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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., Competing Interests: Funding Support and Author Disclosures Dr Klein has received research grants from Kiniksa Pharmaceuticals and Cardiol Therapeutics, and is on advisory boards for Kiniksa Pharmaceuticals, Cardiol Therapeutics, and Pfizer. Dr Cremer has received research grants from Kiniksa Pharmaceutics and Novartis, and is on advisory boards for Kiniksa Pharmaceutics and Swedish Orphan Biovitrum. Antonio Abbate has received consulting fees from Cardiol Therapeutics, Kiniksa Pharmaceuticals, Implicit Biosciences, Novo Nordisk, Olatec, R-Pharm, Serpin Pharma, and Swedish Orphan Biovitrum. Dr Asher has received royalties from Wolters-Kluwer Publishing Company. Dr Brucato’s institution has received funding from Kiniksa Pharmaceuticals as an investigative site, unrestricted research grants from Swedish Orphan Biovitrum and ACARPIA, and travel and accommodation for advisory committee from Swedish Orphan Biovitrum and Kiniksa. Dr Hoit is speaker for Philips Medical. Dr Kwon has received a research grant from the National Heart, Lung, and Blood Institute of the National Institutes of Health (1R01HL170090-01) and has research agreements with Circle cvi42 and Myocardial Solutions. Dr LeWinter has received a research grant from and is on an advisory board for Kiniksa Pharmaceuticals. Dr Lin is on an advisory board for Kiniksa Pharmaceuticals. Dr Luis is a consultant for Medtronic, Kiniksa Pharmaceuticals, Cardiol Therapeutic, and Swedish Orphan Biovitrum Pharmaceuticals; Dr Ordovas has received a research grant from the American College of Radiology; Dr Schenone is on the speaking bureau for Bristol Myers Squibb; Dr Weber is on advisory boards for Kiniksa Pharmaceuticals, Novo Nordisk, and Horizon Therapeutics; Dr Imazio is on advisory boards for Kiniksa Pharmaceuticals and Cardiol Therapeutics. The other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

A 75-year-old man underwent chemoradiotherapy for advanced esophageal cancer. After nine years, he was hospitalized for left pyothorax. Consequently, the patient underwent drainage and window opening surgery. He experienced cardiopulmonary arrest but was resuscitated. Based on cardiac catheterization data, the patient was diagnosed with constrictive pericarditis. Unfortunately, extracorporeal circulation did not improve his condition, and he ultimately died. An autopsy revealed adhesion between the pericardium and pleura, especially the pericardium in contact with the left thoracic cavity, which was markedly thickened. This suggests that constrictive pericarditis, a latent complication of chemoradiotherapy, is aggravated by pyothorax.

Introduction: Constrictive pericarditis (CP) can result from uncontrolled inflammation of the pericardium. This can be due to various etiologies. CP can lead to both left- and right-sided heart failure with associated poor quality of life, so early recognition is key. The evolving role of multimodality cardiac imaging allows for earlier diagnosis and facilitates management to help mitigate this adverse outcome., Areas Covered: This review discusses the pathophysiology of constrictive pericarditis, chronic inflammation and autoimmune etiologies, clinical presentation of CP, and advances in multimodality cardiac imaging for diagnosis and management. Echocardiography and cardiac magnetic resonance (CMR) imaging remain cornerstone modalities to evaluate this condition, whereas additional imaging modalities such as computed tomography and FDG-positron emission tomography can provide complementary information., Expert Opinion: Advances in multimodality imaging allow for a more precision diagnosis of constrictive pericarditis. There has been a paradigm shift in pericardial disease management with advances in multimodality imaging, especially CMR, to detect subacute and chronic inflammation. This has enabled imaging-guided therapy (IGT) to both help prevent and potentially reverse established constrictive pericarditis.

