Search Results (71)

Postpericardiotomy syndrome (PPS) is the most frequent inflammatory after-effect of cardiac surgery and is characterized by high morbidity, delayed hospitalization, and increased long-term mortality rates. Although PPS is common, empirical anti-inflammatory therapy has historically been employed for its prevention, and mechanism-based approaches have not yet been standardized. In this literature review, which was conducted on the basis of randomized controlled trials, meta-analyses, cohort studies, and mechanistic research regarding pharmacologic interventions, surgical modalities, and biomarker-based preventive strategies, the deficiencies of a critical synthesis of existing preventive strategies and emerging risk stratification instruments for PPS are addressed. The review affirms that the most evidence-based pharmacologic intervention is colchicine, which demonstrates a consistent reduction in PPS incidence across a range of randomized trials. Nonsteroidal anti-inflammatory drugs show variable responses, whereas corticosteroids are no longer recommended for routine prophylaxis due to relapse. Specific anti–interleukin-1 therapies represent a promising novel approach for high-risk patients. Surgical interventions, such as pericardial closure using biomaterials and posterior pericardiotomy, are important and do not lead to increased hemodynamic complications, while postoperative effusions, atrial fibrillation, and tamponade are reduced. Less invasive methods may also be employed to mitigate inflammatory causes, particularly in valve-sparing procedures and congenital operations. Emerging biomarker data, including postoperative neutrophil-to-lymphocyte ratios, C-reactive protein levels, and pericardial fluid cytokines, enable the identification of high-risk patients and form the basis for a personalized prevention approach. In summary, pharmacologic prophylaxis, innovative surgical techniques, and biomarker-based risk stratification represent a pathway toward reducing the incidence and burden of PPS in modern cardiac surgery. Full article

Introduction: Malignant pericardial effusion (MPE) represents a relatively rare complication in various types of solid tumors. Its management is often challenging. One solution can be represented by surgical approaches, including a pericardio-peritoneal window (PPW), which allows draining the fluid into the abdominal cavity. The aim of this study is to investigate the efficacy and long-term outcomes of the PPW procedure as a definitive therapeutic strategy for MPE. Materials and methods: We retrospectively and prospectively observed pre-, peri-, and postoperative data of patients undergoing pericardio-peritoneal window creation from 2010 to December 2023 at the European Institute of Oncology (IEO), including the surgical procedures needed, total and specific postoperative complications, 30-day mortality rate, relapse rate, and the treatment of possible relapses. Results: A total of 44 consecutive patients underwent a pericardio-peritoneal window. In 28 patients (63.8%) PPW was associated with mono or bilateral videothoracoscopy for pleural biopsies/talc poudrage. In 23 cases, pre-operative percutaneous pericardial drainage (usually 1–2 days before surgery) was performed. No intraoperative deaths were observed. The 30-day mortality was 9% (four patients). We observed pericardial effusion recurrence in three patients at two months and in five patients at six months. In only two cases we treated this condition because of a pre-tamponade condition, treated by percutaneous pericardial drainage. The success rate of the PPW regarding pericardial relapse requiring further procedures was 95.5%. Conclusions: Patients presenting with a favorable short-term prognosis benefit from the pericardio-peritoneal window as a safe and effective method for resolving malignant pericardial effusion. Conversely, pericardial drainage is recommended as the most appropriate therapy for those with a less favorable prognosis. Full article

Background/Objectives: Various pathophysiological mechanisms play a role in the development of cardiovascular diseases (CVDs). There is a need for new biomarkers that can complement existing clinical findings, particularly in the early diagnosis and prognostic assessment of coronary artery disease (CAD) and that can also contribute to more effective management of the diagnosis and treatment process. Therefore, both blood and pericardial fluid samples can provide important diagnostic information. This study aims to investigate Stromal Cell-Derived Factor 4 (SDF4) levels and thiol/disulfide homeostasis in the blood and pericardial fluid of patients with established CAD undergoing open-heart surgery with cardiopulmonary bypass (CPB), in order to better characterize oxidative stress-related and redox-mediated pathophysiological processes associated with the development and progression of coronary heart disease. Comparisons with a healthy control group were performed to elucidate disease-related biochemical alterations rather than to propose these markers as diagnostic tools for CAD. Methods: In this study, intraoperatively collected venous blood and pericardial fluid samples from 45 patients undergoing on-pump coronary artery bypass grafting were analyzed. SDF4 levels were measured using enzyme-linked immunosorbent assay (ELISA), while thiol–disulfide homeostasis was assessed via spectrophotometric analysis. Results: The study revealed statistically significant differences in parameters such as SDF-4, native thiol, total thiol, disulfide, and disulfide/total thiol ratio among the control, patient serum, and pericardial fluid groups (p < 0.05). Notably, SDF-4 and disulfide levels were elevated, while thiol levels were reduced in the pericardial fluid group, suggesting increased oxidative stress and disrupted redox balance. Principal Component Analysis (PCA) and Variable Importance in Projection (VIP) analyses successfully demonstrated the discriminative power of these parameters among the groups. Conclusions: The increased SDF-4 levels and disturbances in the thiol–disulfide balance observed in this study indicate elevated oxidative stress and impaired cellular redox homeostasis in CAD. These findings suggest that SDF-4 and thiol–disulfide parameters may serve as important biochemical markers in the pathophysiology of CVD and hold potential as diagnostic and prognostic biomarkers. Full article

