). In patients with tamponade, those with PH demonstrated a significantly higher in-hospital mortality than those without PH, 38.8% (95% CI 26.4-52.8%) vs. 14.4% (95% CI 14.2-14.6%), p < 0.0001, OR 3.77 (95% CI 2.12-6.70). Long-term mortality in patients with tamponade was significantly lower in those with PH than in those without PH, 45.5% (95% CI 33.0-58.5%) vs. 59.1% (95% CI 54.7-63.4%), p = 0.0258, OR 0.576 (95% CI 0.33-1.01). However, after stratifying by non-malignant etiologies, the long-term mortality benefit for those with PH disappeared. In the studies that described specific echocardiographic findings of cardiac tamponade, only 10.5% of patients with PH and tamponade showed right atrial and right ventricular collapse. When evaluating patients with pericardial effusions, physicians must recognize the effects of underlying PH on the incidence, in-hospital and long-term mortality rates, and potentially atypical echocardiographic presentation of cardiac tamponade.

Re-enforcing High-Risk Acute Pericarditis Requiring Hospital Admission: An Unusual Case of Critical Idiopathic Acute Pericarditis Presenting As Tamponade and Pleuro-Pericardial Complications in a Patient Presenting With Flu-Like Symptoms

Pericarditis is an inflammatory process that affects the pericardium, the fibrous sac surrounding the heart. Acute pericarditis accounts for approximately 0.1% of inpatient admissions and 5% of non-ischemic chest pain visits to the emergency departments (EDs). Most patients who present with acute pericarditis have a benign course and good prognosis. However, a rare percent of the patients develop complicated pericarditis. Examples of complications include pericardiac effusion, cardiac tamponade, constrictive pericarditis, effusive and constrictive pericarditis and, even more rarely, large pleural effusion The occurrence of complicated pericarditis can lead to high morbidity and mortality if not urgently managed in most patients. Our case presents a 60-year-old male that presented to the emergency room with flu-like symptoms. However, the viral panel test was negative. He initially got discharged with supportive care but was brought back to the ED by his wife in a critical, life-threatening state due to pericarditis symptoms complicated by tamponade and shock. His condition required urgent intervention and critical level of care. The patient's course was also complicated by myopericarditis and recurrent bilateral pleural effusions, which required therapeutic interventions. This unique case presents the patient group that develop multiple life-threatening complications of acute pericarditis, including cardiac tamponade and shock, affecting several end organs. This case also highlights clues to the predisposing factors to complications of acute pericarditis. Patients who present with high-risk signs and symptoms indicating poorer prognosis warrant further observation and admission. This will also add to the literature reviews regarding the risk factors associated with development of complicated acute pericarditis. This will also serve as a review of pathophysiology, etiology, current diagnosis and available novel treatment for such patients.

Fever and dyspnea after anti-Covid-19 vaccination: a challenging diagnosis

There is still little information regarding the long-term safety of the vaccines. We report a case of new-onset adult-onset Still's disease (AOSD) that occurred following Covid-19 vaccination. This patient went to the emergency room with dyspnea from the last two weeks and bilateral swellings that occurred several weeks after the first vaccination. Based on the symptoms and laboratory results, we suspected AOSD. Considering the time relationship between Covid-19 vaccination and AOSD onset in our patient, and possible mechanisms linking vaccination with the onset of autoimmune disorders, physicians should consider adverse events from Covid-19 vaccination and assess the benefits and risks of vaccination for each patient.

