Contemporary management of 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.

Variations in current clinical practice of postoperative pericardial effusion: a questionnaire study

OBJECTIVE

Postoperative pericardial effusion (PPE) occurs frequently after cardiac surgery, potentially leading to life-threatening cardiac tamponade. Specific treatment guidelines are currently lacking, possibly leading to variations in clinical practice. Our goal was to assess clinical PPE management and evaluate variation between centres and clinicians.

METHODS

A nationwide survey was sent to all interventional cardiologists and cardiothoracic surgeons in the Netherlands, regarding their preferred diagnostic and treatment modality of PPE. Clinical preferences were explored utilising four patient scenarios, each with a high/low echocardiographic and clinical suspicion of cardiac tamponade. Scenarios were also stratified by three PPE sizes (<1 cm, 1-2 cm, >2 cm).

RESULTS

In total, 46/140 interventional cardiologists and 48/120 cardiothoracic surgeons responded (27/31 contacted centres). Cardiologists favoured routine postoperative echocardiography in all patients (44%), whereas cardiothoracic surgeons preferred routine imaging after specific procedures, especially mitral (85%) and tricuspid (79%) valve surgery. Overall, pericardiocentesis (83%) was preferred over surgical evacuation (17%). Regarding all patient scenarios, cardiothoracic surgeons significantly preferred evacuation compared with cardiologists (51% vs 37%, p<0.001). This was also observed with cardiologists employed in surgical centres compared with non-surgical centres (43% vs 31%, p=0.02). Inter-rater analysis varied from poor to near-excellent (к 0.22-0.67), suggesting varying PPE treatment preferences within one centre.

CONCLUSION

There is significant variation in the preferred management of PPE between hospitals and clinicians, even within the same centre, possibly due to the lack of specific guidelines. Therefore, robust results of a systematic approach to PPE diagnosis and treatment are needed to formulate evidence-based recommendations and optimise patient outcome.

Pediatric Pericarditis: Update

PURPOSE OF REVIEW

While there have now been a variety of large reviews on adult pericarditis, this detailed review specifically focuses on the epidemiology, clinical presentation, diagnosis, and management of pediatric pericarditis. We have tried to highlight most pediatric studies conducted on this topic, with special inclusion of important adult studies that have shaped our understanding of and management for acute and recurrent pericarditis.

RECENT FINDINGS

We find that the etiology of pediatric pericarditis differs from adult patients with pericarditis and has evolved over the years. Also, with the current COVID-19 pandemic, it is important for pediatric clinicians to be aware of pericardial involvement both due to the infection and from vaccination. Oftentimes, pericarditis maybe the only cardiac involvement in children with COVID-19, and so caregivers should maintain a high index of suspicion when they encounter children with pericarditis.  Large-scale contemporary epidemiological data regarding incidence and prevalence of both acute and recurrent pericarditis is lacking in pediatrics, and future studies should focus on highlighting this important research gap. Most of the current management strategies for pediatric pericarditis are from experiences gathered from adult data. Pediatric multicenter trials are warranted to understand the best management strategy for those with acute and recurrent pericarditis.

CASE VIGNETTE

A 6-year-old child with a past history of pericarditis almost 2 months ago comes in with a 2-day history of chest pain and fever. Per mother, he stopped his steroids about 2 weeks ago, and for the last 2 days has had a temperature of 102F and has been complaining of sharp mid-sternal chest pain that gets worse when he lies down and is relieved when he sits up and leans forward. On examination, he is tachycardic (heart rate 160 bpm), with normal blood pressure for age. He appears to be in pain (5/10), and on auscultation has a pericardial friction rub. His lab studies are notable for elevated white blood cell count and inflammatory markers (CRP and ESR). His electrocardiogram reveals sinus tachycardia and diffuse ST-elevation in all precordial leads. His echocardiogram demonstrates normal biventricular function and a trace pericardial effusion. His cardiac MRI confirms recurrent pericarditis. He is started on indomethacin and colchicine. He has complete resolution of his symptoms by day 3 of admission and is discharged with close follow-up.