We report the case of a 53-year-old male patient who presented to the cardiology department with presyncope and atypical chest pain. The transthoracic echocardiography revealed a homogeneous hypoechoic mass measuring 2.5 × 5.7 cm at the level of the anterolateral wall of the right ventricle. In order to further characterize the identified right-ventricle-adjacent mass, we performed a cardiac computed tomography, which confirmed the presence of a homogeneous hypodense mass with a single wall, without septation. Cardiac magnetic resonance imaging demonstrated a serous fluid mass capping the right atrium, right atrial appendage, and coronary sinus, without evidence of myocardial invasion. The multimodality imaging performed clarified the diagnosis of an uncomplicated pericardial cyst. The patient was managed conservatively with every 6 months echocardiographic evaluation. At a 2-year follow-up, he presented no recurrent symptoms, and the pericardial cyst maintained the same characteristics. The cornerstone of this case report was relying on multimodality imaging in order to characterize the adjacent cardiac mass and to arrive at the diagnosis of an uncomplicated pericardial cyst, which established the prognosis and management of the patient. Full article

Modern therapies aimed at stimulating heart vascularization are critical for regenerating damaged heart tissue and treating ischemic heart disease. Approaches based on developmental biology concepts, particularly those involving the use of cells to coordinate vascular network formation, are of great interest. In this context, epicardial mesothelial cells (MCs) have emerged as a key regulator of blood and lymphatic vessel development during cardiogenesis. However, therapeutic targeting of MCs remains challenging because of anatomical constraints and the difficulties related to isolation of viable cell cultures for research. In this study, we demonstrate for the first time that the pericardial fluid contains cell layers, being an easily accessible source of cardiac MCs. These cells exhibit a characteristic epithelial-like morphology and robust in vitro proliferation, and an ability to undergo epicardial-to-mesenchymal transition in response to TGFβ1. They secrete a broad range of proangiogenic and proinflammatory factors and exert a potent effect on endothelial cells, stimulating proangiogenic behavior and promoting vascular structure formation on Matrigel^TM. Treating MCs with TGF-β1 enhances the secretion of VEGF, G-CSF, GM-CSF and MCP-3, thereby boosting their proangiogenic properties. Therefore, pericardial fluid is an easily accessible source of MCs for studying their regulatory mechanisms, for being applied in tissue engineering, and for developing approaches to improve heart vascularization. Full article

Background: The Sandwich technique is a commonly adopted method for reinforcing the dissected aortic wall during acute Type A aortic dissection (ATAAD) repair, using either felt or bovine pericardial strips. However, complications such as anastomotic bleeding, distal anastomotic new entry (DANE) and persistent false lumen (PFL) remain major challenges. This study evaluated and compared the sealing efficacy of felt versus pericardium in a human cadaver model. Methods: ATAAD was simulated in 20 fresh human cadavers. Repairs were performed using the sandwich technique with either felt (n = 10) or pericardium (n = 10), followed by end-to-end prosthetic graft anastomosis. Procedure time was recorded. Following the repair, the aortas were perfused at 160/90 mmHg using a glycerol-water solution to assess fluid leakage (mL), DANE and PFL. Results: Median leakage was significantly lower in the pericardium group (67.5 mL [IQR 40–198.8]) compared to the felt group (315 mL [IQR 285–445], p = 0.002). Procedure times were comparable between groups. DANE occurred in 20% (pericardium) and 30% (felt) of cases, while PFL was observed in 30% of cases in both groups; differences were not statistically significant. Conclusions: The superior sealing properties of pericardium in this study suggest a promising approach for reducing leakage in ATAAD repair. While rates of DANE and PFL were comparable, the advantage of pericardium was confined to leakage reduction. These findings highlight the need for further research to determine whether this experimental benefit translates into improved clinical outcomes. Full article