Epicardial Space: Comprehensive Anatomy and Spectrum of Disease

The epicardial space (ES) is the anatomic region located between the myocardium and the pericardium. This space includes the visceral pericardium and the epicardial fat that contains the epicardial coronary arteries, cardiac veins, lymphatic channels, and nerves. The epicardial fat represents the main component of the ES. This fat deposit has been a focus of research in recent years owing to its properties and relationship with coronary gossypiboma plaque and atrial fibrillation. Although this region is sometimes forgotten, a broad spectrum of lesions can be found in the ES and can be divided into neoplastic and nonneoplastic categories. Epicardial neoplastic lesions include lipoma, paraganglioma, metastases, angiosarcoma, and lymphoma. Epicardial nonneoplastic lesions encompass inflammatory infiltrative disorders, such as immunoglobulin G4-related disease and Erdheim-Chester disease, along with hydatidosis, abscesses, coronary abnormalities, pseudoaneurysms, hematoma, lipomatosis, and gossypiboma. Initial imaging of epicardial lesions may be performed with echocardiography, but CT and cardiac MRI are the best imaging modalities to help characterize epicardial lesions. Due to the nonspecific onset of signs and symptoms, the clinical history of a patient can play a crucial role in the diagnosis. A history of malignancy, multisystem diseases, prior trauma, myocardial infarction, or cardiac surgery can help narrow the differential diagnosis. The diagnostic approach to epicardial lesions should be made on the basis of the specific location, characteristic imaging features, and clinical background. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Echocardiographic manifestations in end-stage renal disease

End-stage renal disease (ESRD) is a common but profound clinical condition, and it is associated with extremely increased morbidity and mortality. ESRD can represent four major echocardiographic findings-myocardial hypertrophy, heart failure, valvular calcification, and pericardial effusion. Multiple factors interplay leading to these abnormalities, including pressure/volume overload, oxidative stress, and neurohormonal imbalances. Uremic cardiomyopathy is characterized by left ventricular (LV) hypertrophy and marked diastolic dysfunction. In ESRD patients on hemodialysis, LV geometry is changeable bidirectionally between concentric and eccentric hypertrophy, depending upon changes in corporal fluid volume and arterial pressure, which eventually results in a characteristic of LV systolic dysfunction. Speckle tracking echocardiography enabling to detect subclinical disease might help prevent future advancement to heart failure. Heart valve calcification also is common in ESRD, keeping in mind which progresses faster than expected. In a modern era, pericardial effusion observed in ESRD patients tends to result from volume overload, rather than pericarditis. In this review, we introduce and discuss those four echocardiography-assessed findings of ESRD, with which known and conceivable pathophysiologies for each are incorporated.

Diagnostic accuracy of Point Of Care UltraSound (POCUS) in clinical practice: A retrospective, emergency department based study

AIMS

Point-of-care ultrasound (POCUS) is the acquisition and interpretation of ultrasound imaging at the bedside to solve specific clinical questions based on signs and symptoms of presentation. While several studies evaluated POCUS diagnostic accuracy for a variety of clinical pictures in the emergency department (ED), only a few data are available on POCUS diagnostic accuracy performed by physicians with different POCUS skills. The objective of this research was to evaluate the diagnostic accuracy of POCUS compared to standard diagnostic imaging in the ED.

MATERIALS AND METHODS

This was a retrospective study conducted in the ED of a third-level university hospital. Patients who underwent cardiac, thoracic, abdominal, or venous lower limb POCUS and a standard imaging examination between June 2021 and January 2022 were included.

RESULTS

1047 patients were screened, and 844 patients included. A total of 933 POCUS was included (102, 12.09%, cardiac; 466, 55.21%, thoracic; 336, 39.8%, abdominal; 29, 3.44%, lower limb venous POCUS), accounting for 2029 examinations. POCUS demonstrated 96.6% (95% CI 95.72-97.34) accuracy, 47.73 (95% CI 33.64-67.72) +LR, 0.09 (95% CI 0.06-0.12) -LR. +LR was greater than 10 for all investigations but for hydronephrosis (5.8), and -LR never exceeded 0.4.

CONCLUSIONS

POCUS exhibited high diagnostic accuracy for virtually all conditions when performed by emergency department physicians.

Spontaneous Hemorrhagic Pericardial Effusion as a Consequence of Apixaban Utilization for New-Onset Atrial Fibrillation

Although anticoagulation stands as a standardized therapeutic approach for mitigating thrombotic risks in atrial fibrillation, the potential for bleeding associated with direct oral anticoagulants (DOACs) is consistently weighed in the risk/benefit analysis prior to initiating therapy for non-valvular atrial fibrillation. While the typical bleeding risks from DOACs predominantly affect the gastrointestinal system, occurrences of spontaneous hemorrhagic pericardial effusions are rare. This case presentation illustrates a patient developing spontaneous hemorrhagic pericardial effusion four days after commencing apixaban therapy and subsequent management.