Purpose of Review: Thyroid disorders, especially hypothyroidism, are known to be associated with pericardial diseases. The aim of this paper is to review the current knowledge of the pericardial manifestations of hypothyroidism and hyperthyroidism., Recent Findings: Many reports have described associations between dysthyroidism, which encompasses hypothyroidism and hyperthyroidism, and several pericardial diseases, including acute pericarditis, constrictive pericarditis, pericardial effusion, and tamponade. The diagnosis of dysthyroidism-induced pericardial diseases consists of a combination of thyroid blood levels that fall outside of the normal range and the exclusion of other causes. Treatment of the thyroid disorder is key, along with treatment of the pericardial disease as recommended by the guidelines. Early recognition of the thyroid disorder is key in patients with pericardial diseases, since treating the underlying cause should assist resolution of the pericardial issues and ideally prevent recurrence and possible future complications of suboptimally treated pericarditis or pericardial effusions., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: Patients with constrictive pericarditis (CP) with active inflammation may show resolution with anti-inflammatory therapy. We aimed to investigate the impact of anti-inflammatory medications on constrictive pathophysiology using echocardiography in patients with CP., Methods: We identified 35 patients with CP who were treated with anti-inflammatory medications (colchicine, prednisone, non-steroidal anti-inflammatory drugs) after diagnosis of CP (mean age 58±13; 80% male). Clinical resolution of CP (transient CP) was defined as improvement in New York Heart Association class during follow-up. We assessed constrictive pathophysiology using regional myocardial mechanics by the ratio of peak early diastolic tissue velocity (e') at the lateral and septal mitral annulus by tissue Doppler imaging (lateral/septal e') or the ratio of the left ventricular lateral and septal wall longitudinal strain (LS lateral /LS septal ) by two-dimensional speckle-tracking echocardiography. Longitudinal data were analysed using a mixed effects model., Results: During a median follow-up of 323 days, 20 patients had transient CP, whereas 15 patients had persistent CP. Transient CP had higher baseline erythrocyte sedimentation rates (ESR) (p=0.003) compared with persistent CP. There were no significant differences in LS lateral /LS septal and lateral/septal e'. During follow-up, only transient CP showed improvement in lateral/septal e' (p<0.001) and LS lateral /LS septal (p=0.003), and recovery of inflammatory markers was similar between the two groups. In the logistic model, higher baseline ESR and greater improvement in lateral/septal e' and LS lateral /LS septal were associated with clinical resolution of CP using anti-inflammatory therapy., Conclusions: Improvement of constrictive physiology detected by lateral/septal e' and LS lateral /LS septal was associated with resolution of clinical symptoms after anti-inflammatory treatment. Serial monitoring of these markers could be used to identify transient CP., Competing Interests: Competing interests: ALK: research grant and scientific advisory board for Kiniksa; scientific advisory board for Sobi and Pfizer. PCC: scientific advisory board for Kiniksa., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Despite the monumental advances in the diagnoses and therapeutics of malignancy, several cancer patients have presented with pericardial involvement, including acute pericarditis, constrictive pericarditis, and pericardial effusion. Multiple factors can contribute to acute pericarditis, including direct metastasis to the heart, pericardial hemorrhage, infections due to immunosuppression, and cancer therapies that include chemotherapy, immunotherapy, and radiation. Pericardial effusion, either due to cancer invasion or cancer treatment, is one of the most common incidental findings in cancer patients, which significantly worsens morbidity and mortality. If left untreated, pericardial effusion is known to cause complications such as pericardial tamponade. Constrictive pericarditis can be due to radiation exposure, chemotherapy, or is a sequela of a previous episode of acute pericarditis. In conclusion, early detection, prompt treatment, and understanding of pericardial diseases are necessary to help improve the quality of life of cancer patients, and we aim to summarize the knowledge of pericardial involvement in patients with cancer., (Copyright © 2021 Elsevier Inc. All rights reserved.)

We report two male patients aged 18 and 19 years, respectively, undergoing total pericardiectomy for chronic calcific constrictive pericarditis who developed systemic ventricular failure unresponsive to medical management following surgery. The failing circulation was successfully reestablished using intra-aortic balloon counterpulsation. Aortic counterpulsation facilitates recovery of ventricular function and appears to be a reasonable alternative in select instances of refractory cardiac failure following pericardiectomy.

Purulent pericarditis is a rare infectious disease with significant mortality, even in the modern antibiotic era. The presenting signs can often be subtle and patients can deteriorate rapidly with cardiac tamponade. We report a previously healthy 16-month-old female who developed purulent pericarditis associated with paronychia and sepsis caused by methicillin-sensitive Staphylococcus aureus . In addition to antibiotic treatment, she required emergent pericardiocentesis for cardiac tamponade, followed by two surgical interventions including full median sternotomy incision and partial pericardiectomy. At 4-month follow-up, she did well with no evidence of constrictive pericarditis on echocardiogram.

Tuberculous pericarditis is a severe form of extrapulmonary tuberculosis and is the commonest cause of pericardial effusion in high incidence settings. Mortality ranges between 8 and 34%, and it is the leading cause of pericardial constriction in Africa and Asia. Current understanding of the disease is based on models derived from studies performed in the 1940-50s. This review summarises recent advances in the histology, microbiology and immunology of tuberculous pericarditis, with special focus on the effect of Human Immunodeficiency Virus (HIV) and the determinants of constriction., Competing Interests: Declaration of Competing interest The authors have no conflict of interest to declare., (Copyright © 2020 Institut Pasteur. Published by Elsevier Masson SAS. All rights reserved.)

