Malignant Pericardial Effusion: A Systematic Review.

Background: Malignant pericardial effusion (Eff) is often asymptomatic and has an unknown prevalence, due to its occult presentation. The condition often is identified postmortem on autopsy, and it is associated with a poor prognosis. Given the late presentation of malignant pericardial Effs, a minimal volume of literature has examined the epidemiology, clinical characteristics, and outcomes of these complex patients. We conducted a systematic review to advance present understanding of this condition. Methods: A search of 4 databases resulted in 41 case reports meeting criteria. Inclusion criteria were being a patient aged > 18 years who presented with pericardial Eff in the setting of malignancy. Intervention was medical and/or surgical therapy, and the outcome was mortality. Results: For the 41 patients included, the median age was 54 years, and the majority were male patients (58%). Dyspnea was the leading symptom (90%), and cardiac tamponade was present in 78% of cases. Common cancers included lung, gastrointestinal, and renal neoplasms (59%). Pericardiocentesis occurred in 98% of cases, with a median fluid extraction volume of 1000 mL. Death occurred in 44%, primarily due to disease progression and/or metastasis. Conclusions: This study presents the largest systematic review on malignancy-induced pericardial Effs to date. Notably, solid tumours, and specifically lung adenocarcinomas, are common culprits. Malignant pericardial Effs are often severe, with a majority of patients presenting with cardiac tamponade. Overall, treatment options are limited, and the associated mortality rate is high.

Contexte: L'épanchement péricardique malin (EPM) est un état généralement asymptomatique, de prévalence inconnue en raison de son tableau clinique occulte. Il est souvent reconnu post-mortem, à l'autopsie, et est associé à un pronostic médiocre. En raison de la consultation tardive pour un EPM, les données publiées relatives à l'épidémiologie, aux caractéristiques cliniques et à l'issue de ces cas complexes sont limitées. Nous avons réalisé une analyse systématique dans le but d'élargir les connaissances sur cette affection. Méthodologie: Une recherche réalisée dans quatre bases de données a permis de repérer 41 rapports de cas qui répondaient aux critères de recherche. Les critères d'inclusion étaient les suivants : être âgé de plus de 18 ans; présenter un épanchement péricardique en présence d'un cancer; intervention pharmacologique et/ou chirurgicale; issue mortelle. Résultats: L'âge médian des 41 patients inclus était de 54 ans; la majorité d'entre eux étaient des hommes (58 %). Le symptôme principal était la dyspnée (90 %), et une tamponnade cardiaque était présente dans 78 % des cas. Les cancers les plus fréquents étaient le cancer du poumon, le cancer gastro-intestinal et les néoplasmes rénaux (59 %). Une péricardiocentèse a été réalisée dans 98 % des cas. Le volume de drainage médian était de 1 000 mL. Quarante-quatre pour cent des sujets sont décédés, principalement en raison de la progression de la maladie et/ou de métastases. Conclusions: Cette étude est la plus vaste analyse systématique réalisée à ce jour sur l'EPM. Les tumeurs solides, et plus particulièrement les adénocarcinomes pulmonaires, sont des causes fréquentes. L'EPM est souvent grave, la majorité des patients présentant une tamponnade cardiaque. Les traitements disponibles sont généralement limités, et le taux de mortalité associé est élevé.

Predicting Long-Term Clinical Outcomes of Patients With Recurrent Pericarditis.

BACKGROUND: Recurrent pericarditis (RP) is a complex condition associated with significant morbidity. Prior studies have evaluated which variables are associated with clinical remission. However, there is currently no established risk-stratification model for predicting outcomes in these patients. OBJECTIVES: We developed a risk stratification model that can predict long-term outcomes in patients with RP and enable identification of patients with characteristics that portend poor outcomes. METHODS: We retrospectively studied a total of 365 consecutive patients with RP from 2012 to 2019. The primary outcome was clinical remission (CR), defined as cessation of all anti-inflammatory therapy with complete resolution of symptoms. Five machine learning survival models were used to calculate the likelihood of CR within 5 years and stratify patients into high-risk, intermediate-risk, and low-risk groups. RESULTS: Among the cohort, the mean age was 46 ± 15 years, and 205 (56%) were women. CR was achieved in 118 (32%) patients. The final model included steroid dependency, total number of recurrences, pericardial late gadolinium enhancement, age, etiology, sex, ejection fraction, and heart rate as the most important parameters. The model predicted the outcome with a C-index of 0.800 on the test set and exhibited a significant ability in stratification of patients into low-risk, intermediate-risk, and high-risk groups (log-rank test; P < 0.0001). CONCLUSIONS: We developed a novel risk-stratification model for predicting CR in RP. Our model can also aid in stratifying patients, with high discriminative ability. The use of an explainable machine learning model can aid physicians in making individualized treatment decision in RP patients.

Immune checkpoint inhibitors and pericardial disease: a systematic review.

INTRODUCTION: Despite the growing use of immune checkpoint inhibitors (ICI) in cancer treatment, data regarding ICI-associated pericardial disease are primarily derived from case reports and case series. ICI related pericardial disease can be difficult to diagnose and is associated with significant morbidity. We conducted a systematic review to further characterize the epidemiology, clinical presentation, and outcomes of this patient population. METHODS: A search of four databases resulted in 31 studies meeting inclusion criteria. Patients > 18 years old who presented with ICI mediated pericardial disease were included. Intervention was medical + surgical therapy and outcomes were development of cardiac tamponade, morbidity, and mortality. RESULTS: Thirty- eight patients across 31 cases were included. Patients were majority male (72%) with a median age of 63. Common symptoms included dyspnea (59%) and chest pain (32%), with 41% presenting with cardiac tamponade. Lung cancer (81%) was the most prevalent, and nivolumab (61%) and pembrolizumab (34%) were the most used ICIs. Pericardiocentesis was performed in 68% of patients, and 92% experienced symptom improvement upon ICI cessation. Overall mortality was 16%. DISCUSSION: This study provides the most comprehensive analysis of ICI-mediated pericardial disease to date. Patients affected were most commonly male with lung cancer treated with either Nivolumab or Pembrolizumab. Diagnosis may be challenging in the setting of occult presentation with normal EKG and physical exam as well as delayed onset from therapy initiation. ICI-associated pericardial disease demonstrates high morbidity and mortality, as evidenced by a majority of patients requiring pericardiocentesis.

An Unusual Case of Parasitic Constrictive Pericarditis.

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

Inflamed Colon and Pericardium: A Rare Combination of Colitis and Recurrent Pericarditis.

A 29-year-old woman with severe ulcerative colitis presented with complicated recurrent pericarditis. Cardiac magnetic resonance imaging showed improvement in pericardial inflammation with a prolonged course of anti-inflammatory therapy, but she developed several relapses on biologics. Rilonacept (newer interleukin-1 antagonist), disease-modifying antirheumatic drugs, and pericardiectomy may be considered in such patients. (Level of Difficulty: Intermediate.).