Variability in Interpretation of Echocardiographic Signs of Tamponade: A Survey of Emergency Physician Sonographers

BACKGROUND

Cardiac tamponade is associated with high mortality, and making the diagnosis is a core skill of emergency physicians. Proper diagnosis relies on specific clinical and echocardiographic findings. It is not known whether expert sonographers consistently recognize echocardiographic signs of tamponade.

OBJECTIVES

To assess whether expert sonographers agree on echocardiographic signs of tamponade.

METHODS

A 20-question survey consisting of 18 cine loops and 2 still images was distributed to the Academy of Emergency Ultrasound Section of the Society for Academic Emergency Medicine. Respondents answered "yes" or "no" to whether there was echocardiographic evidence of tamponade. Subgroup analyses of demographics and echocardiographic views were reported. The data were analyzed using Krippendorff's alpha (α) to assess interrater reliability (IRR) between respondents.

RESULTS

Eighty-four physicians responded and 56 completed the survey. All partial and completed surveys were analyzed. The overall IRR was poor (α = 0.60, 95% confidence interval [CI] 0.44-0.76). Residency graduation within 5 years (α = 0.66, 95% CI 0.5-0.8) was associated with higher IRR compared with those > 5 years (α = 0.53, 95% CI 0.37-0.69). The highest IRR was observed when images of mitral valve inflow pulse-wave Doppler (α = 0.81, CI 0.70-0.92) were used and the poorest IRR was on images from the parasternal short view (α = 0.28, 95% CI 0.05-0.49).

CONCLUSION

There was poor agreement among expert emergency medicine sonographers in identifying echocardiographic signs of cardiac tamponade from a single cine loop or clip without clinical context. Further investigation is warranted to understand differences in recognition of clinical tamponade.

Effects of pericardiocentesis on renal function and cardiac hemodynamics

BACKGROUND

Previous case studies have reported reversal of acute renal failure after pericardiocentesis in pericardial effusion. This study examines the effects of pericardiocentesis on preprocedural low cardiac output and acute renal dysfunction in patients with pericardial effusion.

METHODS

This is a retrospective study of 95 patients undergoing pericardiocentesis between 2015 and 2020. Pre- and post-procedure transthoracic echocardiograms (TTE) were reviewed for evidence of cardiac tamponade, resolution of pericardial effusion, and for estimation of right atrial (RA) pressure and cardiac output. Laboratory values were compared at presentation and post-procedure. Patients on active renal replacement therapy were excluded.

RESULTS

Ninety-five patients were included for analysis (mean age 62.2 ± 17.8 years, 58% male). There was a significant increase in glomerular filtration rate pre- and post-procedure. Fifty-six patients (58.9%) had an improvement in glomerular filtration rate after pericardiocentesis (termed "responders"), and these patients had a lower pre-procedure glomerular filtration rate than "non-responders." There was a significant improvement in estimated cardiac output and right atrial pressure for patients in both groups. Patients who had an improvement in renal function had significantly lower pre-procedural diastolic blood pressure and mean arterial pressure.

CONCLUSIONS

Pericardial drainage may improve effusion-mediated acute renal dysfunction by reducing right atrial pressure and thus systemic venous congestion, and by increasing forward stroke volume and perfusion pressure.

Point-of-Care Echocardiographic Evaluation of the Pericardium

Acute pericardial conditions, such as tamponade, are often rapidly progressive and can become life-threatening without timely diagnosis and intervention. In this review, we aim to describe bedside ultrasonographic evaluation of the pericardium and diagnostic criteria for tamponade, identify confounders in the diagnosis of pericardial tamponade, and delineate procedural details of ultrasound-guided pericardiocentesis.

Epidemiological characteristics, etiological spectrum, and outcomes of adult patients with pericardial effusion at a Teaching Hospital in Somalia

Background

Pericardial effusion (PE) is an abnormal fluid volume in the pericardial space and is a common clinical entity. The incidence of PE is estimated diversely and depends on risk factors, etiologies, and geographic locations.

Objectives

This study aimed to assess the clinical characteristics, etiologic spectrum, echocardiographic features, and outcomes among patients with different types of PE.