Constrictive pericarditis (CP) and restrictive cardiomyopathy (RCM) are indolent disabling diseases of diastolic function. The two conditions share common pathophysiologic features, resulting in similar and overlapping clinical presentations, echocardiographic findings, and hemodynamic characteristics. However, their clinical course differs, as CP is surgically curable whereas RCM is a chronic condition managed medically. Separating these two entities is based on delineation of anatomic and physiologic derangements employing multimodality hemodynamic interrogation by advanced imaging techniques (Echo-Doppler, CT, and especially MRI) combined with sophisticated invasive hemodynamics., (© 2020 Wiley Periodicals, Inc.)

Neoplastic pericardial effusion is a common and serious manifestation of advanced malignancies. Lung and breast carcinoma, haematological malignancies, and gastrointestinal cancer are the most common types of cancer involving the pericardium. Pericardial involvement in neoplasia may arise from several different pathophysiological mechanisms and may be manifested by pericardial effusion with or without tamponade, effusive-constrictive pericarditis and constrictive pericarditis. Management of these patients is a complex multidisciplinary problem, affected by clinical status and prognosis of patients., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Despite advances in cardiovascular imaging, the diagnosis of constrictive pericarditis remains challenging. A multimodality approach to the diagnosis of CP is essential to (a) fully assess the extent of pericardial thickening and calcification, (b) detect the functional and hemodynamic consequences of the constricting pericardium, and (c) implement the optimal management strategy in these often complex cases. This case-based review highlights the role and diagnostic ambiguities of multimodality imaging., (© 2020 Wiley Periodicals, Inc.)

Competing Interests: Competing interests: None declared.

Objectives: This scoping review sought to summarise available data on the prevalence, aetiology, diagnosis, treatment and outcome of pericardial disease in Africa., Methods: We searched PubMed, Scopus and African Journals Online from 1 January 1967 to 30 July 2017 to identify all studies published on the prevalence, aetiologies, diagnosis, treatment and outcomes of pericardial diseases in adults residing in Africa., Results: 36 studies were included. The prevalence of pericardial diseases varies widely according to the population of interest: about 1.1% among people with cardiac complaints, between 3.3% and 6.8% among two large cohorts of patients with heart failure and up to 46.5% in an HIV-infected population with cardiac symptoms. Tuberculosis is the most frequent cause of pericardial diseases in both HIV-uninfected and HIV-infected populations. Patients with tuberculous pericarditis present mostly with effusive pericarditis (79.5%), effusive constrictive pericarditis (15.1%) and myopericarditis (13%); a large proportion of them (up to 20%) present in cardiac tamponade. The aetiological diagnosis of pericardial diseases is challenging in African resource-limited settings, especially for tuberculous pericarditis for which the diagnosis is not definite in many cases. The outcome of these diseases remains poor, with mortality rates between 18% and 25% despite seemingly appropriate treatment approaches. Mortality is highest among patients with tuberculous pericarditis especially those coinfected with HIV., Conclusion: Pericardial diseases are a significant cause of morbidity and mortality in Africa, especially in HIV-infected individuals. Tuberculosis is the most frequent cause of pericardial diseases, and it is associated with poor outcomes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

This CME review takes stock of the progress in the etiology, pathophysiology, diagnostics and treatment of pericarditis and pericardial effusion brought about by the publication of the 2nd European Society of Cardiology (ESC) guidelines on the management of pericardial diseases in 2015. It also emphasizes special forms, which have received less attention in the past, such as therapy-refractory (incessant), effusive-constrictive and constrictive pericarditis and the treatment of acute and recurrent pericarditis with colchicine. After the diagnosis of pericarditis with or without effusion has been made, the first step is to clarify its etiology, which affects the clinical symptoms, course, treatment and the prognosis. In this aspect the requirements of the guidelines and the reality of an etiological classification of pericardial diseases diverge in many cases. The diagnosis of "idiopathic" acute or recurrent pericarditis is still much too often the result of insufficient efforts to find the cause. Too often only malignant and bacterial forms are excluded. If the etiology is known local intrapericardial treatment with the already inserted pigtail catheter from the diagnostic pericardial puncture can be carried out with few systemic side effects. The 2015 ESC guidelines recommend colchicine as first line treatment in all forms of pericarditis except for neoplastic pericardial effusion. It accelerates healing and reduces the frequency of recurrence of pericarditis but cannot eliminate recurrence completely. The best treatment and prevention of recurrence is the eradication of the underlying etiological cause.

