Multimodality imaging in patients with post-cardiac injury syndrome

Update for diagnosis and treatment of syndrome after cardiac injury: a mini-review

Post-Cardiac Injury Syndrome (PCIS) refers to a collective term encompassing post-myocardial infarction syndrome, post-pericardiotomy syndrome, and post-traumatic pericarditis. With an aging population, the incidence of PCIS is on the rise annually. This condition is considered to be an autoimmune-mediated inflammatory response leading to pericarditis as the primary manifestation of the cardiac disease. Early diagnosis and effective treatment can improve the quality of life and prognosis for PCIS patients. This review aims to provide a comprehensive explicit of the epidemiological characteristics, relevant pathophysiological mechanisms, diagnostic methods, and treatment strategies associated with PCIS, further fostering a deeper understanding and promoting advancements in the prevention and treatment of PCIS.

A Common Diagnostic Dilemma: Inflammation or Infarction

Early infarct-associated pericarditis is a rare entity, given the availability of early coronary angiography and intervention. Although the electrocardiogram and the surface echocardiogram are initial studies, definitive imaging with cardiac magnetic resonance is recommended. We present a case of early infarct-associated pericarditis in the setting of a late-presenting silent right coronary artery myocardial infarction.

The Emerging Role of Multimodality Imaging in the Diagnosis and Management of Post Pericardiotomy Syndrome

PURPOSE OF REVIEW

This review aims to evaluate current diagnostic and therapeutic strategies for postpericardiotomy syndrome (PPS), with a focus on the evolving role of multimodality imaging, including echocardiography, cardiac computed tomography (CCT), and cardiac magnetic resonance imaging (CMR). The review also explores the potential benefits of advanced imaging in improving the accuracy and management of PPS.

RECENT FINDINGS

PPS, a common complication following cardiac surgery, presents with pleuritic chest pain, fever, and pericardial or pleural effusion. Traditional diagnostic methods like echocardiography and X-ray are increasingly supplemented by advanced imaging modalities such as CCT and CMR. These tools allow for better visualization of pericardial inflammation and effusion, aiding in diagnosis and guiding treatment. Colchicine and NSAIDs remain the most effective treatments for PPS, while the role of corticosteroids remains uncertain. Biological treatments have shown promising results in managing recurrent pericarditis. This review presents a proposed algorithm for the diagnosis and management of PPS, drawing on our institutional experience. Multimodality imaging is emerging as an essential tool in diagnosing and managing PPS. It enhances diagnostic precision, informs treatment strategies, and provides prognostic insights. As imaging technology advances, integrating these modalities into PPS care has the potential to improve patient outcomes.

Management of Systemic Inflammatory Response Syndrome After Cardiovascular Interventions. Diagnostic, Prognostic, and Therapeutic Implications

A substantial number of patients may experience systemic inflammatory response syndrome (SIRS) and related adverse events after transcatheter aortic valve implantation and endovascular aortic aneurysm repair. Although a clear etiology has not been established, endothelial disruption and tissue-ischemic response secondary to the foreign material may represent the trigger events. A latency period (0 to 48 hours) may occur between the initial injury and onset of symptoms mirroring an initial local response followed by a systemic response. Clinical presentation can be mild or severe depending on external triggers and characteristics of the patient. Diagnosis is challenging because it simulates an infection, but lack of response to antibiotics, negative cultures are supportive of SIRS. Increased in-hospital stay, readmissions, major cardiovascular events, and reduced durability of the device used are the main complications. Treatment includes non-steroidal anti-inflammatory drugs or corticosteroids. In conclusion, further studies are warranted to fully explore pathophysiologic mechanisms underpinning SIRS and the possibility of enhancing device material immune compatibility to reduce the inflammatory reaction of the host tissue.

Post-cardiac injury syndrome after surgical repair of atrial septal defect: Reporting a rare occurrence

A 16-year-old male with past medical history of congenital atrial septal defect surgical repair, presented with recurrent pericarditis secondary to post-cardiotomy injury syndrome (PCIS), After failing medical therapy, he ultimately underwent pericardiectomy for symptom resolution, PCIS is underdiagnosed in children and should be considered in patients with recurrent chest, pain.

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.

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.

Post cardiac injury syndromes: diagnosis and management

Post cardiac injury syndromes (PCIS) are becoming increasingly common, due to the growing number of cardiovascular procedures (cardiac surgery, percutaneous interventions) and the high burden of cardiovascular diseases such as acute coronary syndromes. This review aims to provide an overview of the main clinical characteristics of PCIS, along with their management in clinical practice.

Post-pericardiotomy syndrome: insights into neglected postoperative issues

ABSTRACT OBJECTIVES

Pericardial effusion is a common complication after cardiac surgery, both isolated and in post-pericardiotomy syndrome (PPS), a condition in which pleuropericardial damage triggers both a local and a systemic inflammatory/immune response. The goal of this review was to present a complete picture of PPS and pericardial complications after cardiac surgery, highlighting available evidence and gaps in knowledge.

METHODS

A literature review was performed that included relevant prospective and retrospective studies on the subject.

RESULTS

PPS occurs frequently and is associated with elevated morbidity and significantly increased hospital stays and costs. Nevertheless, PPS is often underestimated in clinical practice, and knowledge of its pathogenesis and epidemiology is limited. Several anti-inflammatory drugs have been investigated for treatment but with conflicting evidence. Colchicine demonstrated encouraging results for prevention.

CONCLUSIONS

Wider adoption of standardized diagnostic criteria to correctly define PPS and start early treatment is needed. Larger studies are necessary to better identify high-risk patients who might benefit from preventive strategies.