Method

This retrospective observational study included 93 patients with confirmed PE. Their medical records were reviewed in the hospital information system of Mogadishu Somali Turkish Training and Research Hospital between April 2022 and September 2022. Patient demographics, clinical characteristics, chest X-rays, echocardiography, laboratory findings, management approaches, and outcome reports were reviewed and recorded.

Results

Out of the 3000 participants, 3.1% (n = 93/3000) met the definition of definitive PE. In this study, we included 51 females and 42 males. Among the patients, 86% (n = 80) had at least one comorbidity, with diabetes (38.7%) and hypertension (37.6%) being the most common. The most frequently reported clinical presentation findings were shortness of breath (67.7%), chest pain (49.4%), cough (47.3%), and palpitations (47.3%). Cardiac tamponade developed in 9.7% (n = 9) of the patients. Pericardial taps were performed in 64.5% of the cases. Our analysis showed that the most common cause of PE was cardiac disease (n = 33, 35.4%), followed by tuberculosis (TB) (n = 25, 26.8%), uremic pericarditis (n = 24, 25.8%), and hypothyroidism (n = 10, 10.7%). Regarding the severity of PE based on echocardiographic findings, nearly half of the patients (n = 46, 49.4%) had mild PE, whereas 26.8% (n = 25) had moderate PE, and 23.6% (n = 22) had severe PE. Two-thirds of the cases (66.6%) were managed with furosemide, 48 (51.6%) patients were treated with an anti-inflammatory, hemodialysis was performed in 24 (25.8%) patients and antituberculous medications were administered to 7 (7.5%) patients. Out of the 93 patients, 24 (25.8%) died during the hospital stay. It was determined that the mortality risk of patients with renal failure was 7.518 times higher than those without (p = 0.004), and the risk for those with TB was 5.554 times higher than those without (p = 0.011). Other variables were not influential on mortality (p > 0.050).

Conclusion

Our study results demonstrate the epidemiological profile of PE in Somalia. The leading causes of PE were cardiac diseases, uremic pericarditis, TB, and hypothyroidism. PE is a significant cause of morbidity and mortality in Somalia, especially in individuals with renal failure and TB infection.

Preprocedural Controlling Nutritional Status Score as a Predictor of Mortality in Patients Undergoing Transcatheter Mitral Valve Repair - A Single Center Experience in Japan

Background: A high score for controlling nutritional status (CONUT) due to poor nutritional status has been associated with adverse outcomes in patients with chronic heart failure. However, because little is known about the effect of CONUT score on mortality rates after transcatheter mitral valve repair, we evaluated nutrition screening tools for prognosis prediction in patients undergoing transcatheter mitral valve repair using the MitraClipTM system. Methods and Results: We retrospectively analyzed 148 patients with severe mitral regurgitation (MR) who underwent MitraClipTM implantation between April 2018 and April 2021. The preprocedural CONUT scores were assessed at the time of hospitalization, the primary outcome was all-cause death, and the analysis was of the mortality and incidence rates of cardiac events 1 year post-operation. Functional MR was of ischemic origin in the majority of patients (69.6%), with a mean left ventricular ejection fraction of 48.9±15.8%. Kaplan-Meier curves indicated that all-cause death was significantly worse in the high-CONUT score group than in the low-CONUT score group. Cox hazard analysis showed a significant association between all-cause death and CONUT score, as well as MitraScore. Conclusions: Preprocedural CONUT score, as well as MitraScore, in patients undergoing transcatheter edge-to-edge mitral valve repair may predict an increased risk of all-cause death. This knowledge should allow the heart team to accurately assess the clinical implications and prognostic benefits of the procedure in individual patients.

Surgical Approaches for Pericardial Diseases: What Is New?

PURPOSE OF REVIEW

The purpose of this review is to discuss the evolving techniques and approaches for pericardiectomy, with a focus on the use of cardiopulmonary bypass (CPB) and the extent of radical pericardial resection. The review aims to highlight the benefits and considerations associated with these modifications in radical pericardiectomy.