Constrictive pericarditis is one of the most feared complications of patients with pericarditis, especially if recurrent. The common perception is that the higher the number of recurrences, the higher the risk of constriction. However, the risk of constriction is related to the etiology and not to the number of recurrences. Constriction has never been reported as a complication of idiopathic recurrent pericarditis, while the risk is low (<1%) after a first attack of idiopathic or viral pericarditis, intermediate for immune-mediated etiologies (2-5%, e.g. systemic inflammatory diseases, post-pericardiotomy syndromes) and cancer, and high especially for bacterial etiologies (20.30%, e.g. tuberculosis, purulent pericarditis). Constriction may be reversible in the setting of pericarditis and about 7-10% of patients with acute pericarditis may have transient constriction during the acute phase of inflammation, due to increased pericardial stiffness. Empiric anti-inflammatory therapy may prevent pericardiectomy in one half of cases.The clinical diagnosis is not easy but feasible with prompt recognition of the clinical symptoms and signs that may mimic heart failure and chronic hepatic disease (e.g. jugular vein distention, peripheral edema, ascites), the echocardiographic signs (e.g. septal bounce, respiratory variations of transmitral and tricuspid flows, annulus reversus, inferior vena cava plethora), and other imaging features (e.g. pericardial thickening in about 80% of cases, pericardial calcifications).In this paper, we will try to give an answer to common clinical doubts for assessing the risk of constriction, making the diagnosis, and addressing the therapy of these patients also underlying the possible outcomes.

