Pericardial disease

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.

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.

Pyopericardium progressing to cardiac tamponade in a patient with dengue fever

Pyopericardium is a rare cause of cardiac tamponade. We present a case of a dengue fever patient who presented with cellulitis of the upper limbs, later manifesting cardiac tamponade, which was fatal. Although echocardiography on admission revealed a small pericardial effusion only, it later manifested as tamponade, causing cardiogenic shock. Staphylococcus pyopericardium was found later. Early identification could be possible with bedside point-of-care ultrasonography and echocardiography. Emergent pericardiocentesis or pig tail drain placement is life saving.

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.

Pericardial Diseases Mortality Trends in Brazil From 2000 to 2022

Background Pericardial diseases manifest in various clinical forms, including acute pericarditis, constrictive pericarditis, pericardial effusion, and cardiac tamponade, with acute pericarditis being the most prevalent. These conditions significantly contribute to mortality rates. Therefore, this article aimed to analyze mortality trends in the Brazilian population based on age and sex, shedding light on the impact of pericardial diseases on public health outcomes. Methods  This is a retrospective time-series analysis of pericardial disease mortality rates in Brazil (2000-2022). Data was obtained from the Department of Informatics of the Unified Health System (DATASUS), and the 10th edition of the International Classification of Diseases (ICD-10) codes: I30, I31, and I32 were included for analysis. We gathered population and demographic data categorized by age range and sex from the Brazilian Institute of Geography and Statistics (IBGE). Subsequently, we computed the age-standardized mortality rate per 100,000 individuals and assessed the annual percentage changes (APCs) and average annual percentage changes (AAPCs) using joinpoint regression, along with their corresponding 95% confidence intervals (CIs). Results  In terms of mortality trends based on sex, overall mortality rates remained stable for males and combined sexes over the study period. However, there was a notable increase in mortality rates among females (AAPC=1.18), particularly between 2020 and 2022, with a significant APC of 27.55. Analyzing pericardial diseases across different age groups (20 to 80 years and above), it wasobserved that mortality rates significantly increased in the 70-79 and 80 years and above age groups throughout the study period (AAPC=1.0339 and AAPC=3.4587, respectively). These two age groups experienced the highest significant rise in mortality between 2020 and 2022. Other age groups did not exhibit a significant change in AAPC. Conclusions  This comprehensive analysis spanning two decades (2000-2022), examined the mortality trends of pericardial diseases in Brazil and revealed relative stability overall. Males exhibited an overall higher mortality number due to pericardial diseases; however, females showed the most significant increase in mortality trend throughout the whole period. In the first segment (2000-2015), mortality rose across all cohorts, which was attributed to substandard healthcare facilities and infectious diseases like tuberculosis. The second segment (2016-2020) saw a decline in mortality, likely due to improved healthcare, particularly the increased availability of echocardiograms. However, the third segment (2020-2022) witnessed a sharp rise in mortality, coinciding with the COVID-19 pandemic, with post-COVID-19 symptoms, particularly pericarditis. Pericarditis-related death rates declined compared to pericardial effusion, and mortality rates correlated directly with age, with older cohorts experiencing higher mortality due to increased comorbidities, and decline in health and immunocompetency.

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.

Cardiac tamponade associated with primary myelofibrosis: a case report

Background

Cardiac tamponade is a life-threatening condition that occurs when an abnormal amount of fluid accumulates in the pericardial sac and impedes the cardiac filling process. Although extremely rare, haematological diseases have the potential to trigger an extramedullary haematopoiesis (EMH) process within the pericardium, resulting in a substantial build-up of pericardial effusion.

Case summary

We present the case of a 29-year-old male previously diagnosed with primary myelofibrosis (PMF), who presented to the emergency unit with cardiac tamponade. An emergent pericardiocentesis procedure was performed, successfully evacuating 850 mL of haemorrhagic fluid. Over the course of 3 days, a total of 1.5 L of haemorrhagic effusion were drained from the pericardial space. Analysis of the pericardial fluid revealed evidence of haematopoietic activity, suggesting a potential association with the EMH process occurring within the pericardium. Following a 7-day hospitalization, the patient was discharged in stable condition but later experienced the development of constrictive pericarditis.

Discussion

Haemorrhagic pericardial effusion is a rare occurrence. The majority of cases stems from complications of medical procedures (iatrogenic), malignancies, or side effects of antiplatelet/anticoagulant medications. In patients with PMF, the impaired haematopoietic ability caused by the fibrotic process in the bone marrow compels the body to produce blood components elsewhere, a phenomenon known as EMH. On very rare occasions, EMH can develop in the pericardial space, potentially leading to life-threatening cardiac tamponade. Our patient was successfully managed through pericardial fluid evacuation and drainage but later developed constrictive pericarditis.

Pericardial Disease in the Developing World

Pericardial disease in the developing world is dominated primarily by effusive and constrictive syndromes and contributes to the acute and chronic heart failure burden in many regions. The confluence of geography (location in the tropics), a significant burden of diseases of poverty and neglect, and a significant contribution of communicable diseases to the general burden of disease is reflected in the wide etiological spectrum of causes of pericardial disease. The prevalence of Mycobacterium tuberculosis in particular, is high throughout much of the developing world where it is the most frequent and important cause of pericarditis and is associated with significant morbidity and mortality. Acute viral/idiopathic pericarditis, which is the primary manifestation of pericardial disease in the developed world is believed to occur significantly less frequently in the developing world. Although diagnostic approaches and criteria to establish the diagnosis of pericardial disease are similar throughout the globe, resource constraints such as access to multimodality imaging and hemodynamic assessment are a major limitation in much of the developing world. These important considerations significantly influence the diagnostic and treatment approaches, and outcomes related to pericardial disease.

Chronic Pericardial Effusion: Causes and Management

Chronic pericardial effusion is a common pericardial syndrome whose approach has been well standardised in recent years. The main challenge associated with this condition is the progression (sometimes unheralded) to cardiac tamponade. Pericardial effusions may present either as an isolated finding or in the context of a specific etiology including autoimmune, neoplastic, or metabolic disease. Among investigations used during diagnostic work-up, echocardiography is of paramount importance for the diagnosis, sizing, and serial evaluation of the hemodynamic impact of effusions on heart diastolic function. In an individualised manner, advanced imaging including computed tomography and cardiac magnetic resonance imaging should be performed, especially if baseline tests are inconclusive. Triage of these patients according to the most recent 2015 European Society of Cardiology Guidelines for the diagnosis and management of pericardial diseases should take into account the presence of hemodynamic compromise as well as suspicion of malignant or purulent pericarditis as first step, C-reactive protein serum level measurement as second step, investigations for a specific condition known to be associated with pericardial effusion as third step, and finally the size and the duration of the effusion. Treatment depends on the evaluation of the above-mentioned parameters and should ideally be tailored to the individual patient. Prognosis of chronic pericardial effusions depends largely on the underlying etiology. According to novel data, the prognosis of individuals with idiopathic, chronic (> 3 months), large (> 2 cm), asymptomatic pericardial effusions is usually benign and a watchful waiting strategy seems more reasonable and cost-effective than routine drainage as previously recommended.