Cardiovascular Complications of Viral Respiratory Infections and COVID-19

Viral respiratory infections (VRI) are the most prevalent type of infectious diseases and constitute one of the most common causes of contact with medical care. Regarding the pathophysiology of the cardiovascular system, VRI can not only exacerbate already existing chronic cardiovascular disease (such as coronary artery disease or heart failure) but also trigger new adverse events or complications (e.g., venous thromboembolism), the latter particularly in subjects with multimorbidity or disease-related immobilization. In the current paper, we provide a narrative review of diverse cardiovascular complications of VRI as well as summarize available data on the pathology of the circulatory system in the course of coronavirus disease 2019 (COVID-19).

Acute pericarditis in patients receiving coronavirus disease 2019 vaccines: a case series from the community

BACKGROUND

International agencies reported that cases of pericarditis occur very rarely following the administration of coronavirus disease 2019 (COVID-19) vaccines. Herewith, we described a series of patients from the community diagnosed with acute pericarditis after vaccination.

METHODS

We retrospectively included 28 patients (median age 51 years, 79% female) with or without a positive history of acute respiratory syndrome coronavirus 2 recovered infection who were diagnosed with acute pericarditis following the administration of COVID-19 vaccine. We excluded specific identifiable causes of pericarditis, including infectious, autoimmune, neoplastic and metabolic disease. Patients were referred for a complete cardiovascular evaluation. Transthoracic echocardiography (TTE) was performed and diagnosis of acute pericarditis was achieved according to current guidelines.

RESULTS

There were 16 patients administered with Pfizer-BioNTech/Comirnaty vaccine, 8 with Moderna/Spikevax vaccine and 4 with Astra Zeneca/Vaxzevria vaccine. Nine patients had been previously diagnosed with COVID-19, while the others had no prior history of COVID-19. Eleven patients had no comorbidity while the others had between one and four comorbidities. Ten patients had a history of rheumatic or autoimmune diseases. Chest pain was present in 24 patients. Minor ECG abnormalities were detected in 10 patients, T-wave inversion in 6, and 7 patients had concave ST elevation. The majority of patients showed mild pericardial effusions at TTE. Only two patients exhibited large pericardial effusions.

CONCLUSION

This case series shows a higher incidence of acute pericarditis in patients administered with COVID-19 vaccines than previously estimated, probably because of a more comprehensive assessment of clinical as well as echocardiographic parameters.

Recurrent Pericarditis: a Stubborn Opponent Meets New Treatments in 2022

Purpose of Review

Our goal in writing this review was to provide a comprehensive appraisal of current therapies for idiopathic recurrent pericarditis with a particular focus on the newest therapeutic agents. We sought to understand the role of the inflammasome in the pathophysiology of pericarditis and how it informs the use of interleukin-1 (IL-1)-directed therapies.

Recent Findings

The latest research on this topic has focused on the critical role of the NLRP3 (NACHT, leucine-rich repeat, and pyrin domain-containing protein) inflammasome. Very recently, components of the NLRP3 inflammasome were detected by immune staining in pericardial tissue from patients with recurrent idiopathic pericarditis. In a mouse model of pericarditis, anti-IL-1 agents anakinra and rilonacept reduced NLRP3 immunostaining. Subsequent study of these drugs in human subjects with idiopathic recurrent pericarditis demonstrated their efficacy.

Summary

Recurrent idiopathic pericarditis, while relatively rare, poses a continued treatment challenge and contributes to a diminished quality of life for those patients who are afflicted. Recent developments, including an animal model of the disease and the use of IL-1-directed therapies, represent an exciting leap forward in our understanding of treatment targets. These advances offer not only new tools in our fight against this disease, but also the promise of earlier intervention and attenuation of disease morbidity. As our experience with these new agents expands, we can address questions about the ideal timing of introduction of anti-IL-1 therapy and duration of therapy and better understand the potential side effect profile.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11886-022-01719-z.

Incidence, clinical presentation, management, and outcome of acute pericarditis and myopericarditis

AIMS

Little is known about the epidemiology, clinical presentation, management, and outcome of acute pericarditis and myopericarditis.