RECENT FINDINGS

Recent studies have demonstrated that the use of CPB during pericardiectomy does not increase procedural risk or negatively impact survival. In fact, it has been shown to contribute to a more radical resection and improve postoperative outcomes, which is associated with less recurrence and better survival. The review emphasizes the importance of radical pericardiectomy and the use of CPB in achieving successful outcomes. Radical resection of the pericardium, facilitated by CPB, helps minimize the risk of recurrent constrictions and the need for reinterventions. The findings highlight the correlation between postoperative outcomes and survival, further supporting the use of CPB.

Insights Into the Standard Echocardiographic Views From Multimodality Imaging: Ventricles, Pericardium, Valves, and Atria

The widespread use of cardiac computed tomography and cardiac magnetic resonance imaging in patients undergoing echocardiography presents an opportunity to correlate the images side by side. Accordingly, the aim of this report is to review aspects of the standard echocardiographic examination alongside similarly oriented images from the two tomographic imaging modalities. It is hoped that this exercise will enhance understanding of the structures depicted by echocardiography as they relate to other structures in the thorax. In addition to reviewing basic cardiac anatomy, the authors take advantage of these correlations with computed tomography and cardiac magnetic resonance imaging to better understand the issue of foreshortening, a common pitfall in transthoracic echocardiography. The authors also highlight an important role that three-dimensional echocardiography can potentially play in the future, especially as advances in image processing permit higher fidelity multiplanar reconstruction images.

Multimodality Imaging Approach Evaluation of the Congenital Pericardial Defect: a Contemporary Review

PURPOSE OF REVIEW

This review presents the etiology, clinical manifestations, diagnostic approach, and treatment of congenital pericardial defects. It also highlights the critical role of echocardiography, cardiac computed tomography (CCT), and cardiac magnetic resonance (CMR) in the diagnosis and management approach.

RECENT FINDINGS

Congenital pericardial defects are rare. Although most cases are found incidentally, some cases could potentially be associated with serious outcomes including sudden cardiac death. The diagnosis is often challenging due to non-specific clinical manifestations and electrocardiogram findings. Echocardiography is the first-line imaging investigation for the evaluation of this condition. Advanced cardiac imaging modalities, including CCT and CMR, play important adjuvant roles in establishing the diagnosis and assists with prognostication.

Novel Imaging Approaches to Cardiac Manifestations of Systemic Inflammatory Diseases: JACC Scientific Statement

Derangements in the innate and adaptive immune responses observed in systemic inflammatory syndromes contributes to unique elevated atherosclerotic risk and incident cardiovascular disease. Novel multimodality imaging techniques may improve diagnostic precision for the screening and monitoring of disease activity. The integrated application of these technologies lead to earlier diagnosis and noninvasive monitoring of cardiac involvement in systemic inflammatory diseases that will aid in preclinical studies, enhance patient selection, and provide surrogate endpoints in clinical trials, thereby improving clinical outcomes. We review the common cardiovascular manifestations of immune-mediated systemic inflammatory diseases and address the clinical and investigational role of advanced multimodality cardiac imaging.

Echocardiographic Patterns of Abnormal Septal Motion: Beyond Myocardial Ischemia

Abnormal septal motion (ASM), which often is associated with myocardial ischemia, is also observed in other diseases. Owing to the position of the interventricular septum (IVS) in the heart, its movement not only relies on contractile properties but is also affected by the pressure gradient between the 2 ventricles and by the mode of electrical activation. Echocardiography allows the operator to focus on the motion of the IVS, analyzing its characteristics and thereby gaining information about the possible underlying pathophysiological mechanism. In this review, we focused on the main echocardiographic patterns of ASM that are not related to a failure of contractile properties of the septum (i.e., acute coronary syndrome and cardiomyopathies), showing their pathophysiological mechanisms and underlining their diagnostic usefulness in clinical practice.