Constrictive pericarditis (CP) is a form of diastolic heart failure that arises because an inelastic pericardium inhibits cardiac filling. This disorder must be considered in the differential diagnosis for unexplained heart failure, particularly when the left ventricular ejection fraction is preserved. Risk factors for the development of CP include prior cardiac surgery and radiation therapy, but most cases are still deemed to be idiopathic. Making the diagnosis may be challenging and requires meticulous echocardiographic assessment, often supplemented by cross-sectional cardiac imaging and haemodynamic catheterisation. The key pathophysiological concepts, which serve as the basis for many of the diagnostic criteria, remain: (1) dissociation of intrathoracic and intracardiac pressures and (2) enhanced ventricular interaction. Complete surgical pericardiectomy is the only effective treatment for chronic CP. A subset of patients with subacute inflammatory CP, often identified by cardiac MRI, may respond to anti-inflammatory treatments., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objectives: This study sought to investigate the incidence, associated findings, and natural history of effusive-constrictive pericarditis (ECP) after pericardiocentesis., Background: ECP is characterized by the coexistence of tense pericardial effusion and constriction of the heart by the visceral pericardium. Echocardiography is currently the main diagnostic tool in the assessment of pericardial disease, but limited data have been published on the incidence and prognosis of ECP diagnosed by echo-Doppler., Methods: A total of 205 consecutive patients undergoing pericardiocentesis at Mayo Clinic, Rochester, Minnesota, were divided into 2 groups (ECP and non-ECP) based on the presence or absence of post-centesis echocardiographic findings of constrictive pericarditis. Clinical, laboratory, and imaging characteristics were compared., Results: ECP was subsequently diagnosed in 33 patients (16%) after pericardiocentesis. Overt clinical cardiac tamponade was present in 52% of ECP patients and 36% of non-ECP patients (p = 0.08). Post-procedure hemopericardium was more frequent in the ECP group (33% vs. 13%; p = 0.003), and a higher percentage of neutrophils and lower percentage of monocytes were noted on pericardial fluid analysis in those patients. Clinical and laboratory findings were otherwise similar. Baseline early diastolic mitral septal annular velocity was significantly higher in the ECP group. Before pericardiocentesis, respiratory variation of mitral inflow velocity, expiratory diastolic flow reversal of hepatic vein, and respirophasic septal shift were significantly more frequent in the ECP group. Fibrinous or loculated effusions were also more frequently observed in the ECP group. Four deaths occurred in the ECP group; all 4 patients had known malignancies. During median follow-up of 3.8 years (interquartile range: 0.5 to 8.3 years), only 2 patients required pericardiectomy for persistent constrictive features and symptoms., Conclusions: In a large cohort of unselected patients undergoing pericardiocentesis, 16% were found to have ECP. Pre-centesis echocardiographic findings might identify such patients. Long-term prognosis in those patients remains good, and pericardiectomy was rarely required., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Pericardial effusion of various sizes is a quite common clinical finding, while its progression to effusive-constrictive pericarditis occurs in about 1.4-14% of cases. Although available evidence on prevalence and prognosis of this rare pericardial syndrome is poor, apparently a considerable proportion of patients conservatively managed has a spontaneous resolution after several weeks. A 61-year-old female presented to our emergency department reporting fatigue, effort dyspnea and abdominal swelling. The echocardiography showed large pericardial effusion with initial hemodynamic impact, so she underwent a pericardiocentesis with drainage of 800-850cm 3 of exudative fluid, on which diagnostic investigations were undertaken: possible viral and bacterial infections, medical conditions, iatrogenic causes, neoplastic and connective tissue diseases were all excluded. Despite empirical therapy with NSAIDs and colchicine, after about one week she had a recurrence of pericardial effusion and progressive development of constriction. Echocardiography performed after a few weeks of anti-inflammatory therapy showed resolution of constriction and PE, with clinical improvement. If progression of pericardial syndromes to a constrictive form is rarely described in literature, cases of transitory effusive-constrictive phase are even more uncommon, mainly reported during the evolution of pericardial effusion. According to the available data, risk of progression to a constrictive form is very low in case of idiopathic pericardial effusion. We report a case of large idiopathic subacute pericardial effusion, treated with pericardiocentesis and then evolved into an effusive-constrictive pericarditis. A prolonged anti-inflammatory treatment leads to complete resolution of pericardial syndrome without necessity of pericardiectomy., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Rationale: Purulent pericarditis is a rare and usually fatal disease. Immunodeficiency state and preexisting pericardial effusion can predispose patients to infections. However, we are not aware of similar cases in patients with adult-onset Still's disease (AOSD). In addition, it is seldom caused by Salmonella bacteria., Patient Concerns: We report a 30-year-old woman with dyspnea on exertion and epigastric fullness. She was newly diagnosed with AOSD 4 months previously and medicated with prednisolone., Diagnoses: Transthoracic echocardiography (TTE) and computed tomography revealed a thickened pericardium with loculations in the pericardial space, consistent with purulent constrictive pericarditis. Subsequent cultures of blood and pericardial fluid yielded S enteritidis., Interventions: She underwent subtotal pericardiectomy through a limited median sternotomy, and antibiotic therapy (ceftriaxone) for 1 month., Outcomes: The New York Heart Association functional classification downgraded from class III to class I. There was no recurrence during the 1-year follow-up., Lessons: This case presents an opportunity to highlight the importance of considering purulent pericarditis in patients previously diagnosed with AOSD. High clinical suspicion, early diagnosis, and prompt management can result in a better outcome in purulent pericarditis., (Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Effusive-constrictive pericarditis (ECP) corresponds to the coexistence of a hemodynamically significant pericardial effusion and decreased pericardial compliance. The hallmark of ECP is the persistence of elevated right atrial pressure postpericardiocentesis. The prevalence of ECP seems higher in tuberculous pericarditis and lower in idiopathic cases. The diagnosis of ECP is traditionally based on invasive hemodynamics but the presence of echocardiographic features of constrictive pericarditis post-pericardiocentesisis can also identify ECP. Data on the prognosis and optimal treatment of ECP are still limited. Anti-inflammatory agents should be the first line of treatment. Pericardiectomy should be reserved for refractory cases., (Copyright © 2017 Elsevier Inc. All rights reserved.)

A rising prevalence of end-stage renal disease (ESRD) has led to a rise in ESRD-related pericardial syndromes, calling for a better understanding of its pathophysiology, diagnoses, and management. Uremic pericarditis, the most common manifestation of uremic pericardial disease, is a contemporary problem that calls for intensive hemodialysis, anti-inflammatories, and often, drainage of large inflammatory pericardial effusions. Likewise, asymptomatic pericardial effusions can become large and impact the hemodynamics of patients on chronic hemodialysis. Constrictive pericarditis is also well documented in this population, ultimately resulting in pericardiectomy for definitive treatment. The management of pericardial diseases in ESRD patients involves internists, cardiologists, and nephrologists. Current guidelines lack clarity with respect to the management of pericardial processes in the ESRD population. Our review aims to describe the etiology, classification, clinical manifestations, diagnostic imaging tools, and treatment options of pericardial diseases in this population., (© 2017 Wiley Periodicals, Inc.)