METHODS AND RESULTS

The final diagnoses of acute pericarditis, myopericarditis, and non-ST-segment elevation myocardial infarction (NSTEMI) of patients presenting to seven emergency departments in Switzerland with acute chest pain were centrally adjudicated by two independent cardiologists using all information including serial measurements of high-sensitivity cardiac troponin T. The overall incidence of pericarditis and myopericarditis was estimated relative to the established incidence of NSTEMI. Current management and long-term outcome of both conditions were also assessed. Among 2533 chest pain patients, the incidence of pericarditis, myopericarditis, and NSTEMI were 1.9% (n = 48), 1.1% (n = 29), and 21.6% (n = 548), respectively. Accordingly, the estimated incidence of pericarditis and myopericarditis in Switzerland was 10.1 [95% confidence interval (95% CI) 9.3-10.9] and 6.1 (95% CI 5.6-6.7) cases per 100 000 population per year, respectively, vs. 115.0 (95% CI 112.3-117.6) cases per 100 000 population per year for NSTEMI. Pericarditis (85% male, median age 46 years) and myopericarditis (62% male, median age 56 years) had male predominance, and commonly (50% and 97%, respectively) resulted in hospitalization. No patient with pericarditis or myopericarditis died or had life-threatening arrhythmias within 30 days [incidence 0% (95% CI 0.0-4.8%)]. Compared with NSTEMI, the 2-year all-cause mortality adjusted hazard ratio of pericarditis and myopericarditis was 0.40 (95% CI 0.05-2.96), being 0.59 (95% CI 0.40-0.88) for non-cardiac causes of chest pain.

CONCLUSION

Pericarditis and myopericarditis are substantially less common than NSTEMI and have an excellent short- and long-term outcome.

CLINICAL TRIAL REGISTRATION

ClinicalTrial.gov, number NCT00470587, https://clinicaltrials.gov/ct2/show/NCT00470587.

Investigating the Usefulness of European Society of Cardiology Guidelines for Hospitalization in Acute Pericarditis at a Single Tertiary Center

Background The European Society of Cardiology (ESC) guidelines for the diagnosis and management of pericardial diseases identify predictive factors of poor prognosis and advise either in favor or against hospitalization accordingly. We aim to evaluate the adequacy of hospitalization criteria in a cohort of patients presenting to the emergency department (ED) with acute pericarditis. Methods Retrospective analysis of patients admitted to ED with acute pericarditis, from 2009 to 2019. During ED stay, all patients were evaluated by a cardiologist who decided if the patient was to be discharged or hospitalized. Hospitalized and discharged patients were compared regarding the primary outcome, defined by a composite of: the need for pericardiocentesis and/or cardiac surgery, pericarditis recurrence, and all-cause death. The clinical decision was then counterpoised with ESC guidelines. Results A total of 192 patients were included in the analysis (median age 44.5 years old, 83.3% male) of which 87 (45.5%) were hospitalized. A total of 25% registered the primary outcome, mainly due to acute pericarditis recurrence, occurring in 21.9%. Predictors of recurrence were: glucocorticoid therapy (Odds Ratio [OR]=11.93, 95% Confidence Inirtval [CI] 3.13-45.5, p<0.001), fever at admission (OR=2.67, 95% CI 1.29-5.49, p=0.008), immunosuppression (OR=4.03, 95% CI 1.280-12.659, p=0.017) and increased cardiothoracic index (OR 3.85, CI 95% 1.67-8.86, p=0.002). Regarding hospitalisation/discharge decision, the ESC guidelines were respected in 73.4% of the cases. However, no significant difference in the primary outcome was noted whether the ESC guidelines were respected or not (27.5% vs. 24.3%, p=0.707). Conclusions Discrepancy between current guidelines and the clinical decision did not translate into a different outcome.