Cardiopulmonary bypass (CPB) can lead to cardiac damage due to oxidative stress (OS) and inflammation in heart failure (HF). We tested the hypothesis that preoperative HF patients with reduced ejection fraction (HFrEF) subjected to CBP have higher levels of OS and NLRP3 (NOD-, LRR- and pyrin domain-containing protein 3) in heart and plasma and in those that develop postoperative AF (pAF) as a clinical outcome. HF was categorized for preoperative left ventricular EF: preserved (HFpEF > 50%, n = 27) and reduced EF (HFrEF ≤ 40%, n = 25). Samples of atrial tissue, pericardial fluid, and plasma were collected at surgery to assess NLRP3 expression; 3-nitrotyrosine (3-NT), thiobarbituric acid reaction (TBARS), and nuclear factor erythroid 2-related factor 2 (Nrf2) in atrial tissue; NLRP3, IL-1β, and IL-18 expression in pericardial fluid; and antioxidant capacity, 8-isoprostanes, and malondialdehyde (MDA) in plasma. Reactive oxygen species, 3-NT, and NLRP3 in atrial tissue were determined by immunohistochemistry in a subset of pAF patients. Plasma and atrial tissue 3-NT and MDA were higher in HFrEF compared with HFpEF. Lipid peroxidation products were higher in both plasma and atrial tissue in pAF (n = 29), compared to sinus rhythm (SR) (n = 23). In HFrEF patients, the values of tissue ROS, 3-NT, and NLRP3 were higher than in HFpEF patients. In addition, the expression levels of NLRP3, IL-1β, and IL-18 were higher in atrial tissue and pericardial fluid in HFrEF. Patients with preoperative HFrEF showed higher OS in plasma and the expression of NLRP3, ROS, and 3-NT in atrial tissue biopsies and pericardial fluid. This finding suggests a potential pharmacologic therapy for pAF and clinical complications due to CPB. Full article

This study investigates T cell subsets in pericardial fluid samples obtained from heart transplantation donors, heart transplantation recipients, and coronary artery bypass graft patients. Using flow cytometry, we characterized regulatory T cells (Tregs), tissue-resident memory T cells (Trm), and exhausted T cells based on specific markers. Our results showed significant alterations in the CD4⁺ and CD8⁺ T cell subsets, migration (CXCR3, CCR5), and exhaustion markers (PD-1, TIM3) across the groups. Notably, Tregs and Trm cells were enriched in recipients, while markers of T cell exhaustion showed a complex regulation. These findings provide novel insights into the local immune regulation in cardiac disease and transplantation. Full article

Bedside echocardiography stands as a cornerstone diagnostic tool in internal medicine, offering rapid, real-time evaluation of cardiac structure and function across a wide spectrum of acute and chronic conditions. Its application, particularly when combined with lung and inferior vena cava (IVC) ultrasound, significantly enhances diagnostic accuracy for fluid balance assessment, dyspnea, and hypotensive states, guiding timely therapeutic decisions. Focused cardiac ultrasound (FoCUS) enables internists to assess left ventricular function, right atrial pressure, valvular abnormalities, and pericardial effusion, facilitating differentiation between cardiac and non-cardiac causes of symptoms such as dyspnea, chest pain, and hemodynamic instability. While operator-dependent, echocardiography can be effectively integrated into internal medicine practice through structured training programs that combine theoretical knowledge with supervised hands-on experience. This integration enhances clinical decision-making, optimizes patient management, and reduces the need for immediate specialist consultation. Widespread adoption of focused ultrasound techniques in internal medicine wards promises not only improved patient outcomes but also more efficient utilization of healthcare resources. Continued education and institutional support are fundamental to embedding echocardiography into routine care, ensuring internists are equipped to leverage this powerful bedside modality. This narrative review aims to underscore the transformative impact of bedside echocardiography in internal medicine, demonstrating its capacity, when combined with lung and IVC ultrasound, to optimize diagnostic pathways and treatment decisions across diverse acute and chronic settings. Full article