Constrictive pericarditis (CP) represents a form of severe diastolic heart failure (HF), secondary to a noncompliant pericardium. The true prevalence of CP is unknown but it is observed in 0.2-0.4% of patients who have undergone cardiac surgery or have had pericardial trauma or inflammation due to a variety of etiologies. Despite its poor prognosis if untreated, CP is a potentially curable disease and surgical pericardiectomy can now be performed at low perioperative mortality in tertiary centers with surgical expertise in pericardial diseases. Cardiologists should have a high index of suspicion for CP in patients presenting with predominant right-sided (HF), particularly when a history of cardiac surgery, pericarditis or pericardial effusion is present. Transthoracic two-dimensional and Doppler echocardiography is usually the first diagnostic tool in the evaluation of HF and can reliably identify CP in most patients by characteristic real-time motion of the heart and hemodynamic features. Computerized tomography and magnetic resonance imaging provide incremental data for the diagnosis and management of CP and are especially helpful when clinical or echocardiographic findings are inconclusive. Cardiac catheterization has been the gold-standard for the diagnosis of CP, but may not be necessary if non-invasive test(s) demonstrate diagnostic features of CP; it should then be reserved for selected cases or for assessment of concomitant coronary disease. Although most patients with CP require pericardiectomy, anti-inflammatory therapy may be curative in patients presenting with subacute symptoms, especially when evidence of marked ongoing inflammation is seen., (Copyright © 2016. Published by Elsevier Inc.)

Background: In areas where Mycobacterium tuberculosis is endemic, tuberculosis is known to be the most common cause of pericarditis. However, the difficulty in diagnosis may lead to late complications such as constrictive pericarditis and increased mortality. Therefore, identification of patients at a high risk for poor prognosis, and prompt initiation of treatment are important in the outcome of TB pericarditis. The aim of this study is to identify the predictive factors for unfavorable outcomes of TB pericarditis in HIV-uninfected persons in an intermediate tuberculosis burden country., Methods: A retrospective review of 87 cases of TB pericarditis diagnosed at a tertiary referral hospital in South Korea was performed. Clinical characteristics, treatment outcomes, complications during treatment, duration of treatment, and medication history were reviewed. Unfavorable outcome was defined as constrictive pericarditis identified on echocardiography performed 3 to 6 months after initial diagnosis of TB pericarditis, cardiac tamponade requiring emergency pericardiocentesis, or death. Predictive factors for unfavorable outcomes were identified., Results: Of the 87 patients, 44 (50.6%) had unfavorable outcomes; cardiac tamponade (n = 36), constrictive pericarditis (n = 18), and mortality (n = 4). 14 patients experienced both cardiac tamponade and constrictive pericarditis. During a 1 year out-patient clinic follow up, 4 patients required repeat pericardiocentesis and pericardiectomy was performed in 0 patients. In the multivariate analysis, patients with large amounts of pericardial effusion (P = .003), those with hypoalbuminemia (P = .011), and those without cardiovascular disease (P = .011) were found to have a higher risk of unfavorable outcomes., Conclusion: HIV-uninfected patients with TB pericarditis are at a higher risk for unfavorable outcomes when presenting with low serum albumin, with large pericardial effusions, and without cardiovascular disease.

Pericardial disorders constitute a relatively common cause of heart disease. Although acute pericarditis, especially the idiopathic forms that are the most prevalent, is considered a benign disease overall, its short- and long-term complications, namely, recurrent pericarditis, cardiac tamponade and constrictive pericarditis, constitute a matter of concern in the medical community. In recent years, several clinical trials contributed to redefining our traditional approach to pericardial diseases. In this review, we provide the most recent evidence concerning diagnosis, treatment modalities and short- and long-term prognosis of the most common pericardial disorders., (Copyright © 2016 Hellenic Cardiological Society. Published by Elsevier B.V. All rights reserved.)

A 61-year-old man presented with an 18-month history of progressive shortness of breath on exertion, fatigue, worsening bilateral lower extremity edema, abdominal swelling, and increased assistance with activities of daily living. Pertinent past medical history included right-sided pneumonia secondary to Streptococcus pneumoniae that was complicated by empyema, requiring right-sided video-assisted thoracoscopic surgery with decortication 2 years earlier. He had a negative cardiac history, no recent travel in the last 3 years, and no known exposure to tuberculosis. His medications included aspirin and daily furosemide. His symptoms appeared to be refractory to diuretic therapy. Previous workup 6 months earlier included an echocardiography (ECHO) showing enlarged left and right atria with a normal ejection fraction, and a catheterization of the left side of the heart with reported normal left ventricular function and unobstructed coronary arteries., (Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Diseases of the pericardium commonly manifest in one of three ways: acute pericarditis, pericardial effusion and constrictive pericarditis. In the developed world, the most common cause of acute pericarditis is viral or idiopathic disease, while in the developing world tuberculous aetiology, particularly in sub-Saharan Africa, is commonplace owing to the high prevalence of HIV. This article provides an approach to the diagnosis, investigation and management of these patients.