[CME-ECG 70: Chest Pain in a Young Patient - Differential Diagnoses beyond the Acute Coronary Syndrome]

CME-ECG 70: Chest Pain in a Young Patient - Differential Diagnoses beyond the Acute Coronary Syndrome Abstract. Older patients with chest pain and typical ECG changes are most likely to be diagnosed with cardiovascular diseases. However, younger patients with similar symptoms may reveal different disease patterns. In this case report, differential diagnoses and diagnostic steps, with particular attention to the ECG, will be discussed.

Pericardial effusion after pediatric cardiac surgery: A single-center study

BACKGROUND

Postoperative pericardial effusion (pPE) still remains a frequent complication after congenital heart surgery and it usually leads to an increased morbidity and re-hospitalization rate. There are only few published papers about pPE clinical course or large randomized studies that analyze its prevalence or preoperative risk factors. In this regard, we report a single-center 10-years retrospective analysis of prevalence, outcomes and risk factors of postoperative pericardial effusion after congenital heart surgery.

METHODS

A retrospective analysis was carried out on 624 patients who underwent congenital heart surgery from January 2010 to December 2019. Study population was divided in two groups basing of the presence of pPE during the first 30 days after the surgery and their perioperative data were compared. Univariate and multivariate analysis were used to find possible risk factors for pPE developing.

RESULTS

Ninety-four patients were enrolled in pPE group and 530 in ¬ pPE group. Pericardial effusion was assessed as "mild" in 57 patients (60,6%), as "moderate" in 25 (26,6%), and as "severe" in 12 patients (12,8%). Total correction of Tetralogy of Fallot/Pulmonary atresia seems to be associated with a higher prevalence of pPE in the "Infant" subgroup, while atrial septal defect showed to be a risk factor among "Toddler". In addition, pPE was proved to be much more frequent in Fontan patients in all studied subgroups. Univariate and multivariate analysis revealed that total drain amount, Fontan procedure, postoperative Warfarin therapy, Redo-operations and surgical correction of Tetralogy of Fallot/Pulmonary atresia seem to be risk factors for pPE. Postoperative pericardial effusion was diagnosed between the 4th and the 28th postoperative day but in 88,3% of the cases (83/94) it occurred before the 14th day after the operation. In 58 patients, pPE was clinically silent.

CONCLUSIONS

Postoperative pericardial effusion was detected in 88.3% of cases within the first 14 days after the operation. About 69% of these patients were asymptomatic therefore it suggests that routinely echocardiogram after intensive care unit discharge could be a useful tool to screen clinically silent pPE at an early stage, especially in high-risk or unstable patients.

Rapidly Developing Methicillin-Resistant Staphylococcus Aureus Pericarditis and Pericardial Tamponade

Methicillin-resistant staphylococcus aureus (MRSA) pericarditis is a rare life-threatening infection. A 46-year-old female with hypertension, acquired immunodeficiency syndrome (AIDS) and recurrent neck abscesses, presented with a neck abscess and sepsis. Bloody purulent drainage from the abscess was found and antibiotics were started. Drainage was positive for MRSA. Four days after, course was complicated by acute pericarditis and pericardial tamponade; pericardial fluid was drained and was positive for MRSA. Vancomycin was continued, and aspirin and colchicine were started. Two days later, there was a recurrent pericardial fluid collection with loculation. Surgery was thought to be dangerous in the setting of CD4 count of 12. She was managed conservatively thereafter, with vancomycin, aspirin and colchicine, and was successfully discharged from the hospital.

Comparative transcriptome analysis to elucidate the therapeutic mechanism of colchicine against atrial fibrillation

In recent years, colchicine has been used to reduce the risk of cardiovascular events; in particular, it has been effectively used for the treatment of atrial fibrillation (AF). We first discovered that colchicine can treat AF in a rat model and that it can reverse the effects of atrial fibrosis. To illustrate the potential therapeutic mechanism of colchicine against AF, we performed comparative transcriptome analyses; our aim was to elucidate the therapeutic effects of colchicine so as to improve treatment and prognoses of AF. Genomics and bioinformatics analyses revealed that the IL-17 signaling pathway, and renin secretion pathway are involved in the mechanism of action of colchicine. Furthermore, there was a significant correlation between overlapping genes in the two groups of differentially expressed genes. The genes encoding Akap4, Pcdha9, Gp2, Cd177, Krt15, Aqp3, Chia, and Bpifb1 were pivotal and possible action sites for the therapeutic mechanisms of colchicine. We conclude that AF involves a multifactorial pathological process. The mechanisms underlying the action of colchicine in the treatment of AF warrant further studies.