Role of non-invasive multimodality imaging in autoimmune pericarditis

Systemic autoimmune diseases are an important cause of pericardial involvement and contribute to up to ∼22% cases of pericarditis with a known aetiology. The underlying mechanism for pericardial involvement varies with each systemic disease and leads to a poor understanding of its management. Multimodality imaging establishes the diagnosis and determines the type and extent of pericardial involvement. In this review, we elaborate upon various pericardial syndromes associated with different systemic autoimmune and autoinflammatory diseases and the multitude of imaging modalities that can be used to further characterize autoimmune pericardial involvement. Lastly, these forms of pericarditis have a greater likelihood of recurrence, and clinicians need to understand their unique treatment approaches to improve patient outcomes.

Management of acute and recurrent pericarditis in pregnancy

This review summarizes the currently available evidence on the management of acute and recurrent pericarditis during pregnancy, focusing on the safety of diagnostic procedures and treatment options for the mother and foetus. Family planning should be addressed in women with recurrent pericarditis of reproductive age and adjustment of therapy should be considered before a planned pregnancy. The treatment of pericarditis in pregnancy is similar to that for non-pregnant women but considers current knowledge on drug safety during pregnancy and lactation. The largest case series on this topic described 21 pregnancies with idiopathic recurrent pericarditis. Pregnancy should be planned in a phase of disease quiescence. Non-steroidal anti-inflammatory drugs can be used at high dosages until the 20th week of gestation (except low-dose aspirin 100 mg/die). Colchicine is allowed until gravindex positivity; after this period, administration of this drug during pregnancy and lactation should be discussed with the mother if its use is important to control recurrent pericarditis. Prednisone is safe if used at low-medium doses (2,5 - 10 mg/die). General outcomes of pregnancy in patients with pericarditis are good when the mothers are followed by a multidisciplinary team with experience in the field.

Recurrent pericarditis: an update on diagnosis and management

Acute pericarditis is a disease of the pericardium characterized by inflammation. Around 16-38% of patients develop recurrent events after the first episode. Recurrent pericarditis (RP) seems to be caused by a pathologic immune response. An inadequate treatment in terms of drug choice, dose, duration of therapy or tapering, has been shown to increase the risk of recurrences. Symptoms, physical signs and electrocardiographic signs are usually less severe during a recurrent event as compared to the first episode, thus favoring imaging as a tool to confirm the diagnosis of RP. Cardiac magnetic resonance is becoming the technique of choice because of its ability to detect active pericardial inflammation. Inflammatory biomarkers can be used to assess the risk of recurrences and to guide the tapering of treatments. First-line treatment is based on non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine. NSAIDs are useful for pain control, and colchicine has shown to reduce the risk of further recurrences. Glucocorticoids are often used as second-line drugs, but they are associated with a high rate of recurrent events. Interleukin-1 inhibitors, such as anakinra and rilonacept, significantly reduce the risk of recurrences in patients with RP while on treatment.

Pericarditis and Post-cardiac Injury Syndrome as a Sequelae of Acute Myocardial Infarction

PURPOSE OF REVIEW

Pericarditis secondary to acute myocardial infarction (AMI) is known to develop either immediately or after a latent period of few months. Due to varied presentation and timing, its diagnosis and treatment can be challenging. This article reviews underlying mechanisms and the role of cardiac imaging in investigating and managing this condition.

RECENT FINDINGS

Timely diagnosis of pericarditis after AMI is important to prevent potential progression to complicated pericarditis. Clinical suspicion warrants initial investigation with serum inflammatory levels, electrocardiogram, and echocardiography. When findings are inconclusive, cardiac magnetic resonance imaging and computerized tomography can provide additional diagnostic information. Pericarditis after AMI is a treatable condition. Clinicians should maintain a high suspicion in this era of revascularization and develop a strategic plan for timely diagnosis and management.

Novel Pharmacotherapies for Recurrent Pericarditis: Current Options in 2020

Recent advances have shown impressive results by anti-interleukin 1 (IL-1) agents in refractory idiopathic recurrent pericarditis. PURPOSE OF REVIEW: We critically discuss the current state of the art of therapy of relapsing pericarditis, with a focus on new pharmacological approaches and on specific clinical settings such as pregnancy, pediatric patients, and secondary forms of relapsing pericarditis. RECENT FINDINGS: Antagonism of the IL-1 is highly effective in idiopathic recurrent pericarditis with autoinflammatory features. Currently, available anti-IL-1 agents are anakinra and canakinumab. Rilonacept is another IL-1 antagonist, currently studied in the phase-3 clinical trial RHAPSODY. Available data suggest similar efficacy and safety profiles of these three agents, although only anakinra has been tested in randomized clinical trials. These agents have slightly different pharmacological properties, being canakinumab a specific IL-1ß antagonist while anakinra and rilonacept are unselective IL-1α and IL-1ß blockers. To date, there is no evidence that specificity against IL-1ß affects safety and efficacy in patients with relapsing pericarditis, although it has been proposed that unspecific blockage might be useful in severe disease. Anakinra is the first anti-IL-1 agent with well-documented efficacy and safety in adult and pediatric patients with idiopathic relapsing pericarditis. Other anti-IL-1 agents are currently under study. Future research should clarify the optimal duration of therapy and tapering schedule of treatment with these agents. Moreover, biomarkers would be required to understand which patients will benefit from early administration of IL-1 blockers due to refractoriness to conventional therapy and which others will suffer from recurrences during the tapering of these agents. Lastly, future studies should focus on the subjects with the autoimmune or the pauci-inflammatory phenotype of idiopathic refractory pericarditis.