Large Pericardial Cyst Mimicking Recurrent Unilateral Pleural Effusion on CT Scan: A Case Report and Literature Review

Pericardial cysts are an uncommon, benign condition that can manifest with diverse clinical symptoms influenced by their size and position within the body. Detecting pericardial cysts typically relies on imaging studies for a conclusive diagnosis. Surgical removal remains the definitive treatment approach for addressing pericardial cysts. This case report presents the clinical course of a 56-year-old female with a known case of asthma, and rheumatoid arthritis (RA) which exhibited recurrent symptoms such as shortness of breath and cough with recurrent pleural effusion to be investigated for suspected empyema, encysted effusion, TB, or malignancy, leading to diagnostic challenges. Through a combination of reviewing the case's clinical history, imaging modalities, and diagnostic procedures, including serial computed tomography (CT) and x-rays, the accurate diagnosis of a pericardial cyst sized 4.4 cm x 10.5 cm x 6.2 cm was achieved. In this specific case, recurrent percutaneous pleural aspirations were attempted as a treatment approach for three years. However, despite these efforts, this method proved unsuccessful in effectively managing the patient's condition. Using minimally invasive techniques, video-assisted thoracoscopic surgery (VATS) proved valuable in providing effective diagnostic and therapeutic options with reduced invasiveness. Timely diagnosis, proper monitoring, and patient education contributed to the patient's overall recovery.

D-dimer as a diagnostic and prognostic plasma biomarker in patients with a first episode of acute pericarditis

OBJECTIVES

The impact of plasma biomarkers on diagnosis and prognosis of patients with acute pericarditis (AP) has been poorly investigated. This study aims to assess the diagnostic and prognostic role of d-dimer (DD), an easily obtainable biomarker, in patients with AP.

PATIENTS AND METHODS

This is a prospective clinical study enrolling 265 consecutive patients hospitalized between September 2010 and May 2019 with a first episode of AP. At baseline, demographics, clinical features, laboratory and imaging findings were recorded. All patients were followed-up for a minimum of 18 months. Endpoints included cardiac tamponade, new-onset atrial fibrillation, pericardial drainage, recurrent/constrictive pericarditis and death.

RESULTS

DD was measured in 165 out of 265 patients (62.3%, median levels 1456 ng/mL) Among them, 121 patients (73.3%) presented with elevated age-adjusted DD levels. Patients with elevated DD depicted a higher rate of pleural (69.4%, vs 38.6%, p<0.001) and pericardial effusions (89.3% vs 72.7%, p = 0.009). Elevated DD correlated with admission (rho=0.37) and peak (rho=0.36) C-reactive protein values. Patients with elevated DD depicted a trend towards a greater prevalence of pericardial tamponade vs those without (14.9% vs 4.5% respectively, p = 0.07). In the 43.8% of patients with elevated DD who underwent computed tomography pulmonary angiography (CTPA), no case of pulmonary embolism or aortic syndrome was unveiled.

CONCLUSION

DD elevation is detected in the majority of AP cases at presentation and may herald cardiac tamponade. In patients with chest pain not attributable to alternative causes, elevated DD denotes an inflammatory condition and should not prompt unnecessary investigations, such as CTPA.

An Unusual Case of Parasitic Constrictive Pericarditis

Parasitic constrictive pericarditis is a rare entity. We present a case of a 75-year-old man who presented with dyspnea, ascites, and pedal edema and was found to have constrictive pericarditis on multimodality imaging with positive serology for Strongyloides Stercoralis. Treatment required ivermectin and radical pericardiectomy with significant clinical improvement. (Level of Difficulty: Intermediate.).

Pericardial agenesis - the wandering heart

BACKGROUND

Congenital pericardial absence is an uncommon cardiac anomaly that is typically asymptomatic and commonly misdiagnosed due to a lack of symptoms or atypical symptoms. Pericardial agenesis (PA) should be considered one of the differential diagnoses when the patient presents with chest pain. This case shows how the diagnosis of pericardial agenesis is made exclusively using multi-modality imaging, starting from findings in a basic chest radiograph to cardiac MRI, while also demonstrating the classic signs seen in this condition. Magnetic resonance imaging of the heart is the gold standard for determining the absence of pericardium in the prognosis.

CASE PRESENTATION

A 32-year-old male who presented with chest discomfort and radiating pain to his back and left shoulder mimicking myocardial infarction with normal ECG and enzyme markers. A chest radiograph (taken 24 h apart) demonstrates the left lateral position of the heart and the bulging contour of the left heart border, a lucent area between the aorta and pulmonary artery. Subsequently, cardiac MRI reveals left pericardial agenesis.

