Pericardial Diseases: International Position Statement on New Concepts and Advances in Multimodality Cardiac Imaging.

Pericardial diseases have gained renewed clinical interest, leading to a renaissance in the field. There have been many recent advances in pericardial diseases in both multimodality cardiac imaging of diagnoses, such as recurrent, transient constrictive and effusive-constrictive pericarditis, and targeted therapeutics, especially anti-interleukin (IL)-1 agents that affect the inflammasome as part of autoinflammatory pathophysiology. There remains a large educational gap for clinicians, leading to variability in evaluation and management of these patients. The latest pericardial imaging (American Society of Echocardiography, European Association of Cardiovascular Imaging) and clinical guidelines (European Society of Cardiology) are >8-10 years of age and may not reflect current practice. Recent clinical trials involving anti-IL-1 agents in recurrent pericarditis, including anakinra (AIRTRIP), rilonacept (RHAPSODY), and goflikicept have demonstrated their efficacy. The present document represents an international position statement from world leaders in the pericardial field, focusing on novel concepts and emphasizing the role of multimodality cardiac imaging as well as new therapeutics in pericardial diseases.

Coronary periarteritis and pericarditis are rare but distinct manifestations of heart involvement in IgG4-related disease: a retrospective cohort study.

BACKGROUND: The heart can be involved in immunoglobulin (Ig)-G4-related disease (IgG4-RD). This study aimed to summarize the clinical features and efficacy of treatment for IgG4-RD patients with heart involvement. METHODS: We conducted a retrospective study enrolling 42 IgG4-RD patients with heart involvement from the IgG4-RD cohorts of the Peking Union Medical College Hospital and Beijing An Zhen Hospital, from 2010 to 2022. Clinical, laboratory, radiological data were collected, and treatment responses to glucocorticoids and immunosuppressants were analyzed. RESULTS: IgG4-related cardiac involvement is a rare part of the IgG4-RD spectrum. The incidences of coronary periarteritis and pericarditis were 1.2%(13/1075) and 3.1%(33/1075), respectively in our cohort. Valvular disease possibly related to IgG4-RD was detected in two patients. None of the patients with myocardial involvement were identified. The average age was 58.2 ± 12.8 years, with a male predominance (76.7%). Coronary artery CT revealed that mass-like and diffuse wall-thickening lesions were the most frequently observed type of coronary periarteritis. Pericarditis presented as pericardial effusion, localized thickening, calcification and mass. After treatment with glucocorticoid and immunosuppressants, all patients achieved a reduced IgG4-RD responder index score and achieved radiological remission. Two patients with coronary peri-arteritis experienced clinical relapses during the maintenance period. CONCLUSIONS: Cardiac involvement in IgG4-RD is rare and easily overlooked since many patients are asymptomatic, and the diagnosis relies on imaging. Patients showed a satisfactory response to glucocorticoid based treatment.

Hemodynamics of low-pressure cardiac tamponade: An illustrative case report.

A 55-year-old male with acute pericarditis presented with low-pressure cardiac tamponade (LPCT) unresponsive to volume infusion. Subsequent pericardiocentesis resulted in hemodynamic improvement and unmasking of pericardial constriction. This case provides illustrative hemodynamic tracings of LPCT. Additionally, the presence of concurrent pericardial constriction that may indicate a plausible underlying mechanism for the blunted responsiveness to fluid expansion in LPCT. The underlying physiologic processes and the associated hemodynamic tracings are discussed.

Atrial and ventricular strain using cardiovascular magnetic resonance in the prediction of outcomes of pericarditis patients: a pilot study.

OBJECTIVE: Our study aimed to explore with cardiovascular magnetic resonance (CMR) the impact of left atrial (LA) and left ventricular (LV) myocardial strain in patients with acute pericarditis and to investigate their possible prognostic significance in adverse outcomes. METHOD: This retrospective study performed CMR scans in 36 consecutive patients with acute pericarditis (24 males, age 52 [23-52]). The primary endpoint was the combination of recurrent pericarditis, constrictive pericarditis, and surgery for pericardial diseases defined as pericardial events. Atrial and ventricular strain function were performed on conventional cine SSFP sequences. RESULTS: After a median follow-up time of 16 months (interquartile range [13-24]), 12 patients with acute pericarditis reached the primary endpoint. In multivariable Cox regression analysis, LA reservoir and LA conduit strain parameters were all independent determinants of adverse pericardial diseases. Conversely, LV myocardial strain parameters did not remain an independent predictor of outcome. With receiving operating characteristics curve analysis, LA conduit and reservoir strain showed excellent predictive performance (area under the curve of 0.914 and 0.895, respectively) for outcome prediction at 12 months. CONCLUSION: LA reservoir and conduit mechanisms on CMR are independently associated with a higher risk of adverse pericardial events. Including atrial strain parameters in the management of acute pericarditis may improve risk stratification. CLINICAL RELEVANCE STATEMENT: Atrial strain could be a suitable non-invasive and non-contrast cardiovascular magnetic resonance parameter for predicting adverse pericardial complications in patients with acute pericarditis. KEY POINTS: • Myocardial strain is a well-validated CMR parameter for risk stratification in cardiovascular diseases. • LA reservoir and conduit functions are significantly associated with adverse pericardial events. • Atrial strain may serve as an additional non-contrast CMR parameter for stratifying patients with acute pericarditis.