[Imagen multimodal de la pericarditis constrictiva: reporte de un caso de cirrosis cardiaca]

Constrictive pericarditis is a rare cause of ascites and cardiac cirrhosis. We present the case of a 36-year-old male patient with a history of cirrhosis of unknown etiology, who consulted for refractory ascites, dyspnea, and lower limb swelling. Echocardiography determined constrictive pericarditis, which was corroborated by the findings of computed tomography. The clinical and hemodynamic worsening of the patient led to an emergency pericardiectomy with satisfactory recovery. This report shows a severe clinical consequence of constrictive pericarditis, cardiac cirrhosis, which was reversible with pericardial extirpation. Multimodal imaging was essential in the diagnosis of constrictive pericarditis.

Surgical and Medical Management of Purulent Bacterial Pericarditis With Pericardial Mass in a Young Child

Purulent bacterial pericarditis is rare and associated with significant short- and long-term morbidity. We report a case of purulent bacterial pericarditis caused by Group A Streptococcus in an immunocompetent young child presenting with a pericardial mass. She was successfully treated with a combined medical and early surgical approach. (Level of Difficulty: Intermediate.).

Multimodality Cardiac Imaging in COVID

Infection with SARS-CoV-2, the virus that causes COVID, is associated with numerous potential secondary complications. Global efforts have been dedicated to understanding the myriad potential cardiovascular sequelae which may occur during acute infection, convalescence, or recovery. Because patients often present with nonspecific symptoms and laboratory findings, cardiac imaging has emerged as an important tool for the discrimination of pulmonary and cardiovascular complications of this disease. The clinician investigating a potential COVID-related complication must account not only for the relative utility of various cardiac imaging modalities but also for the risk of infectious exposure to staff and other patients. Extraordinary clinical and scholarly efforts have brought the international medical community closer to a consensus on the appropriate indications for diagnostic cardiac imaging during this protracted pandemic. In this review, we summarize the existing literature and reference major societal guidelines to provide an overview of the indications and utility of echocardiography, nuclear imaging, cardiac computed tomography, and cardiac magnetic resonance imaging for the diagnosis of cardiovascular complications of COVID.

Comprehensive Management of the Patient With Traumatic Cardiac Injury

Cardiac injuries are rare but potentially life-threatening, with a significant proportion of victims dying before arrival at the hospital. The in-hospital mortality among patients who arrive in-hospital alive also remains significantly high, despite major advancements in trauma care including the continuous updating of the Advanced Trauma Life Support (ATLS) program. Stab and gunshot wounds due to assault or self-inflicted injuries are the common causes of penetrating cardiac injuries, while motor vehicular accidents and fall from height are attributable causes of blunt cardiac injury. Rapid transport of victim to trauma care facility, prompt recognition of cardiac trauma by clinical evaluation and focused assessment with sonography for trauma (FAST) examination, quick decision-making to perform emergency department thoracotomy, and/or shifting the patient expeditiously to the operating room for operative intervention with ongoing resuscitation are the key components for a successful outcome in cardiac injury victims with cardiac tamponade or exsanguinating hemorrhage. Blunt cardiac injury with arrhythmias, myocardial dysfunction, or cardiac failure may need continuous cardiac monitoring or anesthetic care for operative procedure of other associated injuries. This mandates a multidisciplinary approach working in concert with agreed local protocols and shared goals. An anesthesiologist has a pivotal role to play as a team leader or member in the trauma pathway of severely injured patients. They are not only involved in in-hospital care as a perioperative physician but also participate in the organizational aspects of prehospital trauma systems and training of prehospital care providers/paramedics. There is sparse literature available on the anesthetic management of cardiac injury (penetrating as well as blunt) patients. This narrative review discusses the comprehensive management of cardiac injury patients, focusing on the anesthetic concerns and is guided by our experience in managing cardiac injury cases at Jai Prakash Narayan Apex Trauma Center (JPNATC), All India Institute of Medical Sciences, New Delhi. JPNATC is the only level 1 trauma center in north India, providing services to a population of approximately 30 million with around 9000 operations being performed annually.

A Wireless, Wearable Carotid Doppler Ultrasound Aids Diagnosis and Monitoring of Pericardial Tamponade: A Case Report

Pericardial tamponade can often be diagnosed through clinical findings and echocardiography; however, the diagnosis can be aided by demonstrating the hemodynamic consequences of the effusion. We describe the use of a wearable carotid Doppler device to help diagnose and monitor pericardial tamponade.

CASE SUMMARY

A 54-year-old man developed hypotension after an endobronchial biopsy for a lung mass. Echocardiography showed a pericardial effusion with sonographic evidence of tamponade. A wearable carotid Doppler device demonstrated low corrected carotid flow time (CFT) (a surrogate for stroke volume) with significant respiratory variation, supporting the diagnosis of tamponade. The patient underwent pericardiocentesis which revealed purulent pericardial fluid from a mediastinal abscess. After drainage there was increased CFT and reduced respiratory variability in Doppler, surrogates of improved stroke volume.

CONCLUSION

A wearable carotid Doppler device is a noninvasive tool that can help determine the hemodynamic impact of a pericardial effusion, and potentially aid in the diagnosis of pericardial tamponade.

Not all Shock States Are Created Equal: A Review of the Diagnosis and Management of Septic, Hypovolemic, Cardiogenic, Obstructive, and Distributive Shock

Shock in the critically ill patient is common and associated with poor outcomes. Categories include distributive, hypovolemic, obstructive, and cardiogenic, of which distributive (and usually septic distributive) shock is by far the most common. Clinical history, physical examination, and hemodynamic assessments & monitoring help differentiate these states. Specific management necessitates interventions to correct the triggering etiology as well as ongoing resuscitation to maintain physiologic milieu. One shock state may convert to another and may have an undifferentiated presentation; therefore, continual re-assessment is essential. This review provides guidance for intensivists for management of all shock states based on available scientific evidence.