Life-threatening Development of Cardiac Tamponade in the Span of 24 Hours

Cardiac tamponade is a medical emergency that requires immediate treatment. Caused by the development of fluid in the pericardial space, it can result in a severe decrease in cardiac output. When encountering patients with severe hypotension and tachycardia, emergency physicians must always consider the diagnosis of tamponade to facilitate prompt and effective treatment and stabilization. We report our experience with a patient who developed life-threatening cardiac tamponade within a span of less than 24 hours.

Management of idiopathic recurrent pericarditis during pregnancy

BACKGROUND

Data concerning idiopathic recurrent pericarditis in pregnancy are scarce.

OBJECTIVES

To evaluate the management and outcome of idiopathic recurrent pericarditis during pregnancy.

METHODS AND RESULTS

Twenty-one pregnancies were evaluated in fourteen women with a history of recurrent idiopathic pericarditis (mean maternal age 31.5 years, mean gestational age 39.0 weeks), and subdivided in 2 cohorts: eight pregnancies were analyzed retrospectively (2002-2010), thirteen (2011-2017) prospectively and followed according a predefined management protocol. Ten pregnancies were uneventful, three ended in spontaneous early abortion, one fetal death occurred at 19 weeks. Recurrences of pericarditis occurred in eight and were treated by adding NSAIDs in two cases; in five cases the dose of corticosteroids was increased and in two cases aspirin was started/increased; paracetamol was always allowed. Colchicine was used in two cases in the prospective cohort. HELLP syndrome occurred in one patient, which resolved after delivery, and one patient experienced arterial hypertension and elevated transaminase. All infants had a good outcome (mean birth weight 3114 g, 10 males). Birth weight was significantly lower in the retrospective cohort (respectively 2806 g vs. 3320 g, p-value 0.017) in which higher doses of corticosteroids were used (median dose respectively 10.0 mg vs. 2.5 mg, p-value 0.048). Five recurrences of pericarditis occurred after delivery, easily treated with standard therapy.

CONCLUSION

General outcomes of pregnancy in patients with idiopathic recurrent pericarditis is good, especially when patients are carefully followed by multidisciplinary teams according to standardized protocols.

Risk of Clinically Relevant Pericardial Effusion After Pediatric Cardiac Surgery

Pericardial effusion (PE) after pediatric cardiac surgery is common. Because of the lack of a uniform classification of the presence and severity of PE, we evaluated PE altering clinical management: clinically relevant PE. Risk factors for clinically relevant PE were studied. After cardiac surgery, children were followed until 1 month after surgery. Preoperative variables were studied in the complete cohort. Perioperative and postoperative variables were studied in a case-control manner. Patients with and without clinically relevant PE were matched on age, gender, and diagnosis severity in a 1:1 ratio. Multivariate analysis was conducted using important preoperative variables from the complete cohort combined with perioperative and postoperative variables from the case-control data. 1241 surgical episodes in 1031 patients were included. Clinically relevant PE developed in 136 episodes (11.0%). Multivariate correlation with the outcome was present for age, BSA (adjusted odds ratio: 1.6, 95% CI 0.9-2.8), right-sided heart defect (adjusted odds ratio: 1.3, 95% CI 0.9-1.9), history of previous operation (adjusted odds ratio: 0.5, 95% CI 0.3-0.7), cardiopulmonary bypass use (adjusted odds ratio: 2.1, 95% CI 0.9-4.5), duration of CPAP postoperatively, and an inotropic score (adjusted odds ratio: 1.01, 95% CI 0.998-1.03). In this large patient cohort, 11.0% of postoperative periods of pediatric cardiac surgery were complicated by PE requiring alteration of treatment. Secondly, we newly identified cardiopulmonary bypass use and right-sided heart defects as risk factors for clinically relevant PE and confirmed previously described risk factors: age, CPAP duration, BSA, and inotropic score and a previously described risk reductor: history of previous operation.