Acute pericarditis as the presenting symptom of a case of oesophageal carcinoma.

Oesophageal carcinoma is a globally prevalent form of cancer. Patients with advanced disease often experience progressive dysphagia and weight loss as initial symptoms, but pericarditis is an uncommon presentation. This study describes a young man who presented with pericarditis and was diagnosed with oesophageal squamous cell carcinoma. The patient's diagnosis came after presenting with intermittent chest pain. His diagnostic tests included an ECG showing ST elevation, echocardiography showing pericardial effusion and elevated inflammatory markers. His imaging tests revealed a neoplastic lesion in the lower oesophagus with metastases. He was initially treated as a case of pericarditis, followed by palliative chemotherapy for his cancer. Pericarditis, as the initial presentation of oesophageal carcinoma, is rare. There have only been 19 cases reported and published in the literature. Treatment depends on the stage of the disease. This case emphasises the importance of considering malignancy in unusual presentations of pericarditis, especially in young patients.

Immune checkpoint inhibitor-induced myopericarditis.

A woman in her 30s with a medical history of metastatic rectal adenocarcinoma, currently on pembrolizumab, which started a few weeks ago, was admitted for abdominal pain. During the hospital stay, she experienced sharp chest pain. Troponin was 1885 ng/mL which peaked at 7338 ng/mL. ECG was unremarkable. The echocardiogram showed an Ejection fraction (EF) of 55%-60% and basal-inferior wall hypokinesis. Left heart catheterisation showed no coronary abnormalities. Cardiac MRI showed a non-coronary area of focal T1 and T2 hyperintense signal and transmural delayed gadolinium enhancement in the mid-basal inferior/inferoseptal wall consistent with myocardial damage. Pericardium showed increased thickness and adhesions at the right ventricular outflow tract consistent with pericarditis. Steroid therapy was initiated, and a marked clinical response was achieved. Immune checkpoint inhibitor-induced myocarditis and pericarditis is a rare complication associated with a high mortality rate, if untreated. Diagnosis requires a multidisciplinary approach, and early detection is critical to preventing a fatal outcome.

Successful Management of Malignant Pericarditis Using Nivolumab for Metastatic Esophageal Squamous Cell Carcinoma.

Esophageal cancer is a malignant disease with a poor prognosis and is one of the most common causes of cardiac metastasis. Malignant pericarditis may cause the repetitive accumulation of pericardial effusion, which can occasionally pose a clinical challenge. We herein report a case of malignant pericarditis in a patient with metastatic esophageal squamous cell carcinoma with cardiac tamponade, which was successfully managed with single pericardial drainage and systemic nivolumab monotherapy. This is the first case report to suggest that systemic therapy with nivolumab is a promising option for the management of malignant pericarditis.

Haemorrhagic Mycobacterium avium complex pericarditis presenting with cardiac tamponade in an immunocompetent woman.

A young woman in her mid-40s was referred by her primary care physician for fever, worsening shortness of breath, pleuritic chest pain and tachycardia. CT angiogram of the chest revealed a large pericardial effusion. Echocardiogram confirmed tamponade physiology despite her being haemodynamically stable. She had an emergency pericardiocentesis which revealed evidence of a haemorrhagic pericardial effusion. However, the patient was still symptomatic after treatment and had to undergo video-assisted thoracoscopic surgery with a pericardial window and chest tube. Postoperatively, her fevers resolved. Pan-culture was initially negative, and all antibiotics were discontinued. Acid-fast bacilli cultures later grew Mycobacterium avium complex. She continued to have chest discomfort postoperatively, but follow-up CT of the chest 3 months postoperatively showed continued resolution of her pericardial effusion. The patient's symptoms improved, and she has had no recurrence of effusion without the need for anti-tuberculosis drugs.

Cardiac magnetic resonance imaging of pericardial diseases: a comprehensive guide.

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

Bivalent mRNA COVID-19 Vaccine-Related Pericarditis on 18 F-FDG PET/CT.

ABSTRACT: A 13-year-old boy was suspected with pericarditis after a second booster dose of bivalent mRNA COVID-19 vaccine. After specific preparation for cardiac inflammation with carbohydrate-free, high-fat diet, the 18 F-FDG PET/CT successfully demonstrated simultaneous presentation of vaccination-related axillary lymphadenopathy and pericarditis without the interference of physiological myocardial uptake.

Evaluation of Pericardial Thickening and Adhesion Using High-Frequency Ultrasound.