Spatial Gene Expression Changes in the Mouse Heart After Base-Targeted Irradiation

PURPOSE

Radiation cardiotoxicity (RC) is a clinically significant adverse effect of treatment for patients with thoracic malignancies. Clinical studies in lung cancer have indicated that heart substructures are not uniformly radiosensitive, and that dose to the heart base drives RC. In this study, we aimed to characterize late changes in gene expression using spatial transcriptomics in a mouse model of base regional radiosensitivity.

METHODS AND MATERIALS

An aged female C57BL/6 mouse was irradiated with 16 Gy delivered to the cranial third of the heart using a 6 × 9 mm parallel opposed beam geometry on a small animal radiation research platform, and a second mouse was sham-irradiated. After echocardiography, whole hearts were collected at 30 weeks for spatial transcriptomic analysis to map gene expression changes occurring in different regions of the partially irradiated heart. Cardiac regions were manually annotated on the capture slides and the gene expression profiles compared across different regions.

RESULTS

Ejection fraction was reduced at 30 weeks after a 16 Gy irradiation to the heart base, compared with the sham-irradiated controls. There were markedly more significant gene expression changes within the irradiated regions compared with nonirradiated regions. Variation was observed in the transcriptomic effects of radiation on different cardiac base structures (eg, between the right atrium [n = 86 dysregulated genes], left atrium [n = 96 dysregulated genes], and the vasculature [n = 129 dysregulated genes]). Disrupted biological processes spanned extracellular matrix as well as circulatory, neuronal, and contractility activities.

CONCLUSIONS

This is the first study to report spatially resolved gene expression changes in irradiated tissues. Examination of the regional radiation response in the heart can help to further our understanding of the cardiac base's radiosensitivity and support the development of actionable targets for pharmacologic intervention and biologically relevant dose constraints.

Pyo-pericardium secondary to bacteremia in intra-venous drug user

Pyo-pericardium is a collection of purulent fluid in the pericardial sac. It is a rare finding seen in less than 1% of patients who develop acute pericarditis. The condition, though uncommon, has a mortality risk of 100% in untreated patients and 40% in treated patients. Most of the reported cases in the literature describe the occurrence of pyo-pericardium in IV drug users that's secondary to needle fragment embolization to the pericardium diagnosed through an echocardiogram and CT scan with no evidence of bacteremia. Unlike reported cases, we present a case of pyo-pericardium in a 37-year-old woman with bacteremia from a wound infection on her leg secondary to IV drug use. Needle embolization was ruled out in our case as no foreign object was identified on echocardiography or CT scan. Prompt identification followed by aggressive treatment with pericardial window and systemic antibiotics is crucial for decreasing mortality in such high-risk patients.

Pericardial computed tomography imaging findings in the setting of coccidioidomycosis

Background

Pericardial disease can be a manifestation of infection and imaging can have a role in its diagnosis. coccidioidomycosis endemic fungal infection has been more frequently reported over the past few decades. Other than case reports or series, there has been no systemic study evaluating pericardial imaging findings in patients with coccidioidomycosis to the best of our knowledge. The purpose of this study was to evaluate intrathoracic computed tomographic (CT) imaging abnormalities in patients with coccidioidal infection with specific emphasis on the pericardium.

Methods

Retrospective review of radiology reports and clinical chart review was performed to identify patients with coccidioidomycosis between January 2000 and September 2021 at our medical center. Diagnosis of infection was confirmed predominately with serology. Patients were excluded if a CT was not performed within 3 months of confirmed diagnosis date and if there was concomitant additional granulomatous or fungal infection. Chest CT was reviewed for pericardial and additional intrathoracic findings.

Results

The final retrospective cohort consisted of 37 patients. Imaging findings included lung nodules (N = 33/37), consolidation (N = 25/37), mediastinal or hilar lymphadenopathy (N = 20/37) and pleural effusions (N = 13/37). Eleven of 37 patients (30%) had either trace pericardial fluid (N = 3/37) or small pericardial effusions (N = 8/37). One patient had pericardial enhancement/thickening and history of pericardial tamponade. No other patient had clinical pericarditis or pericardial tamponade. Pericardial calcifications were not seen in any patient. Pericardial effusion was statistically associated with presence of pleural effusion as 9/13 patients with pleural effusion had pericardial effusion versus 2/26 patients without pleural effusion had pericardial effusion (p < 0.001). Otherwise patients with and without pericardial imaging findings were similar in terms of demographics, comorbidities and other imaging findings.

Conclusion

Pulmonary parenchymal pathology is a common manifestation of coccidioidal infection. Most patients with coccidioidomycosis do not have pericardial imaging abnormalities on CT.

Autoimmune Pericarditis: Multimodality Imaging

PURPOSE OF THE REVIEW

The purpose of this review is to understand the underlying mechanism that leads to pericarditis in systemic autoimmune and autoinflammatory diseases. The underlying mechanism plays a vital role in the appropriate management of patients. In addition, we will review the current landscape of available cardiac imaging modalities with emphasis on pericardial conditions as well as proposed treatment and management tailored toward pericardial autoimmune and autoinflammatory processes.

RECENT FINDINGS

Approximately 22% of all cases of pericarditis with a known etiology are caused by systemic autoimmune diseases such as systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, and vasculitis. In recent years, there have been advancements of imaging modalities including cardiac MRI, cardiac CT scan, and PET scan and their respective nuances in regard to contrast use, technique, and views which clinicians may utilize to better understand the extent of a patient's pericardial pathology and the trajectory of his or her disease process. In this review, we will discuss systemic autoimmune and autoinflammatory diseases that involve the pericardium. We will also review different imaging modalities that are currently used to further characterize such conditions. Having a deeper understanding of such techniques will improve patient outcomes by helping clinicians tailor treatment plans according to the unique underlying condition.