Acute and Recurrent Pericarditis

Acute and recurrent pericarditis is the most common pericardial syndrome encountered in clinical practice either as an isolated process or as part of a systemic disease. The diagnosis is based on clinical evaluation, electrocardiogram, and echocardiography. The empiric therapy is based on nonsteroidal anti-inflammatory drugs plus colchicine as first choice, resorting to corticosteroids for specific indications (eg, systemic inflammatory disease on corticosteroids, pregnancy, renal failure, concomitant oral anticoagulants), for contraindications or failure of the first-line therapy. The most common complication is recurrence, occurring in up to 30% of cases after a first episode of pericarditis.

Acute Pericarditis Occurring Three Days after Intravesical Instillation of Mitomycin C after Transurethral Bladder Tumor Resection in a 64-Year-Old Woman

We present a 64-year-old woman who developed symptoms of acute pericarditis three days after undergoing intravesical instillation of mitomycin C following transurethral bladder tumor resection. Mitomycin C is a chemotherapeutic agent which acts by alkylation of DNA and is known to be cardiotoxic when systemically administered. Despite classic pericarditis symptoms, the patient underwent an urgent coronary angiogram due to elevated cardiac troponin I level, EKG changes, and wall motion abnormalities on her echocardiogram. During her angiogram, it was found that she had multiple stenotic coronary artery lesions, with no acute total coronary occlusions, and percutaneous coronary intervention (PCI) was done with placement of a single drug-eluting stent for a 95% stenotic lesion in the left anterior descending artery. The patient was discharged after an uneventful hospitalization on dual antiplatelet therapy with aspirin and prasugrel, and colchicine for pericarditis. It is likely that the patient's presentation was the result of a perimyocardial inflammatory process secondary to intravesically administered mitomycin C, rather than an acute coronary syndrome. While the pathophysiological basis of cardiotoxicity of systemically administered mitomycin C is well documented, more studies are needed to determine whether intravesical MMC may cause cardiotoxicity.

European Guidelines on Pericardial Diseases: a Focused Review of Novel Aspects

Pericardial diseases are not uncommon in daily clinical practice. The spectrum of these syndromes includes acute and chronic pericarditis, pericardial effusion, constrictive pericarditis, congenital defects, and neoplasms. The extent of the high-quality evidence on pericardial diseases has expanded significantly since the first international guidelines on pericardial disease management were published by the European Society of Cardiology in 2004. The clinical practice guidelines provide a useful reference for physicians in selecting the best management strategy for an individual patient by summarizing the current state of knowledge in a particular field. The new clinical guidelines on the diagnosis and management of pericardial diseases that have been published by the European Society of Cardiology in 2015 represent such a tool and focus on assisting the physicians in their daily clinical practice. The aim of this review is to outline and emphasize the most clinically relevant new aspects of the current guidelines as compared with its previous version published in 2004.

CT-Guided Drainage of Pericardial Effusion after Open Cardiac Surgery

PURPOSE

This study was designed to evaluate the safety and efficacy of CT-guided drainage of the pericardial effusion in patients after cardiac surgery.

MATERIALS AND METHODS

The study included 128 consecutive patients (82 males, 46 females; mean age 66.6 years, SD: 4.2) complicated by pericardial effusion or hemopericardium after cardiac surgeries between June 2008 and June 2016. The medical indication for therapeutic pericardiocentesis in all patients was hemodynamic instability caused by pericardial effusion. The treatment criteria for intervention were evidence of pericardial tamponade with ejection fraction (EF) <50%. The preintervention ejection fraction was determined echocardiographically with value between 30 and 40%. Exclusion criteria for drainage were hemodynamically unstable patients or impaired coagulation profile (INR <1.8 or platelet count <75,000). Drains (8F-10F) were applied using Seldinger's technique under CT guidance.