Background/Objectives: No reliable noninvasive biomarkers are available to predict RT-induced cardiotoxicity. Because the pericardial sac is a fast responder to cardiac injury, we investigated whether RT-induced radiographic pericardial changes might serve as early imaging biomarkers for late cardiotoxicity. Methods: We performed a retrospective study of 476 patients (210 males, 266 females; median age, 69 years; median follow-up, 26.7 months) treated with chemo-RT for small cell and non-small cell lung cancers at one single institution from 2009 to 2020. The heart and its 4 mm outmost layer (representing the pericardial sac) were contoured on standard-of-care baseline CTs. Six-month post-RT follow-up CTs were deformably registered on the baseline CTs. Data were harmonized for the effect of contrast. We labeled voxels as Fat, Fluid, Heme, Fibrous, and Calcification using Hounsfield units (HUs). We studied pericardial HU-change histograms as well as volume change and voxel-based mass change in each tissue composition. Results: Pericardial HU-change histograms had skewed distributions with a mean that was significantly correlated with mean pericardial dose. Voxels within Fluid, Heme, and Fibrous had mass changes consistent with the dose. In Kaplan–Meier curves, Fibrous and Heme volume changes (translating into thickening and effusion), Fat mass change, mean doses to heart and pericardium, history of cardiac disease, and being male were significantly associated with shorter survival, whereas thickening and effusion were significantly associated with shorter time to a post-RT cardiovascular disease diagnosis. Conclusions: Pericardium composition distribution has dose-dependent changes detectable on standard-of-care CTs at around 6 months post-RT and may serve as surrogate markers for clinically relevant cardiotoxicity. The findings should be validated with additional research. Full article

Background and Objectives: The aim of this study was to investigate IL-40 levels in preoperative blood and intraoperative pericardial fluid samples obtained from healthy individuals and patients with diagnosed heart disease who were scheduled for open heart surgery to determine whether it is a biomarker for cardiovascular diseases. Material and Methods: A total of 90 individuals were included in the study and divided into three groups. Group 1 (Healthy Group, n = 45): Blood was collected from a total of 45 healthy men and women over 18 years of age without any diagnosis of cardiovascular disease. Group 2 (Patient Group 1, n = 45): In this group, blood samples from a total of 45 male and female patients over 18 years of age with a diagnosis of heart disease and scheduled for open heart surgery were studied. Group 3 (Patient Group 2, n = 45): Pericardial fluids were obtained from patients in Group 3 immediately after pericardial incision during surgery. IL-40, TAS, TOS and OSI levels in blood plasma and pericardial fluid were determined by the ELISA kit method. Results: In the statistical analysis between the groups, IL-40, TOS and OSI levels were found to be higher in the patient group and in the pericardial fluid (p < 0.001), while TAS was higher in the control group. It was considered statistically significant (p < 0.001). Conclusions: IL-40, TOS and OSI levels were elevated in patient serum and pericardial fluid. Therefore, we suggest that IL-40 may be a new biomarker for the detection of cardiovascular diseases. Full article

Background and aims: Epicardial RFA is often required when ventricular tachyarrhythmias originate from epicardial or subepicardial substrates that cannot be effectively ablated endocardially. Our objective was to evaluate the impact of intrapericardial fluid accumulation on the lesion size in the myocardium and the extent of thermal damage to adjacent structures, particularly the lung. Methods: An in silico model of epicardial RFA was developed, featuring an irrigated-tip catheter placed horizontally on the epicardium. A 50 W–30 s RF pulse was simulated. Temperature distributions and resultant thermal lesions in both the myocardium and lung were computed. Results: An increase in pericardial space from 2.5 mm to 4.5 mm resulted in a reduction of myocardial lesion depth by up to 1 mm, while the volume of lung damage decreased from 200 to 300 mm³ to nearly zero, irrespective of myocardial or epicardial fat thickness. Myocardial lesion size was markedly influenced by the thickness of the epicardial fat layer. In the absence of fat and with a narrow pericardial space, lesions reached up to 262 mm³ in volume and 6.1 mm in depth. With 1 mm of fat, lesion volume decreased to below 100 mm³ and depth to 3 mm; with 2 mm, to under 40 mm³ and 2 mm; and with 3 mm, to less than 16 mm³ and 1.2 mm. Lung damage increased moderately with greater fat thickness. Cooling the irrigation fluid from 37 °C to 5 °C reduced lung damage by up to 51%, while myocardial lesion size decreased by only 15%. Conclusions: Intrapericardial fluid accumulation can limit myocardial lesion formation while protecting adjacent structures. Cooling the irrigation fluid may reduce collateral damage without compromising myocardial lesion depth. Full article

