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Concept: Pericardium

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BACKGROUND: The efficacy and safety of rigid pericardial endoscopy as the promising minimally invasive approach to the pericardial space was evaluated. Techniques for cell transplantation, epicardial pacemaker lead implantation, and epicardial ablation were developed. METHODS: Two swine and 5 canines were studied to evaluate the safety and efficacy of rigid pericardial endoscopy. After a double pericardiocentesis, a transurethral rigid endoscope was inserted into the pericardial space. The technique to obtain a clear visual field was examined, and acute complications such as hemodynamic changes and the effects on intra-pericardial pressure were evaluated. Using custom-made needles, pacemaker leads, and forceps, the applications for cell transplantation, epicardial pacemaker lead implantation, and epicardial ablation were also evaluated. RESULTS: The use of air, the detention of a stiff guide wire in the pericardial space, and the stretching of the pericardium with the rigid endoscope were all useful to obtain a clear visual field. A side-lying position also aided observation of the posterior side of the heart. As a cell transplantation methodology, we developed an ultrasonography-guided needle, which allows for the safe visualization of transplantation without major complications. Pacemaker leads were safely and properly implanted, which provides a better outcome for cardiac resynchronizing therapy. Furthermore, the success of clear visualization of the pulmonary veins enabled us to perform epicardial ablation. CONCLUSIONS: Rigid pericardial endoscopy holds promise as a safe method for minimally invasive cell transplantation, epicardial pacemaker lead implantation, and epicardial ablation by allowing clear visualization of the pericardial space.

Concepts: Optical fiber, Effectiveness, Safety, Pericardium, Minimally invasive, Artificial pacemaker, Endoscopy, Heart

47

A 56-year-old woman with a history of stage II cancer of the left breast presented with progressive shortness of breath and fatigue. Transthoracic echocardiography revealed a large pericardial effusion with the heart freely swinging in an anterior-posterior fashion, shown in a video.

Concepts: Pericardium, Pericardial effusion, Echocardiography, Cardiology, Breast cancer, Cardiac tamponade, Cancer, Cancer staging

41

Intrapericardial teratoma is a rare, lethal tumor often detected in fetal life. Tumor mass and pericardial effusion cause cardiac tamponade, which if relieved, could be life-saving. Optimal timing of intervention and methods for effective fetal treatment are unknown.

Concepts: Benign tumor, Surgery, Spina bifida, Pericardium, Nature, Pericardial effusion, In Utero, Cardiac tamponade

24

Suppressing perioperative inflammation and post-operative atrial fibrillation requires effective drug delivery platforms (DDP). Localized anti-inflammatory and anti-arrhythmic agent release may be more effective than intravenous treatment to improve patient outcomes. This study utilized a dexamethasone (DEX) and amiodarone (AMIO)-loaded Parylene-C (PPX) nano-structured film to inhibit inflammation and atrial fibrillation. The PPX film was tested in an established pericardial adhesion rabbit model. Following sternotomy, the anterior pericardium was resected and the epicardium was abraded. Rabbits were randomly assigned to five treatment groups: control, oxidized PPX (PPX-Oxd), PPX-Oxd infused with DEX (PPX-Oxd[DEX]), native PPX (PPX), and PPX infused with DEX and AMIO (PPX[AMIO, DEX]). 4 weeks post-sternotomy, pericardial adhesions were evaluated for gross adhesions using a 4-point grading system and histological evaluation for epicardial neotissue fibrosis (NTF). Atrial fibrillation duration and time per induction were measured. The PPX[AMIO, DEX] group had a significant reduction in mean adhesion score compared with the control group (control 2.75 ± 0.42 vs. PPX[AMIO, DEX] 0.25 ± 0.42, P < 0.001). The PPX[AMIO, DEX] group was similar to native PPX (PPX 0.38 ± 0.48 vs. PPX[AMIO, DEX] 0.25 ± 0.42, P[double bond, length as m-dash]NS). PPX-Oxd group adhesions were indistinguishable from controls (PPX-Oxd 2.83 ± 0.41 vs. control 2.75 ± 0.42, P[double bond, length as m-dash]NS). NTF was reduced in the PPX[AMIO, DEX] group (0.80 ± 0.10 mm) compared to control (1.78 ± 0.13 mm, P < 0.001). Total duration of atrial fibrillation was decreased in rabbits with PPX[AMIO, DEX] films compared to control (9.5 ± 6.8 s vs. 187.6 ± 174.7 s, p = 0.003). Time of atrial fibrillation per successful induction decreased among PPX[AMIO, DEX] films compared to control (2.8 ± 1.2 s vs. 103.2 ± 178 s, p = 0.004). DEX/AMIO-loaded PPX films are associated with reduced perioperative inflammation and a diminished atrial fibrillation duration. Epicardial application of AMIO, DEX films is a promising strategy to prevent post-operative cardiac complications.