RESULTS

Pericardiocentesis and placement of a percutaneous pericardial drain was technically successful in all patients. The mean volume of evacuated pericardial effusion was 260 ml (range 80-900 ml; standard deviation [SD]: ±70). Directly after pericardiocentesis, there was a significant improvement of the ejection fraction to 40-55% (mean: 45%; SD: ±5; p < 0.05). The mean percentage increase of the EF following pericardial effusion drainage was 10%. The drainage was applied anteriorly (preventricular) in 39 of 128 (30.5%), retroventricularly in 33 of 128 (25.8%), and infracardiac in 56 of 128 (43.8%). Recurrence rate of pericardial effusion after removal of drains was 4.7% (67/128). Complete drainage was achieved in retroventricular and infracardiac positioning of the catheter (p < 0.05) in comparison to the preventricular position of the catheter. Recorded complications included minimal asymptomatic pneumothorax and pneumomediastinum 2.3% (3/128) and sinus tachycardia 3.9% (5/128).

CONCLUSION

CT-guided drainage of postoperative pericardial effusion is a minimally invasive technique for the release of the tamponade effect of the effusion and improvement of cardiac output.

Contemporary management of pericardial effusion: practical aspects for clinical practice

A pericardial effusion (PE) is a relatively common finding in clinical practice. It may be either isolated or associated with pericarditis with or without an underlying disease. The aetiology is varied and may be either infectious (especially tuberculosis as the most common cause in developing countries) or non-infectious (cancer, systemic inflammatory diseases). The management is essentially guided by the hemodynamic effect (presence or absence of cardiac tamponade), the presence of concomitant pericarditis or underlying disease, and its size and duration. The present paper reviews the current knowledge on the aetiology, classification, diagnosis, management, therapy, and prognosis of PE in clinical practice.

Recent advances in the management of pericardial diseases

Pericardial diseases are relatively common in clinical practice either as isolated diseases or part of an underlying or systemic disease. Recent advances in the diagnosis and treatment have greatly improved the clinical management and lead to consensus documents on multimodality imaging and new guidelines on the diagnosis and therapy of pericardial diseases. The aim of the present paper is to summarize available evidence in order to provide an updated and comprehensive review on the recent advances in the management of pericardial diseases.

Idiopathic recurrent pericarditis as an immune-mediated disease: current insights into pathogenesis and emerging treatment options

Idiopathic recurrent pericarditis affects 30-50% of patients with a previous attack of pericarditis. The etiopathogenesis is incompletely understood and most cases remain idiopathic with a presumed immune-mediated pathogenesis. The mainstay of therapy is aspirin or a nonsteroidal anti-inflammatory drug plus colchicine and the possible adjunct of a low-to-moderate dose of a corticosteroid in more difficult cases. Colchicine as an adjunct to anti-inflammatory therapy reduces by 50% the subsequent recurrent rate. For true refractory cases with failure of standard combination therapies, new and emerging options especially include human intravenous immunoglobulins and biological agents (i.e., anakinra). The outcome of idiopathic recurrent pericarditis is good with a negligible risk of developing constrictive pericarditis. Thus, it is important to reassure patients on their prognosis, explaining the nature of the disease and the likely course. Moreover, therapeutic choices should include less toxic agents and favor cheaper drugs whenever possible.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

Azienda Sanitaria 3 of Torino (now ASLTO2).

Colchicine for the Treatment of Acute and Recurrent Pericarditis

Objective: To evaluate the literature with colchicine for the acute treatment of pericarditis and prevention of recurrent pericarditis. Data Sources: Searches of MEDLINE (1966-March 2014) and Cochrane Database (1993-March 2014) were conducted using the search terms pericarditis and colchicine. Limits were set for articles written in English with human subjects. Additional data were identified through bibliographic reviews. Study Selection and Data Extraction: Case series and clinical trials identified from the data sources were evaluated. Data Synthesis: A total of 16 case series and 5 prospective controlled trials were identified in the search. Early observational studies examined the use of colchicine, as an adjunct to aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs), in patients with multiple cases of recurrent pericarditis. These studies showed decreased rates of recurrence after the initiation of colchicine therapy and formed the basis of the only available guidelines for the treatment of pericarditis. Since then, 5 randomized controlled trials have been published; 3 trials studied colchicine therapy for 6 months in patients with recurrent pericarditis, and the other 2 studied colchicine therapy for 3 months in patients with acute pericarditis. All 5 trials showed decreased rates of recurrence and symptom persistence, with similar rates of adverse events between study groups. Conclusions: Clinical controlled trials have shown that colchicine, as an adjunct to aspirin or NSAIDs, is effective in the prevention of recurrent pericarditis and in the management of acute symptoms. Colchicine was generally well tolerated with a low incidence of adverse events.