CONCLUSIONS

This article provides insight into a rare differential to consider in a young patient presenting with chest discomfort. This case shows how the diagnosis of pericardial agenesis is made exclusively using multi-modality imaging, starting from findings in a basic chest radiograph to cardiac MRI, while also demonstrating the classic signs seen in this condition.

Concordance of Pericardial Effusion Size Between Computed Tomography and Echocardiography

Discrepancy between computed tomography (CT) and transthoracic echocardiography (TTE) regarding pericardial effusion (PEff) size is common, but there is limited data regarding the correlation between these 2 imaging methods. The aim of this study is to examine the real-world concordance of observed PEff size between CT and TTE. We performed a retrospective analysis of all imaging reports available from 2013 to 2019 and identified patients with a PEff who underwent both a chest CT and TTE within a 24-hour period. We evaluated the agreement between CT and TTE in assessing PEff size. Of 1,118 patients included in the study, mean age was 66 (±17 years) and 54% were female. The median time interval between the 2 studies was 9.4 hours (interquartile range 3.5 to 16.6). Patients within a half-grade or full-grade of agreement were 71.9% and 97.2%, respectively. The mean difference in grade of agreement (TTE minus CT) between the 2 imaging methods was -0.1 (±0.6, p <0.0001). CT was more likely to report a higher grade (i.e. larger PEff size) when compared with TTE (261 patients vs 157 patients, p <0.001). The weighted kappa was 0.73 (95% confidence interval 0.69 to 0.76). After excluding patients with trace/no effusion, 42.3% and 94.1% of patients' studies were within a half-grade or full-grade of agreement, respectively. Of the 18 patients who had large discrepancies, 9 patients had loculated effusions, 2 patients had large pleural effusions, and 6 patients had suboptimal TTEs images. In conclusion, TTE and CT showed relatively strong agreement in estimation of PEff size, with CT sizes larger than TTE, on average. Large discrepancies in size may be related to reduced image quality, large pleural effusions, and loculated PEff.

Echocardiographic Evaluation of Diastolic Function in Special Populations

Left ventricular (LV) diastolic dysfunction results from a combination of impaired relaxation, reduced restoring forces, and increased chamber stiffness. Noninvasive assessment of diastology uses a multiparametric approach involving surrogate markers of increased filling pressures, which include mitral inflow, septal and lateral annular velocities, tricuspid regurgitation velocity, and left atrial volume index. However, these parameters must be used cautiously. This is because the traditional algorithms for evaluating diastolic function and estimation of LV filling pressures (LVFPs), as recommended by the American Society of Echocardiography and European Association of Cardiovascular Imaging 2016 guidelines, do not apply to unique patients with underlying cardiomyopathies, significant valvular disease, conduction abnormalities, arrhythmias, LV assist devices, and heart transplants, which alter the relation between the conventional indexes of diastolic function and LVFP. The purpose of this review is to provide solutions for evaluating LVFP through illustrative examples of these special populations, incorporating supplemental Doppler indexes, such as isovolumic relaxation time, mitral deceleration time, and pulmonary venous flow analysis, as needed to formulate a more comprehensive approach.

Pericardial Effusion and Cardiac Tamponade Pathophysiology and New Approaches to Treatment

PURPOSE OF REVIEW

The objective of this manuscript is to examine up-to-date approaches to the diagnosis and treatment of pericardial effusions and cardiac tamponade.

RECENT FINDINGS

Recent recommendations from the American Society of Echocardiography and the European Society of Cardiology have improved our management of the patient with pericardial effusion and cardiac tamponade, but significant knowledge gaps remain. Novel diagnostic and triage strategies have been suggested, and recent information have improved our facility to assess the presence and size of a pericardial effusion, assess its hemodynamic impact, and determine its cause. Despite these recent findings, there is a scarcity of evidence-based data to direct the management of pericardial effusion and cardiac tamponade. While the first-line function of echocardiography in managing these disorders is undisputed, there are increasingly niche functions for multimodality imaging.