Subacute Cardiac Tamponade in a COVID-19 Patient Despite Negative Testing

COVID-19 infection has been documented to cause a wide range of symptoms including cardiac complications. We present a case of subacute cardiac tamponade in a patient infected with COVID-19 in the absence of respiratory symptoms; we also review the current literature on this rare sequela. Our patient is a 67-year-old man who presented to the hospital due to intermittent chest pain for three weeks. COVID-19 polymerase chain reaction (PCR) testing was negative two times. He had an outpatient echocardiogram that showed a moderate pericardial effusion about a week prior to the hospital presentation. On admission, a repeat echocardiogram showed a large pericardial effusion with tamponade physiology. Pericardiocentesis did not reveal a clear etiology of the hemorrhagic effusion but four days later, the patient was found to be positive for COVID-19 infection without any clear respiratory illness. Given the absence of other etiology and negative workup, cardiac tamponade was attributed to pericardial inflammation from this virus and our patient improved with colchicine and steroids. We, therefore, advise providers to consider COVID-19 as a cause of hemorrhagic, cryptogenic cardiac tamponade despite negative COVID-19 testing. We also review 42 additional reported cases of cardiac tamponade in patients infected with COVID-19. COVID-19 can cause cardiac tamponade even in the absence of pulmonary disease. This case and literature review highlight tamponade as a rare complication of COVID-19 and should be considered in the differential of any acute deterioration in this patient population.

Malignant pericardial effusions: A retrospective look at etiology and prognosis in a tertiary oncological center

PURPOSE

Cancer and the associated treatments are important causes of pericardial effusion. However, the natural history of malignant pericardial effusion is largely unknown, especially in the context of newer cancer treatments. We investigated the causes of pericardial effusions in a tertiary oncology center, with particular focus on the prognosis of malignant effusions in the era of contemporary oncological therapies.

METHOD

We obtained data from electronic medical records. Survival analyses were performed utilizing the Kaplan-Meier method. We performed Cox regression to explore the potential clinical factors associated with survival.

RESULTS

Forty-four patients had pericardial effusion treated with pericardiocentesis during the study period. The mean age was 62-years, and 55% were female. Sixty-eight percent of these patients also had cancer, with approximately half (47%) receiving prior chemotherapy, and a quarter (27%) having had chest radiotherapy. Seventy percent of the patients with active cancer had malignant cells on cytology of pericardial fluid. The median survival of the cohort was 227 days, with malignant effusions having a median survival of 62-days compared to nonmalignant effusions with 1408 days (Logrank statistic 7.4, p-value .007). Malignant cytology was significantly associated with mortality on univariable analysis (HR 2.5, 95% CI 1.2-5.3). Complication rates were low, with no deaths as a direct complication of pericardiocentesis.

CONCLUSION

Malignancy is the most common cause of pericardial effusion in this tertiary medical and oncological center. Abnormal cytology with malignant cells has a poor median survival, despite advances in oncological treatment over the last decade. Pericardiocentesis is a safe procedure for these patients.

Tuberculosis of the Heart: A Diagnostic Challenge

Tuberculosis of the heart is relatively rare and presents a significant diagnostic difficulty for physicians. It is the leading cause of death from infectious illness. It is one of the top 10 leading causes of death worldwide, with a disproportionate impact in low- and middle-income nations. The radiologist plays a pivotal role as CMR is a non-invasive radiological method that can aid in identifying potential overlap and differential diagnosis between tuberculosis, mass lesions, pericarditis, and myocarditis. Regardless of similarities or overlap in observations, the combination of clinical and certain particular radiological features, which are also detected by comparison to earlier and follow-up CMR scans, may aid in the differential diagnosis. CMR offers a significant advantage over echocardiography for detecting, characterizing, and assessing cardiovascular abnormalities. In conjunction with clinical presentation, knowledge of LGE, feature tracking, and parametric imaging in CMR may help in the early detection of tuberculous myopericarditis and serve as a surrogate for endomyocardial biopsy resulting in a quicker diagnosis and therapy. This article aims to explain the current state of cardiac tuberculosis, the diagnostic utility of CMR in tuberculosis (TB) patients, and offer an overview of the various imaging and laboratory procedures used to detect cardiac tuberculosis.

Pericardial Recesses Mimicking Mediastinal Adenopathy on CT

Thin-section computed tomography (CT) has improved the detection of pericardial recesses and sinuses. Physiologic fluid in the pericardial recesses and sinuses can mimic mediastinal adenopathy. The misinterpretation of pericardial recesses and other benign pericardial entities in the oncologic setting can lead to inappropriate staging and management. Knowledge of the anatomy of the pericardium with emphasis on the imaging of different pericardial recesses on CT is important to avoid misdiagnosis, unnecessary further investigations, and/or biopsy.

Chronic pericardial effusion: current concepts and emerging trends

INTRODUCTION

Pericardial effusion (PEF) is a common and challenging pericardial syndrome with a variety of clinical manifestations ranging from asymptomatic, incidentally uncovered small PEFs, to life-threatening cardiac tamponade.

AREAS COVERED

: This review focuses on the pathophysiology, epidemiology, etiology, classification, clinical findings, diagnostic work-up, management and outcome of PEFs. Particular emphasis has been given on the most recent evidence concerning the contribution of imaging for the detection, differential diagnosis and evaluation of the hemodynamic impact of PEFs on the diastolic filling of the heart. Moreover, simplified algorithms for PEF triage and management have been included.

EXPERT OPINION

The management of patients with PEFs is mainly based on four parameters namely hemodynamic impact on diastolic function, elevation of inflammatory markers, presence of a specific underlying condition known to be associated with PEF and finally size and duration of the effusion. Novel data have contributed to change our view towards large, asymptomatic, "idiopathic" PEFs and dictated a rather conservative approach in most cases. It is also stressed that there is a compelling need for additional research, which is essential for tailored treatments aiming at the improvement of quality of life and containment of health care costs.

Pericardiocentesis or surgical drainage: A national comparison of clinical outcomes and resource use

Background

While institutional series have sought to define the optimal strategy for drainage of pericardial effusions, large-scale comparisons remain lacking. Using a nationally representative sample, the present study examined clinical and financial outcomes following pericardiocentesis (PC) and surgical drainage (SD) in patients admitted for pericardial effusion and tamponade.

Methods

Adults undergoing PC or SD within 2 days of admission for non-surgically related pericardial effusion or tamponade were identified in the 2016–2019 Nationwide Readmissions Database. Multivariable logistic and linear models were developed to evaluate the association between intervention type and outcomes. The primary outcome of interest was mortality while secondary endpoints included reintervention, periprocedural complications, hospital length of stay (LOS), hospitalization costs and 30-day non-elective readmission.

Results

Of an estimated 44,637 records meeting inclusion criteria, 28,862 (64.7%) underwent PC while the remainder underwent SD for initial management of pericardial effusion or tamponade. PC was associated with significantly increased odds of in-hospital mortality, reintervention and 30-day readmission relative to SD. PC was also associated with greater odds of cardiac complications but lower odds of infection, respiratory failure and blood transfusions compared to SD. Although PC was associated with shorter index hospital length of stay and costs, the two strategies yielded similar 30-day cumulative costs.