Viral genomes in the pericardial fluid and in peri- and epicardial biopsies from a German cohort of patients with large to moderate pericardial effusions

The aetiology of pericardial effusion has been generally assessed by clinical work-up only, which leaves a large cohort of patients with "idiopathic" effusions virtually undiagnosed. In accordance with the ESC guidelines, this contribution intends to change this attitude. After therapeutic or diagnostic pericardiocentesis of 259 patients with large to moderate pericardial effusions, pericardial fluid, epicardial and pericardial biopsies, and blood samples were analysed by PCR for cardiotropic microbial agents. Cytology, histology, immunohistology of tissue and fluids and laboratory tests were performed. Of the 259 patients, 35 % suffered from an autoreactive aetiology, 28 % suffered from a malignant and 14 % from an infectious cause. Investigating all samples by PCR, we identified viral genomes in 51 (19.7 %) patients, parvovirus B19 (B19 V) being identified in 25 and Epstein-Barr virus (EBV) in 19 cases. In patients with a sole infectious aetiology (n = 36), B19 V was detected in 21 and EBV in 10 cases. When differentiating with regard to the material investigated for the presence of cardiotropic viruses, parvovirus B19 was most often detected in the epicardium and EBV was most frequently detected in the pericardial fluid independent from the final diagnostic categorisation. Bacterial cultures including tests for tuberculosis were all negative. Molecular techniques improve sensitivity, specificity and diagnostic accuracy for the underlying aetiology in pericarditis patients with effusion. The identification of specific viral signatures will help to understand pathogenetic mechanisms in pericarditis and allow to tailor an adequate therapy beyond antiphlogistic treatment.

A randomized trial of colchicine for acute pericarditis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Rationale and design of the COlchicine for Prevention of the Post-pericardiotomy Syndrome and Post-operative Atrial Fibrillation (COPPS-2 trial): a randomized, placebo-controlled, multicenter study on the use of colchicine for the primary prevention of the postpericardiotomy syndrome, postoperative effusions, and postoperative atrial fibrillation

BACKGROUND

The efficacy and safety of colchicine for the primary prevention of the postpericardiotomy syndrome (PPS), postoperative effusions, and postoperative atrial fibrillation (POAF) remain uncertain. Although preliminary data from a single trial of colchicine given for 1 month postoperatively (COPPS trial) were promising, the results have not been confirmed in a large, multicenter trial. Moreover, in the COPPS trial, colchicine was given 3 days postoperatively.

METHODS

The COPPS-2 study is a multicenter, double-blind, placebo-controlled randomized trial. Forty-eight to 72 hours before planned cardiac surgery, 360 patients, 180 in each treatment arm, will be randomized to receive placebo or colchicine without a loading dose (0.5 mg twice a day for 1 month in patients weighing ≥70 kg and 0.5 mg once for patients weighing <70 kg or intolerant to the highest dose). The primary efficacy end point is the incidence of PPS, postoperative effusions, and POAF at 3 months after surgery. Secondary end points are the incidence of cardiac tamponade or need for pericardiocentesis or thoracentesis, PPS recurrence, disease-related admissions, stroke, and overall mortality.

CONCLUSIONS

The COPPS-2 trial will evaluate the use of colchicine for the primary prevention of PPS, postoperative effusions, and POAF, potentially providing stronger evidence to support the use of preoperative colchicine without a loading dose to prevent several postoperative complications. ClinicalTrials.gov Identifier: NCT01552187.