Background and Clinical Significance: Tuberous sclerosis complex (TSC) is an autosomal dominant disorder caused by pathogenic variants in TSC1 or TSC2. Cardiac rhabdomyoma is a common prenatal finding and can be associated with severe complications, including pericardial effusion. We administered prenatal sirolimus to mitigate pericardial effusion, which led to postnatal complications. Case Presentation: A 28-year-old pregnant woman with no significant family history underwent routine fetal ultrasound at 28.1 weeks of gestation, which identified a large right ventricular mass consistent with rhabdomyoma. Further fetal brain MRI revealed cortical-subcortical tubers and subependymal nodules, leading to a clinical diagnosis of TSC. At 30.4 weeks, oral sirolimus (3 mg/day) was started due to the significant pericardial effusion. The effusion remained after treatment, requiring pericardiocentesis at 33.6 weeks. The sirolimus dosage was raised to 6 mg/day at 35.6 weeks, reaching a plasma level of 3.76 ng/mL, but there was no discernible improvement because of the continued fluid accumulation. The mother did not experience any adverse side effects from the procedure. Genetic testing confirmed a pathogenic variant in TSC2 (c.1372C>T). After birth, the neonate received a single dose of sirolimus but subsequently developed necrotizing enterocolitis (NEC), highlighting the potential adverse effects and the need for cautious consideration of treatment options. Conclusions: This case illustrates the complexities of managing prenatal tuberous sclerosis complex (TSC). While sirolimus has been explored for fetal cardiac rhabdomyoma and associated complications, its effectiveness in resolving pericardial effusion remains uncertain. Additionally, the development of NEC postnatally raises concerns about the safety of mTOR inhibitors in this context. Further studies are necessary to assess the risks and benefits of this approach in fetal therapy. Full article

Objectives: Pericardial effusion is the accumulation of excess fluid in the pericardial sac. The etiology is multi-factorial and different techniques are used for management, including subxiphoid approaches, anterior and lateral thoracotomies, video-assisted thoracic surgery (VATS), and percutaneous pericardiocentesis. We evaluate the surgical management strategies for pericardial effusion and their outcomes in this systematic review. Methods: A systematic literature review was performed to identify studies on the surgical management of pericardial effusion from inception to February 2024 using PubMed, Cochrane, and Scopus. Articles were independently assessed by two reviewers, with discrepancies resolved by the senior author. Articles were considered for inclusion if they described different pericardial effusion surgical management techniques. Baseline patient characteristics and procedural and outcome variables were extracted. Results: A total of 27 studies comprising 2773 patients were evaluated. The median age was 56.2 years (interquartile range 47–62.2). The most common etiologies of pericardial effusion were malignancy (31.0%), post-cardiac surgery (18.7%), and idiopathic (15.4%). Other causes included uremia (9.6%), infection (9.6%), and autoimmune disease (4.2%). The subxiphoid pericardial window was the most common approach (82.6%), followed by anterior and lateral thoracotomy (12.0%), and median sternotomy (0.6%). At median follow-up of 24 months, the most frequent post-procedural complications were recurrence of effusion (10.5%), arrhythmias (2.7%), and pneumonia (0.7%). Conclusions: Subxiphoid pericardial window is the most common approach for draining pericardial effusions. Prognosis depends on both the underlying etiology and the chosen drainage strategy. Treatment should be tailored to individual patients, considering patient comorbidities and the specific etiology. Full article

Background and Objectives: Perineal wound complications and pelvic fluid collections or abscesses following proctectomy for Crohn’s disease are a common cause of morbidity and might be mitigated by filling the pelvis and occluding the pelvic inlet with a flap. Alternative flap options can be considered when inadequate omentum is available and when avoiding myofasciocutaneous flaps. Materials and Methods: A retrospective review of our Crohn’s proctectomy database was conducted to identify patients who underwent a non-omental or non-myofasciocutaneous local pedicle flap to their pelvis or pelvic exclusion using biological material during surgery. The techniques and outcomes of these alternative techniques are described in detail. Results: 228 patients underwent proctectomy for Crohn’s disease during the 10-year study period. However, only six patients had their pelvis filled or pelvic inlet occluded using a non-omental, non-myofasciocutaneous local pedicled flap or biological material. The techniques identified included two sigmoid mesocolic flaps, one peritoneal, preperitoneal fat and falciform ligament flap, one perivesical fat flap, one Gerota’s fat pad flap, and one bovine pericardial patch assisted pelvic exclusion. These flaps’ clinicopathological and operative characteristics, surgical outcomes, and technical aspects are described. Conclusions: When greater omentum is unavailable or inadequate and myofasciocutaneous flaps need to be avoided, local pedicled flaps using a range of intra-abdominal tissues or biological material can be used to fill the pelvis or occlude the pelvic inlet after proctectomy for Crohn’s disease. These techniques may help to prevent short and long-term complications associated with having a pelvic dead space. Full article