Conclusion

Management of pericardial effusion with PC is associated with greater odds of mortality, reintervention and 30-day readmission but similar 30-day cumulative costs compared to SD. In the setting of adequate hospital capability and operator expertise, SD is a reasonable initial treatment strategy for pericardial effusion.

Septic pericardial disease and mediastinal abscessation in a cat with an intrathoracic needle foreign body

OBJECTIVE

To describe the successful management of a cat with an intrathoracic sewing needle foreign body and septic pericardial effusion.

CASE SUMMARY

A 10-year-old neutered female domestic longhair cat was referred for an intrathoracic metallic foreign body identified via thoracic radiography. Two weeks prior, the cat may have ingested a sewing needle. She was presented hemodynamically unstable; point-of-care thoracic ultrasound identified pericardial effusion with right atrial tamponade. Pericardiocentesis stabilized hemodynamic parameters. The effusion was grossly purulent, and bacterial culture grew an Actinomyces sp. The cat underwent a median sternotomy to remove the foreign body, debride associated mediastinal abscesses, and perform a partial pericardiectomy. Over the next 10 days, the cat was managed in hospital with a left unilateral thoracostomy tube and intermittent lavage of the pleural cavity. The cat was discharged, and follow-up at 7 days showed no evidence of pericardial or pleural effusion.

NEW OR UNIQUE INFORMATION PROVIDED

Contrary to previous reports, this case shows that extra-gastrointestinal, specifically intrathoracic, sewing needle foreign bodies can cause significant morbidity in cats. To the authors' knowledge, this report is the first to describe septic pericardial disease resulting from documented foreign body ingestion in the cat. It is also the first case report of successful surgical management of mediastinal abscessation in the cat.

Treatment with Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Does Not Affect Outcome in Patients with Acute Myocarditis or Myopericarditis

Background: Previous animal studies reported an association of non-steroidal anti-inflammatory drugs (NSAIDs) with adverse outcomes in acute myocarditis, which is why these drugs are currently not recommended in affected patients. In this retrospective case-control study, we sought to investigate the effects of NSAID treatment in patients with acute myocarditis and myopericarditis to complement the available evidence. Method: A total of 114 patients with acute myocarditis were retrospectively enrolled. Demographical, clinical and laboratory data were extracted from hospital records. Patients who received NSAIDs (n = 39, 34.2%) were compared to controls. Follow-up on all-cause mortality was acquired for two years. Propensity score matching was additionally conducted to account for covariate imbalances between groups. Results: Treatment with NSAIDs was neither associated with a worse outcome (p = 0.115) nor with significant differences in left ventricular systolic function (p = 0.228) or in-hospital complications (p = 0.507). Conclusion: Treatment with NSAIDs was not associated with adverse outcomes in our study cohort. Together with the findings of previous studies, our results indicate that these drugs could be safely administered in patients with myocarditis and myopericarditis.

Prevalence, Predictors, and Clinical Presentation of Acute Pericardial Effusion Following Percutaneous Coronary Intervention

Background: Iatrogenic pericardial effusion (PE) has been demonstrated to lead to cardiac injury as a sign of systemic inflammatory response. Objectives: This study sought to determine the anatomical characteristics and clinical presentation associated with PE after percutaneous coronary intervention (PCI) by using echocardiography. Methods: The clinical outcomes of all patients with coronary artery disease who underwent PCI from July 2014 to December 2018 were evaluated. The quantitative and qualitative analyses of PE were performed. The associations between the presence of PE and procedural factors were also evaluated. Results: A total of 882 patients were enrolled. PE was found in 144 patients (16.3%) and was mostly located in the anterior pericardium at low amounts. The serum levels of high-sensitive C-reaction protein before PCI and troponin T in the group with PE after PCI were significantly higher than those in the group without PE (p < 0.0001). The presence of PE was associated with the procedural time (OR = 1.02, p = 0.035) and the degree of interventional complexity (multiple vessels OR = 1.89, p = 0.014; chronic total occlusion OR = 2.04, p = 0.005; and PCI with rotational atherectomy OR = 1.15, p = 0.011) independent of the number of culprit vessels and stents. During 1-year follow-up, a significantly higher number of cardiac deaths (3) and myocardial infarctions (8) occurred in patients with PE than in patients without PE (P < 0.05). Conclusion: Post-PCI acute PE was frequent, generally mild, mainly asymptomatic, and independently associated with procedural time and complexity. This effusion, which is considered as a cardiac damage marker, could be a predominant clinical sign for long-term prognosis.

Cardiac tamponade due to right atrial rupture

Cardiac tamponade is a cardiac emergency that requires urgent intervention. Cardiac tamponade due to penetrating cardiac injury requires urgent thoracotomy. As per the guidelines, pericardiocentesis can be done as a bridge to thoracotomy. However, no clear guidelines exist on the management of cardiac tamponade due to blunt cardiac injury. In the following case report, we propose a management plan for blunt cardiac injury in the emergency department. In the following case report, we describe a patient with a road traffic accident who had a blunt cardiac injury and had cardiac tamponade for whom we did not do emergency pericardiocentesis. Instead, we managed the patient with iv fluids and blood transfusion and the patient was taken up for immediate emergency thoracotomy. Not all cardiac tamponade requires pericardiocentesis. Cardiac tamponade due to injury to the low-pressure system can be best managed by initial resuscitation followed by emergency thoracotomy. We also propose a management plan for managing a patient with cardiac tamponade due to blunt cardiac injury when the injury can be visible in the low-pressure chambers.

Established and Emerging Techniques for Pericardial Imaging with Cardiac Magnetic Resonance

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Where Did the Pericardial Effusion Go? A Case of Cardiopulmonary Resuscitation Acting as Treatment for Pericardial Tamponade

Pericardial tamponade results in multiple organ dysfunction and can lead to cardiac arrest. Cardiopulmonary resuscitation (CPR), a life-saving measure performed on patients in cardiac arrest, can lead to thoracic organ damage. However, CPR rarely acts as a therapeutic treatment for pericardial tamponade. Our case describes a patient admitted with pericardial tamponade in whom CPR provided therapeutic treatment with pericardial rupture and resolution of the tamponade.