Pericardial disease is infrequently encountered in cardiovascular practice, but can lead to significant morbidity and mortality. Clinical data and practice guidelines are relatively sparse. Early recognition and prompt treatment of pericardial diseases are critical to optimize patient outcomes. In this review we provide a concise summary of acute pericarditis, constrictive pericarditis and pericardial effusion/tamponade.

Background: Previous studies on constrictive pericarditis (CP) mainly concerned patients undergoing pericardiectomy. The reported perioperative mortality of CP patients remained high. Data on medically treated CP patients without pericardiectomy have been scarce., Hypothesis: Constrictive pericarditis patients with more comorbidities are less likely to undergo pericardiectomy., Methods: Using the Diagnosis Procedure Combination database from 2007 to 2013, we retrospectively identified CP patients admitted with heart failure of New York Heart Association (NYHA) class II to IV. We compared clinical characteristics between patients treated with and without pericardiectomy. A multivariable logistic regression analysis was performed to assess the factors associated with likelihood of undergoing pericardiectomy., Results: Of 855 eligible patients, 164 (19.2%) underwent pericardiectomy (surgery group) and 691 (80.8%) did not (no-surgery group). The surgery group was younger (mean age, 65.0 years vs 70.3 years; P < 0.001) and more often male (81.7% vs 72.2%; P = 0.013) than the no-surgery group. No significant difference was seen in NYHA class and Barthel Index between the groups, whereas the surgery group had a lower Charlson Comorbidity Index (CCI). Older age, female sex, and higher CCI were significantly associated with a lower likelihood of undergoing pericardiectomy. In the surgery group, 30-day postoperative mortality was significantly higher in patients who underwent cardiopulmonary bypass than in those who did not (11.3% vs 2.9%; P = 0.030)., Conclusions: Patients' backgrounds were associated with the likelihood of undergoing pericardiectomy. Conservative medical therapy may be acceptable in CP patients with severe background and high preoperative need for cardiopulmonary bypass., (© 2015 Wiley Periodicals, Inc.)

Purulent pericardial effusion, although rare, is a life-threatening condition usually produced by the extension of a nearby bacterial infection locus or by blood dissemination in the immune-suppressed subjects or in the course of cardiothoracic surgery. Because clinical features of purulent pericardial effusion are often nonspecific, it can cause delay in diagnosis. Therefore, a high index of suspicion is required for timely diagnosis and management. Herein, we describe a case of giant purulent pericardial effusion due to Streptococcus intermedius with the history of bronchiectasis and pneumonia, which was successfully treated with pericardiocentesis via parasternal approach, appropriate antibiotics, and pericardiectomy., (© 2015, Wiley Periodicals, Inc.)

Cardiac hydatidosis is rare presentation of body hydatidosis. Incidence of cardiac involvements range from 5% to 5% of patients with hydatid disease. Most common site of hydatid cyst in heart is interventricular septum and left ventricular free wall. Right ventricular free wall involvement by cyst that ruptured to pericardial cavity is very rare presentation of hydatid cyst. Cardiac involvement may have serious consequences such as rupture to blood steam or pericardial cavity. Both the disease and its surgical treatment carry a high complication rate, including rupture leading to cardiac tamponade, anaphylaxis and also death. In the present report, a 43-year-old man with constrictive pericarditis secondary to a pericardial hydatid cyst is described.

Background: Low-flow, low-gradient aortic stenosis (AS), associated with a poor prognosis, can be caused by a reduced stroke volume despite a preserved ejection fraction (left ventricular ejection fraction). We hypothesized that impaired ventricular diastolic filling secondary to constrictive pericarditis (CP) could contribute to reduced transaortic gradients in patients with AS+CP. We sought to examine the characteristics and outcomes of this unique cohort., Methods and Results: We analyzed 84 patients with different degrees of AS and preserved left ventricular ejection fraction (≥50%): 28 diagnosed with concomitant CP by echocardiography and 56 patients without CP matched by age, sex, and AS severity during 1998 to 2013. Prior mediastinal radiation (32.1% versus 5.4%; P=0.0072) and cardiac surgery (50.0% versus 3.6%; P=0.0016) were more common in AS+CP patients than those with AS only. AS+CP patients had lower left ventricular stroke volume index and mean transaortic gradients. Five-year survival was 34.3% for AS+CP patients and 89.1% for those with AS only (P<0.001). In univariate analysis, prior mediastinal radiation (hazard ratio, 8.35; 95% confidence interval, 3.38-20.62; P<0.001), reduced left ventricular stroke volume index of <35 mL/m(2) (hazard ratio, 12.52; 95% confidence interval, 3.97-39.48; P<0.001), and concomitant CP (hazard ratio, 13.65; 95% confidence interval, 4.85-38.41; P<0.001) were highly associated with increased mortality., Conclusions: Our findings highlighted the possibility of CP as a pathophysiological mechanism for low-flow, low-gradient AS. Left ventricular stroke volume index and transaortic gradients were commonly reduced in AS in the setting of CP despite a preserved left ventricular ejection fraction, which may result in underestimation of AS severity. Prior mediastinal radiation, lower left ventricular stroke volume index, and concomitant CP were associated with poorer survival in AS patients., (© 2015 American Heart Association, Inc.)

