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.

BACKGROUND: The association between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mRNA vaccines and myocarditis/pericarditis in the Japanese population has not been systematically investigated. This study was aimed at clarifying the association between SARS-CoV-2 mRNA vaccines (BNT162b2 and mRNA-1273) and myocarditis/pericarditis as well as influencing factors by using the Japanese Adverse Drug Event Report database.
METHODS: Reporting odds ratios (RORs) and 95 % confidence intervals (95 % CIs) for the association between the vaccines and myocarditis/pericarditis were calculated using data from the database (April 2004-December 2023). Age, sex, onset time, and outcomes in symptomatic patients were evaluated.
RESULTS: The total number of reports was 880,999 (myocarditis: 1846; pericarditis: 761). The adverse events associated with the vaccines included myocarditis (919 cases) and pericarditis (321 cases), with the ROR [95 % CIs] being significant for both (myocarditis: 30.51 [27.82-33.45], pericarditis: 21.99 [19.03-25.40]). Furthermore, the ROR [95 % CIs] of BNT162b2 and mRNA-1273 were 15.64 [14.15-17.28] and 54.23 [48.13-61.10], respectively, for myocarditis, and 15.78 [13.52-18.42] and 27.03 [21.58-33.87], respectively, for pericarditis. Furthermore, most cases were ≤30 years or male. The period from vaccination to onset was ≤8 days, corresponding to early failure type based on analysis using the Weibull distribution. Outcomes were recovery or remission for most cases; however, they were severe or caused death in some cases.
CONCLUSIONS: In the Japanese population, SARS-CoV-2 mRNA vaccination was significantly associated with the onset of myocarditis/pericarditis. The influencing factors included age of ≤30 years and male. Furthermore, although most adverse events occurred early after vaccination, overall outcomes were good.

Remarkable advances have occurred in the understanding of the pathophysiology of pericardial diseases and the role of multimodality imaging in this field. Medical therapy and surgical options for pericardial diseases have also evolved substantially. Pericardiectomy is indicated for chronic or irreversible constrictive pericarditis, refractory recurrent pericarditis despite optimal medical therapy, or partial agenesis of the pericardium with a complication (eg, herniation). A multidisciplinary evaluation before pericardiectomy is essential for optimal patient outcomes. Overall, given the good outcomes reported, radical pericardiectomy on cardiopulmonary bypass, if feasible, is the preferred approach. Due to patient complexity, as well as the technical aspects of the surgery, pericardiectomy should be performed at high-volume centers that have the required expertise. The current review highlights the essential features of this multidisciplinary approach from diagnosis to recovery in patients undergoing pericardiectomy.

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Advances in multi-modality cardiac imaging have aided the evaluation, surveillance and treatment guidance of pericardial diseases, which have traditionally been a challenging group of conditions to manage. Although echocardiography remains the first-line imaging modality to assess the pericardium, both computed tomography (CT) and magnetic resonance imaging (MRI) have valuable complimentary roles. It is critical for clinicians to have a clear understanding of the utilities, advantages and disadvantages of these cardiac imaging modalities in pericardial pathologies. This contemporary review provides an update regarding the applications of multi-modality cardiac imaging in the evaluation of pericardial syndromes including acute/recurrent pericarditis, effusion/tamponade, constriction, masses and congenital anomalies.

Purulent pericarditis (PP) is rare disease, and if left untreated, it is associated with very high mortality, nearly 100%. A considerable clinical problem due to PP is a very high probability of developing constrictive pericarditis (CP). Pericardial drainage is essential in the treatment of PP and should be performed urgently. The use of broad-spectrum antibiotic therapy is equally important. Unfortunately, fibrin deposits often create occulated spaces and reservoirs that reduce the penetration of antibiotics and their effectiveness. The rationale for the intrapericardial use of fibrinolytic drugs in PP is based on their ability to dissolve fibrin strands and collagen fibres, thus improving the penetration of antibiotics to the pericardial sac and lowering the risk of CP. The choice of the drug, as well as its dosage and the method of administration is still under debate. The authors of the article share their experiences and review current literature on this rare topic.