Pathological Findings of Canine Idiopathic Pericarditis and Pericardial Mesotheliomas: Correlation with Clinical and Survival Data

Idiopathic pericarditis (IP) and pericardial mesothelioma (PM) are causes of pericardial effusion in dogs. Pericardiectomy can be a definitive treatment in the case of idiopathic pericardial effusion or a short-term intervention for mesothelioma. The aim of the present study was to investigate which histopathologic parameters are correlated with clinical outcomes in a cohort of dogs that underwent pericardiectomy. The histopathological findings of 22 IPs and 5 PMs were compared with clinical and survival data and the immunohistochemical characterization of immune cells (CD3, CD79α, Iba1). In IP, the mesothelium was lost in 20 cases, reactive in 9, atypical in 3, and mesothelial papillary hyperplasia (MPH) was observed in 4 cases. Numerous macrophages were found in both IPs and PMs especially at the superficial layer of the pericardium. T lymphocytes were observed in mild to moderate numbers and were more numerous than B lymphocytes in both IPs and PMs. MPH was correlated with the quantity of lymphoplasmacytic infiltrate in the superficial layer, inversely related to the thickness of the pericardium, and associated with a longer overall survival. Pericardial fibrosis was present in 19 out of 22 IPs and in all mesotheliomas and was correlated with increased time from initial presentation and pericardiectomy and lymphoplasmacytic infiltrate in the deep zone. Pericardial thickness was correlated with the amount of lymphoplasmacytic and macrophagic infiltrate in the deep zone. Mesothelioma was associated with an increased number of pericardiocentesis procedures before pericardiectomy and with the presence of macrophages in the superficial pericardial layer, edema, fibrin, and hemorrhage. Disease-free interval and overall survival were significantly shorter in patients with mesothelioma compared with IP.

Contemporary contribution of cardiac surgery for the treatment of cardiomyopathies and pericardial diseases

Cardiomyopathy refers to a spectrum of heterogeneous myocardial disorders characterized by morphological and structural alterations leading eventually to heart failure, by affecting cardiac filling and/or the cardiac systolic function. Heart transplantation is currently the gold standard surgical treatment for patients with heart failure, with a median survival in adults of 12 years according to international registries. However, the limited available donor pool does not allow its extensive employment. For this reason, mechanical circulatory supports are increasingly used, and in the short term are becoming as possible alternatives to heart transplantation, owing to improved technologies and increased biocompatibility. However, long-term outcomes of mechanical assist devices are still burdened with a high rate of adverse events. Conventional surgical treatments could be still considered as alternatives to heart replacement treatment when tailored both on patient clinical conditions and etiology of cardiac diseases. In particular, among patients affected by ischemic cardiomyopathy, coronary artery bypass grafting has proven to improve survival when associated to optimal medical treatment, and surgical ventricular restoration might be considered as a valid treatment in particular cases. Correction of functional mitral valve regurgitation by mitral annuloplasty, which aims to restore left ventricular geometry, has not demonstrated unambiguous results, and outcomes of this procedure are still controversial. Pericardial pathology becomes of surgical interest when it is responsible for a reduced filling capacity of the heart chambers, which can develop acutely (cardiac tamponade) or chronically (as in the case of constrictive pericarditis). This review focuses on the different surgical approaches that could be adopted to treat patients with heart failure and pericardial diseases.

Usefulness of neutrophil-to-lymphocyte ratio for predicting acute pericarditis outcomes

BACKGROUND

In daily practice, C-reactive protein (CRP) may be used to predict recurrence and treatment response in patients with acute pericarditis; however, the predictive role of CRP might be insufficient for clinical prediction in some patients. In this study, we aimed to investigate the relationship between neutrophil-to-lymphocyte ratio (NLR) and the composite endpoint of pericarditis recurrence and/or tamponade within 1 year in patients with acute pericarditis.

METHODS

A total of 104 patients diagnosed with acute idiopathic pericarditis (mean age 42.8 ± 15.2 years, 55.8% male) were included in the study. Physical examination findings of these patients, electrocardiography, echocardiography, chest X-ray and laboratory findings were evaluated and analysed. During the 1-year follow-up, the composite of cardiac tamponade and/or pericarditis recurrence was investigated as the primary endpoint of the study.

RESULTS

Compared to the group without the composite outcome, the group with the composite outcome had significantly higher rates of moderate and severe pericardial effusion (p < 0.01) and higher white blood cell (WBC) count (p:0.001), platelet count (p = 0.003), NLR (2.14 (1.49-3.02) vs 6.60 (5.50-8.68); p < 0.001) and high-sensitivity C-reactive protein (hs-CRP) (8.01 (5.1-24.5 vs 69.5 (40.8-128); p:0.001). Higher hs-CRP (p < 0.001), WBC (p:0.001), NLR (p < 0.001) and platelets (p:0.02) were associated with pericarditis recurrence. NLR and hs-CRP were independently associated with the composite endpoint (p < 0.001 and p < 0.001, respectively).

CONCLUSION

NLR and hs-CRP were found to be independent predictors for the composite endpoint of tamponade and/or recurrence in acute pericarditis patients during the 1-year follow-up. Similar to hs-CRP, NLR may also be used for risk assessment in patients with idiopathic pericarditis.

Cardiogenic shock following cardiac tamponade and Takotsubo in COVID-19

Introduction: Takotsubo is often described as stress-induced cardiomyopathy and is a known cause of heart failure. Objective: Review the clinical course of a young coronavirus disease 2019 (COVID-19) patient who developed Takotsubo following cardiac tamponade. Case presentation: A 42-year-old woman presented to the emergency department with fever, altered mental status and hypoxia. She was ultimately found to be in cardiac tamponade and within 2 hours of a pericardiocentesis she developed Takotsubo and was in cardiogenic shock. Her family decided to place her on comfort measures and she died the same day. Discussion: This case illustrates the increasing number of cardiovascular complications being reported in COVID-19 and highlights the importance of clinicians to be aware of these challenges. Conclusion: Here, we report a distinct presentation of cardiogenic shock in a young COVID-19 patient. The rapid onset of her suspected Takotsubo and the severity of her disease were striking features in this case.

Cardiac Tamponade Secondary to Influenza B Infection

Every year, Influenza infection contributes to significant morbidity and mortality carrying a huge economic burden. Extra-pulmonary manifestations are increasingly being recognized. We present a 29-year-old woman with acute pericarditis and cardiac tamponade requiring emergent pericardiocentesis secondary to Influenza B infection. Although very rare in relation to Influenza B infection, the pericardial disease can occur during the acute infection or as a post-viral syndrome. Considering pericardial disease in patients with chest pain and any viral infection may facilitate timely diagnosis and prevent unnecessary life-threatening complications.