Recurrent right-sided heart failure after pericardiectomy may be caused by incomplete pericardiectomy, recurrent constriction, diastolic dysfunction or myocardial involvement. Identifying recurrent constrictive pericarditis (CP) in patients who have recurring symptoms after pericardiectomy is challenging, since the characteristic Doppler echocardiographic features may not be present if a portion of the ventricles are free of constricting pericardium, and there are no diagnostic or treatment guidelines for management of recurrent CP. The authors report the case of a 59-year-old man with a history of pericardiectomy for tuberculous CP in 1984, admitted to our hospital with signs and symptoms of right heart failure. After a complete diagnostic workup, recurrent CP was diagnosed. Given the scarcity of cases reported on this disease, three possible therapeutic approaches are discussed: a second pericardiectomy, heart transplantation and medical therapy., (Copyright © 2014 Sociedade Portuguesa de Cardiologia. Published by Elsevier España. All rights reserved.)

Chronic constrictive pericarditis is a rare condition characterized by an impairment of myocardial relaxation due to limitation by a rigid pericardium. It is most often associated with infection, thoracic radiotherapy and heart surgery. Clinical features are that of chronic heart failure, therefore non-specific and resulting in a delay of several years before diagnosis is made. The echocardiogram and heart catheterization are part of the initial work-up. Surgical treatment consisting in pericardiectomy can be curative if the disease is recognised early. This article makes use of a case report and review of the litterature to discuss the physiopathology, clinical features and management of chronic constrictive pericarditis.

Objectives: The aetiology and outcome of constrictive pericarditis vary between geographic regions and has changed over time. We describe the diagnostic work-up and outcome in a contemporary cohort of Danish patients with constrictive pericarditis., Design: Hospital databases were searched for patients undergoing cardiac catheterisation for suspected constrictive pericarditis or for patients undergoing pericardiectomy or discharged with the diagnosis of constrictive pericarditis., Results: We identified 57 patients with constrictive pericarditis diagnosed from 1998 to 2012. Previous surgery and inflammatory disease were the most prevalent underlying conditions. Diagnosis was made primarily by echocardiography and right- and left-sided cardiac catheterisation. Echocardiography was particularly notable for dilated inferior caval vein, increased E/A ratio, and high septal tissue velocity in addition to the presence of septal bounce. Pericardiectomy was performed in 47 patients with a 30-day mortality of 8.5%. Clinical improvement was noted in 69% of cases. Several echocardiographic parameters normalised with time, including markers of diastolic function., Conclusions: Long-term outcome after pericardiectomy is acceptable with clinical improvement and partial resolution of the echocardiographic parameters in the majority of patients.

Constrictive pericarditis can result from a stiff pericardium that prevents satisfactory diastolic filling. The distinction between constrictive pericarditis and other causes of heart failure, such as restrictive cardiomyopathy, is important because pericardiectomy can cure constrictive pericarditis. Diagnosis of constrictive pericarditis is based on characteristic haemodynamic and anatomical features determined using echocardiography, cardiac catheterization, cardiac MRI, and CT. The Mayo Clinic echocardiography and cardiac catheterization haemodynamic diagnostic criteria for constrictive pericarditis are based on the unique features of ventricular interdependence and dissociation of intrathoracic and intracardiac pressures seen when the pericardium is constricted. A complete pericardiectomy can restore satisfactory diastolic filling by removing the constrictive pericardium in patients with constrictive pericarditis. However, if inflammation of the pericardium is the predominant constrictive mechanism, anti-inflammatory therapy might alleviate this transient condition without a need for surgery. Early diagnosis of constrictive pericarditis is, therefore, of paramount clinical importance. An improved understanding of how constrictive pericarditis develops after an initiating event is critical to prevent this diastolic heart failure. In this Review, we discuss the aetiology, pathophysiology, and diagnosis of constrictive pericarditis, with a specific emphasis on how to differentiate this disease from conditions with similar clinical presentations.