BACKGROUND: Routine echocardiography using a standard-frequency ultrasound probe has insufficient spatial resolution to clearly visualize the parietal pericardium (PP). High-frequency ultrasound (HFU) has enhanced axial resolution. The aim of this study was to use a commercially available high-frequency linear probe to evaluate apical PP thickness (PPT) and pericardial adhesion in both normal pericardium and pericardial diseases. METHODS: From April 2002 to March 2022, 227 healthy individuals, 205 patients with apical aneurysm (AA) and 80 patients with chronic constrictive pericarditis (CP) were recruited to participate in this study. All subjects underwent both standard-frequency ultrasound and HFU to image the apical PP (APP) and pericardial adhesion. Some subjects underwent computed tomography (CT). RESULTS: Apical PPT was measured using HFU and found to be 0.60 ± 0.01 mm (0.37-0.87 mm) in normal control subjects, 1.22 ± 0.04 mm (0.48-4.53 mm) in patients with AA, and 2.91 ± 0.17 mm (1.13-9.01 mm) in patients with CP. Tiny physiologic effusions were observed in 39.2% of normal individuals. Pericardial adhesion was detected in 69.8% of patients with local pericarditis due to AA and 97.5% of patients with CP. Visibly thickened visceral pericardium was observed in six patients with CP. Apical PPT measurements obtained by HFU correlated well with those obtained by CT in those patients with CP. However, CT could clearly visualize the APP in only 45% of normal individuals and 37% of patients with AA. In 10 patients with CP, both HFU and CT demonstrated equal ability to visualize the very thickened APP. CONCLUSIONS: Apical PPT measured using HFU in normal control subjects ranged from 0.37 to 0.87 mm, consistent with previous reports from necropsy studies. HFU had higher resolution in distinguishing local pericarditis of the AA from normal individuals. HFU was superior to CT in imaging APP lesions, as CT failed to visualize the APP in more than half of both normal individuals and patients with AA. The fact that all 80 patients with CP in our study had significantly thickened APP raises doubt regarding the previously reported finding that 18% of patients with CP had normal PPT.

Viral pericarditis following ocrelizumab in a multiple sclerosis patient.

Ocrelizumab is a humanized monoclonal anti-CD20 antibody, approved for the treatment of relapsing and primary-progressive multiple sclerosis. We reported a case of pericarditis in an RRMS patient treated with ocrelizumab, who presented with chest pain, high body temperature and laboratory findings of systemic inflammation, with a favorable clinical outcome.

Natural Course of Electrocardiogram Changes and the Value of Multimodality Imaging in Acute Pericarditis.

BACKGROUND: ECG is the initial diagnostic tool that in combination with typical symptoms often raises the suspicion of pericarditis. Echocardiography remains the first-line imaging modality for assessment of pericardial diseases, particularly effusion/tamponade, constrictive physiology, and assessment of regional wall motion abnormalities as differential diagnoses. However, cardiac CT and cardiac magnetic resonance may be necessary in complicated cases and to identify pericardial inflammation in specific settings (atypical presentation, new onset constriction), as well as myocardial involvement and monitoring the disease activity. SUMMARY: In acute pericarditis, the most commonly used ECG criteria recommended by international guidelines are the widespread ST-segment elevation or PR depression. However, the classic ECG pattern of widespread ST-segment elevation or PR depression can be seen in less than 60% of patients. In addition, ECG changes are often temporally dynamic, evolve rapidly during the course of disease, and may be influenced by a number of factors such as disease severity, time (stage) of presentation, degree of myocardial involvement, and the treatment initiated. Overall, temporal dynamic changes on ECG during acute pericarditis or myopericarditis have received limited attention. Hence, the aim of this brief clinical review was to increase awareness about the various ECG changes observed during the course of acute pericarditis. KEY MESSAGES: ECG may be normal at presentation or for days after the index episode of chest pain, but serial ECGs can reveal specific patterns of temporally dynamic ST elevation in patients with pericarditis or myopericarditis, particularly during new episodes of chest pain.

The Contemporary Role of Cardiac Computed Tomography and Cardiac Magnetic Resonance Imaging in the Diagnosis and Management of Pericardial Diseases.

Pericardial syndromes encompass different clinical conditions from acute pericarditis to idiopathic chronic pericardial effusion. Transthoracic echocardiography is the first and most important initial diagnostic imaging modality in most patients affected by pericardial disease. However, cardiac computed tomography (CCT) and cardiac magnetic resonance imaging (CMR) have recently gained a pivotal role in cardiology, and recent reports have supported the role of both of these advanced techniques in the evaluation and guiding therapy of pericardial disease. Most promising is the capability of CMR to identify the presence of pericardial inflammation, carrying both diagnostic and prognostic value in the setting of recurrent and chronic pericarditis. In addition, CCT permits accurate evaluation of the presence and extension of pericardial calcification, providing important information in confirming the diagnosis of constrictive pericarditis and during the preprocedural planning for patients undergoing pericardiectomy. Both CCT and CMR require specific expertise, especially for the evaluation of pericardial disease. The aim of the present review is to provide physicians an updated overview of CCT and CMR in pericardial disease, focusing on technical issues, recent research findings, and potential clinical applications.