Relapsing Multiple Myeloma Presenting as Cardiac Tamponade and Obstructive Uropathy

Cardiac tamponade is a rare manifestation of relapsing extramedullary multiple myeloma and portends poor prognosis. No cases of cardiac tamponade with co-occurring renal obstruction from plasmacytoma have been reported in the literature, making this case a unique presentation of relapsing multiple myeloma. The presence of known malignancy should not limit our differential diagnosis when evaluating patients with signs of cardiac tamponade.

Recurrent pericarditis: an update on diagnosis and management

Recurrent pericarditis is a true challenge for clinicians, especially when the patient becomes unresponsive or not tolerant to conventional treatments. An accurate diagnosis of recurrent pericarditis, possibly supported by advanced imaging tools, is critical to provide timely and appropriate treatment of symptoms and prevention of further episodes. The incessant research on the inflammatory pathways underlying cardiovascular diseases, led recently to the assessment of anti interleukin-1 agents in the setting of recurrent pericarditis. This review will focus on the diagnostic assessment of recurrent pericarditis, along with the most modern therapeutic advances in this field. Bibliographic databases were searched (MEDLINE/PubMed, BioMed Central, the Cochrane Collaboration Database of Randomized Trials, Scopus, ClinicalTrials.gov, EMBASE, Google Scholar) using the terms "recurrent pericarditis" AND "diagnosis" OR "treatment" OR "IL-1" OR "inflammation".

A case of Dressler's syndrome successfully treated with colchicine and acetaminophen

The incidence of Dressler’s syndrome after myocardial infarction (MI) has decreased in the reperfusion therapy era. Although guidelines recommend high-dose aspirin for treatment based on evidence from the pre-percutaneous coronary intervention (pre-PCI) era, bleeding and thrombotic concerns occurred upon aspirin administration after coronary stenting. A 69-year-old man with recent MI was admitted to our hospital. The patient presented with chest pain 1 week before admission. Electrocardiography revealed newly detected atrial fibrillation with no ST segment change. Urgent coronary angiography demonstrated a left circumflex artery occlusion. He underwent PCI, and a sirolimus-eluting stent was deployed. Aspirin, prasugrel, and apixaban were administered. However, hospital discharge was delayed because he developed heart failure during hospitalization. Twenty-three days after admission, he developed a fever of >39 °C. Electrocardiography showed anterior ST segment elevation, and echocardiography revealed a 6-mm pericardial effusion. We diagnosed the patient with Dressler’s syndrome, and colchicine 0.5 mg/day + acetaminophen 2000 mg/day were administered. His condition clinically improved after treatment and he was discharged 32 days after admission. There was hesitation about administration of high-dose aspirin in a patient who has undergone recent coronary stenting. Combination therapy of colchicine and acetaminophen could be a treatment option for Dressler’s syndrome.

<Learning objective: Guidelines recommend high-dose aspirin for the treatment of Dressler’s syndrome based on evidence from the pre-percutaneous coronary intervention (pre-PCI) era. However, bleeding and thrombotic concerns are present upon high-dose aspirin administration in patients who have undergone PCI. Therefore, a combination therapy of low-dose colchicine and acetaminophen could be a treatment option for patients with Dressler’s syndrome who have undergone recent coronary stenting.>

MELD and MELD XI Scores as Predictors of Mortality After Pericardiectomy for Constrictive Pericarditis

OBJECTIVE

To assess the association between the preoperative model for end-stage liver disease (MELD) and MELD-XI (exclude international normalized ratio) score and outcomes in patients undergoing pericardiectomy for constrictive pericarditis.

PATIENTS AND METHODS

Patients >18 years of age undergoing pericardiectomy for constrictive pericarditis between January 1, 2007, and October 12, 2017, were analyzed with data for MELD and MELD-XI score calculation within 30 days preoperatively. The association between the MELD and MELD-XI scoring systems and risk of postoperative outcomes was assessed in regression models adjusting for relevant covariates. The primary outcome was operative mortality (death within 90 days or in hospital). Secondary outcomes included various measures of postoperative morbidity.

RESULTS

A total of 175 and 226 patients had data for MELD/MELD-XI, respectively. Ninety-day mortality was 8.7%. When stratified into tertiles of MELD-XI, the unadjusted risk of 90-day mortality was 2.7%, 8.2%, and 16.0%, respectively. In Cox regression models fitted for MELD-XI and MELD, higher scores associated with increased risk of mortality (P<.001 for both). In secondary multivariable analyses, both MELD-XI and MELD were associated with increased incidence of renal failure and greater levels of chest-tube output and transfusion, whereas MELD-XI was additionally associated with prolonged intubation and extended intensive care unit and hospital stays.

CONCLUSION

Among patients undergoing pericardiectomy for constrictive pericarditis, MELD-XI and MELD were associated with increased postoperative morbidity and mortality. Although the simpler MELD-XI score generally performed as well or better than MELD as a correlate of various outcomes, both scores can serve as a simple yet robust risk stratification tool for patients undergoing pericardiectomy for constrictive pericarditis.

An unusual cause of acute pericarditis: a case report

BACKGROUND

Inflammation of the pericardium, or pericarditis, is a frequent cause of acute chest pain in young patients. Pericarditis is typically associated with viral infections, but other potential causes may have distinct prognostic and therapeutic implications.

CASE SUMMARY

A 26-year-old man presented with typical signs and symptoms of acute pericarditis. However, imaging disclosed an anterior mediastinal mass that compressed the right ventricular outflow tract. The coarse outflow murmur convincingly mimicked a pericardial friction rub on auscultation.

CONCLUSION

Clinicians should be aware of alternative aetiologies to pericarditis in patients who present with prolonged or refractory symptoms.

Acute Influenza B Infection Presenting as Cardiac Tamponade: A Case Report

Influenza A and B acute infections usually affect primarily the respiratory system. In rare cases, however, the cardiovascular system is also compromised either via the direct effect of the virus or via the worsening of preexisting cardiac conditions. We present a rare case of acute Influenza B infection presenting as pericardial effusion and cardiac tamponade.