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UNASSIGNED: SARS-CoV-2 infection induces an immune response that causes excessive inflammation damaging cardiac tissue and vascular endothelium. The objective of this study is to review a series of cases of hospitalized patients with pre-existing cardiac disease to describe the clinical behavior and highlight the low frequency of morbidity and mortality.
UNASSIGNED: Retrospective study of 17 patients with a confirmed diagnosis of COVID-19 by polymerase chain reaction test or antigen test, a history of cardiovascular disease with or without comorbidities, and a history of at least one dose of the vaccine for COVID-19, during the period between December 30, 2021 and March 17, 2022 at the Ignacio Chávez National Institute of Cardiology in Mexico City.
UNASSIGNED: The most frequent cardiac pathology was acute myocardial infarction (31.25%) and the most common arrhythmia was atrial fibrillation (25%). The median number of days of hospital stay was 10 days (interquartile range: 4-14). Regarding the outcomes, 94% of the patients were discharged due to clinical improvement, and only one patient died during his hospitalization.
UNASSIGNED: It is crucial to continue investigating SARS-CoV-2 effects in patients pre-existing heart disease and in those with persistent symptoms after infection. This will allow the development of more effective strategies for the treatment and prevention of cardiovascular complications associated with COVID-19.
UNASSIGNED: La infección por SARS-CoV-2 induce una respuesta inmunitaria que causa una inflamación excesiva dañando al tejido cardiaco y al endotelio vascular. El objetivo de este estudio es revisar una serie de casos de pacientes hospitalizados con patología cardiaca preexistente para describir el comportamiento clínico y resaltar la baja frecuencia de morbimortalidad.
UNASSIGNED: Estudio retrospectivo de 17 pacientes con diagnóstico confirmado de COVID-19 mediante prueba de reacción en cadena de la polimerasa o prueba de antígenos, antecedente de enfermedad cardiovascular en presencia o no de comorbilidad, y antecedente de al menos una dosis de la vacuna para la COVID-19, durante el periodo entre el 30 de diciembre de 2021 y el 17 de marzo de 2022, en el Instituto Nacional de Cardiología Ignacio Chávez de la Ciudad de México.
UNASSIGNED: La patología cardiaca previa más frecuente fue el infarto agudo de miocardio (31.25%), y la arritmia más común fue la fibrilación auricular (25%). La mediana de días de estancia hospitalaria fue de 10 (rango intercuartílico: 4-14). En cuanto a los desenlaces, el 94% de los pacientes fueron dados de alta por mejoría clínica y solo un paciente falleció durante su internamiento.
UNASSIGNED: Es crucial continuar investigando y monitoreando los efectos del SARS-CoV-2 en los pacientes con enfermedades cardiacas preexistentes y en aquellos con síntomas persistentes después de la infección. Esto permitirá desarrollar estrategias más efectivas para el tratamiento y la prevención de las complicaciones cardiovasculares asociadas a la COVID-19.

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UNASSIGNED: In this protocol-predefined substudy of the RHAPSODY trial, the primary aim was to assess whether pericardial late gadolinium enhancement (LGE) was associated with time to pericarditis recurrence.
UNASSIGNED: RHAPSODY was a Phase 3 double-blind, placebo-controlled, randomized-withdrawal trial that demonstrated the efficacy of rilonacept in recurrent pericarditis (RP). Patients with a history of multiple RP and an active recurrence were enrolled and had the option to participate in a cardiac magnetic resonance (CMR) imaging substudy. CMRs were interpreted by a blinded independent core laboratory with prespecified criteria to define pericardial LGE. Compared to patients with trace or mild pericardial LGE (n = 9), patients with moderate or severe pericardial LGE (n = 16) generally had a higher number of recurrent episodes per year (5.3 vs. 3.9) and a higher mean CRP level (3.6 vs. 1.1 mg/dL). Overall, 10/14 (71.4%) who received a placebo had a recurrence compared to 0/11 (0%) who received rilonacept. In patients randomized to placebo who had moderate or severe pericardial LGE, the median time to recurrence was 4.2 weeks compared to 10.7 weeks in patients who had trace or mild pericardial LGE. At the conclusion of the event-driven randomized-withdrawal period, among patients receiving a placebo, 5/7 (71.4%) with trace or mild pericardial LGE and 5/7 (71.4%) with moderate or severe pericardial LGE had a recurrence.
UNASSIGNED: Among patients with multiple RP, these preliminary findings support the concept of pericardial LGE as an imaging biomarker that may inform the duration of treatment and risk of recurrence with cessation of therapy and larger studies should be considered.
UNASSIGNED: NCT03737110.
Patients with recurrent pericarditis (RP) can suffer from debilitating pain and a poor quality of life. Rilonacept blocks interleukin 1 (IL-1), the major inflammatory driver of RP, and is highly effective at treating active episodes of RP and preventing recurrence. In pericarditis, there is the recruitment of blood vessels to the pericardium, and the extent of these new blood vessels tracks with the degree of inflammation. Cardiac magnetic resonance imaging (CMR) readily images this blood supply and can therefore assess inflammation by the magnitude of pericardial late gadolinium enhancement (LGE). In this study of RP patients with CMR, no patients who continued rilonacept had a recurrence compared to 10/14 (71.4%) patients who stopped rilonacept and received a placebo. In the patients who received a placebo, the rate of eventual recurrence was similar among patients with trace or mild pericardial LGE at baseline (5/7) compared to patients with moderate or severe pericardial LGE at baseline (5/7). However, patients who demonstrated moderate or severe pericardial LGE had a faster recurrence (∼4 weeks after stopping rilonacept) compared to patients with trace or mild pericardial LGE (∼11 weeks after stopping rilonacept). These results suggest that pericardial LGE can serve as an imaging biomarker to assess the severity of RP and raise the possibility that CMR could be studied in future clinical trials to determine appropriate therapy and treatment duration in patients with RP.