Peritoneal Carcinoma Unveiling a Hidden Threat: A Case of Malignant Pericardial Effusion

Malignant pericardial effusion (MPE) is a slowly progressive and potentially clinically silent condition. Pericardial effusion can arise in oncology patients due to several factors, including disease spreading directly or metastatically, anticancer therapy side effects, or both. Solid and hematological malignancy metastasis more frequently involves the pericardium than primary tumors, with lung cancer being the most common metastatic tumor to involve the pericardium. While 5%-20% of all patients with metastatic neoplasms have pericardial involvement, MPE rarely appears with hemodynamic instability. Occasionally, MPE constitutes the initial manifestation of an underlying malignancy. Diagnosis and treatment require a multidisciplinary approach and a high degree of clinical suspicion. We present a case of a 59-year-old female with a history of peritoneal carcinoma who presented with persistent dyspnea on exertion following an episode of pneumonia that was treated with antibiotics. Physical examination and bedside point-of-care ultrasound (POCUS) revealed fluid in the pericardial sac. The cytological examination of the fluid revealed it to be of malignant origin, resulting from metastasis from gynecologic adenocarcinoma. Pericardiocentesis was done, and symptoms improved after fluid drainage.

Paradigm Shift in Diagnosis and Targeted Therapy in Recurrent Pericarditis

PURPOSE OF THE REVIEW

We review the pathophysiology, diagnosis, and contemporary treatment for recurrent pericarditis, with focus on interleukin-1 (IL-1) inhibitors.

RECENT FINDINGS

Recurrent pericarditis occurs in about 15-30% of patients who have acute pericarditis. With increased understanding of the autoinflammatory pathophysiology of recurrent pericarditis, IL-1 inhibitors including anakinra, canakinumab, and rilonacept have been applied to this condition with great promise. In particular, the RHAPSODY trial found rilonacept significantly improves pain and inflammation, while also reducing recurrence with few adverse events. The next IL-1 inhibitor on the block for pericarditis, goflikicept, is also discussed. Understanding the role of the inflammasome via the autoinflammatory pathway in pericarditis has led to incorporation of IL-1 inhibitors in the treatment of recurrent pericarditis, with proven efficacy and safety and randomized trials. This will lead to increase uptake of this agent which demonstrated lower rates of recurrence and faster time to resolution.

Constrictive pericarditis following cardiac transplantation: a report of two cases and a literature review

The data on constrictive pericarditis following heart transplantation are scarce. Herein, the authors present 2 patients who developed a constrictive pericarditis 19, and 55 months after heart transplantation. They underwent several diagnostic procedures and successfully recovered after a radical pericardiectomy. In addition, the authors review the literature and report the incidence, aetiology, diagnostic features, and management of this rare and challenging condition.

Echocardiographic Criteria to Differentiate Constrictive Pericarditis From Restrictive Cardiomyopathy: A Meta-analysis

Background

To assess the diagnostic accuracy of the Mayo Clinic echocardiographic criteria for differentiating between constrictive pericarditis and restrictive cardiomyopathy.

Methods

We searched electronic databases for the date range from their inception to July 1, 2022. The index tests were the Mayo Clinic echocardiographic criteria. We performed a bivariate random-effects model to estimate the pooled sensitivity and specificity, each with 95% confidence interval (CI). The area under the curve of the summary receiver operator characteristic curves, with 95% CI, was also calculated.

Results

We included 17 case-control studies involving 889 patients. The pooled sensitivity and specificity (95% CI), respectively, were as follows: ventricular septal shift, 82% (60%-94%) and 78% (65%-87%); respiratory variation in mitral inflow ≥ 14.6%, 71% (51%-85%) and 82% (66%-91%); septal e' velocity ≥ 8 cm/s, 83% (80%-87%) and 90% (83%-95%); septal e' velocity/lateral e' velocity ≥ 0.88, 74% (64%-82%) and 81% (70%-88%); and hepatic vein ratio in expiration ≥ 0.79, 73% (65%-81%) and 71% (19%-96%). The area under the curve of the summary receiver operator characteristic curves varied from 0.75 to 0.85, with overlapping CIs across index tests.

Conclusions

Our meta-analysis suggests that all echocardiographic parameters from the Mayo Clinic criteria have good diagnostic accuracy for differentiating between constrictive pericarditis and restrictive cardiomyopathy.