A healthy 32-year-old female was presented to the emergency room with influenza-like symptoms for four days, where she was monitored for a few hours and was subsequently discharged to home after testing positive for Influenza B by polymerase chain reaction (PCR). On the fifth day, she returned to the emergency room with worsening symptoms, primarily exertional dyspnea. She was hypotensive and tachycardic and temporarily improved with fluid administration. She was transferred to the intensive care unit, where a bedside point of care ultrasound (POCUS) and later a formal transthoracic echocardiogram revealed that she had pericardial effusion with sonographic signs of cardiac tamponade. Emergent pericardiocentesis was performed and resulted in hemodynamic and symptomatic improvement. The pericardial drain that was initially left in place and continued to drain pericardial fluid (700 ccs in total), was removed 3 days later, after echocardiographic confirmation of the resolution of the pericardial effusion. She completed a five-day course of Oseltamivir and was subsequently discharged home safely.

In summary, our case describes an acute Influenza B infection that was complicated by pericardial effusion and cardiac tamponade. It also highlights the importance of bedside POCUS and echocardiography in the early diagnosis and treatment of cardiac tamponade cases, frequently with pericardiocentesis as in our case.

Chronic massive pericardial effusion: a case report and literature review

Chronic massive pericardial effusion without cardiac tamponade is relatively rare. Nearly half of all patients with chronic large pericardial effusion are asymptomatic. We report a case of a 77-year-old man who presented with an asymptomatic chronic massive pericardial effusion, with no evidence of cardiac tamponade or pericardial constriction during a 10-year follow-up. The patient had a complex history of lymph node tuberculosis, hypertension, hypothyroidism, and polycythemia vera, as well as high-dose ³¹P radiation exposure 45 years ago. There was no evidence of tuberculosis infection, hypothyroidism, malignant tumor, severe heart failure, uremia, trauma, severe bacterial or fungal infection, chronic myeloid leukemia, or bone marrow fibrosis after admission. The patient underwent pericardiocentesis twice. The pericardial effusion comprised exudate fluid with a high proportion of monocytes. The patient refused indwelling catheter drainage or pericardiectomy. The likely final diagnosis was recurrent chronic large idiopathic pericardial effusion.

Hemopericardium in the acute clinical setting: Are we ready for a tailored management approach on the basis of MDCT findings?

The clinical spectrum of pericardial effusions varies from innocuous serous fluid to life-threatening hemopericardium. A misdiagnosis may be made by similar clinical presentation of acute chest pain/hypotension. Echocardiography is the first-line test for diagnosis of pericardial effusion and its etiology, but sometimes there are different drawbacks to the correct cardiovascular ultrasound diagnosis. Radiologists are reporting an increasing amount of thoracic Multidetector CT examinations at the emergency department. Multidetector CT has now become an established and complementary method for cardiac imaging, and diseases of the pericardium can now be quickly identified with increasing certainty. The aim of this review is to discuss the hemopericardium key Multidetector CT features in acute clinical setting which indicate the need to proceed with predominantly medical or surgical treatment, however, being able to identify forms of bleeding pericardial effusion for which only "a watch and wait strategy" and/or deferred treatment is indicated. In the emergency care setting, radiologists must be aware of different findings of hemopericardium in order to address a tailored and timely management approach.

Surgical treatment of tuberculous chronic constrictive pericarditis: A retrospective observational study from tertiary hospital of eastern Nepal

BACKGROUND

Tuberculosis remains an important cause of chronic constrictive pericarditis (CCP) in developing countries. It is a surgically treatable cause of diastolic heart failure. Without surgery, it is associated with high morbidity and mortality.

METHODS

We conducted a retrospective observational study of clinical presentations and perioperative outcomes of pericardiectomy in all patients operated from July 2015 to December 2018 for tuberculous CCP.

RESULTS

A total 14 patients (mean age - 38 ± 13.3 years, 10 male), underwent pericardiectomy via median sternotomy without cardiopulmonary bypass. Eleven patients (79%) had completed treatment for pulmonary tuberculosis, and three (21%) were on anti-tubercular treatment at the time of referral for surgery. Ten patients (71%) had prior hospitalisation for cardiac failure. At the time of surgery, eight patients (57%) were in New York Heart Association (NYHA) class III-IV. The median duration of symptoms before surgical intervention was 15 months (range 11-24 months). Three patients (21%) had associated cardiac cirrhosis. Twelve patients (86%) underwent total pericardiectomy. Two patients (14%) underwent partial pericardiectomy. The mean operative time was 160 ± 33.8 minutes. The mean central venous press pressure before and after surgery were 28 ± 3.9 and 10 ± 2 mmHg respectively. The mean intensive care unit (ICU) and hospital stays were 4 ± 1.5 and 10 ± 2 days respectively. There was one (7%) 30-day mortality. There were two deaths (14%) due to non-cardiac causes at 10 and 16 months respectively. The remaining 11 patients (79%) are doing well (mean follow-up- 23 months), and are in NYHA class I.

CONCLUSIONS

Tuberculosis is the most common cause of CCP in our region. Pericardiectomy provides definitive treatment to alleviate symptoms resolution and improve survival.

Etiology of Pericardial Effusion and Outcomes Post Pericardiocentesis in the Western Region of Saudi Arabia: A Single-center Experience

Background Pericardial effusion is the accumulation of blood or excess fluid in the cavity between the heart and the pericardium sac. Pericardial effusion can be caused by several etiologies, including malignant and non-malignant causes. Pericardiocentesis is the gold standard assessment method for pericardial effusion etiology. The aim of this study was to identify the long-term outcome of patients who presented with massive pericardial effusion and underwent pericardiocentesis at King Abdulaziz Medical City, Jeddah, a large tertiary hospital in the western part of Saudi Arabia. Methods This is a single-center retrospective cross-sectional study conducted at King Abdulaziz Medical City Jeddah, Saudi Arabia, between January 2013 to December 2018. Data were collected from patient's charts; the clinical and echocardiographic findings, alongside with pericardial fluid analysis, were collected. Procedure and patients outcomes were obtained and reported. Results Of the 107 patients with pericardial effusion, 39 patients had moderate to severe pericardial effusion requiring pericardiocentesis. The mean age was 52 years, and 56.4% were females. The most common chronic disease was hypertension and the presence of metastasis. The most common cause of pericardial effusion was a malignancy. A majority of patients had severe pericardial effusion. Many patients had tamponade (69.6%). Patients with malignant pericardial effusion had a median survival of 54 days. Conclusion Etiologies of pericardial effusion requiring drainage depend on the population studied. Patients with malignant effusions have worse outcomes than non-malignant effusion. Pericardiocentesis is required to ascertain the cause and risk-stratify patients.