Concepts: Redox, Flecainide, Antiarrhythmic agent, Amiodarone, Digoxin, Pericardium, Heart, Atrial fibrillation

23

Pericardial heart disease includes pericarditis, (an acute, subacute, or chronic fibrinous, noneffusive, or exudative process), and its complications, constriction, (an acute, subacute, or chronic adhesive or fibrocalcific response), and cardiac tamponade. The pathophysiology of cardiac tamponade and constrictive pericarditis readily explains their respective findings on clinical examination, Doppler echocardiography, and at cardiac catheterization. The primary abnormality of cardiac tamponade is pan-cyclic compression of the cardiac chambers by increased pericardial fluid requiring that cardiac chambers compete for a fixed intrapericardial volume. Features responsible for the pathophysiology include transmission of thoracic pressure through the pericardium and heightened ventricular interdependence. Constrictive pericarditis is a condition in which the pericardium limits diastolic filling, causes dissociation of intracardiac and intrathoracic pressures, and heightened ventricular interdependence. Both conditions result in diastolic dysfunction, elevated and equal venous and ventricular diastolic pressure, respiratory variation in ventricular filling, and ultimately, reduced cardiac output.

Concepts: Pericarditis, Thoracic cavity, Blood, Cardiac cycle, Cardiac tamponade, Pericardium, Heart, Cardiology

6

OBJECTIVES: Chest drainage following cardiac surgery is used to avoid complications related to the accumulation of blood and serous fluid in the chest. We aimed to determine the incidence of chest tube clogging and the role of bedside assessment in identifying the potential for failure to drain. METHODS: Data from 150 patients undergoing cardiac surgery using cardiopulmonary bypass from March to October 2011 were prospectively entered into a database. Chest tubes were visually inspected and functionally assessed at four time intervals (Hours 0, 2-4, 6-8 and at removal), defining need for clearance and presence of partial or complete obstruction. RESULTS: Complete data were available for 100 patients. We assessed 234 chest tubes: pericardial (n = 158); pleural (n = 76). The incidence of chest tube clogging for the entire group was 36% (any tube completely clogged at any time), with increased prevalence of clogging observed in urgent and reoperative cases and in those with increased intraoperative blood use. Among 51 tubes resulted to have a thrombus formation observed inside the chest tube at removal, 44 were clogged primarily in the internal portion of the tube, meaning that clogging could not be confirmed by simple bedside inspection of the indwelling tube. CONCLUSIONS: The chest tubes can become clogged at any time after their placement. The status of urgency, reoperations and use of blood products can be contributing factors increasing the incidence of chest tube clogging. Clinicians likely underestimate the prevalence of this failure to drain, as most clogging occurs in the internal portion of the tube.

Concepts: Scientific method, Pericardium, Heart, Observational study, Chest tube

4

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.

Concepts: Pericardium, Echocardiography, Heart failure, Heart, Myocardial infarction, Medical terms, Ejection fraction, Cardiology

3

CorMatrix is a non-crosslinked, acellular bioscaffold used for pericardial closure and cardiac tissue repair. A redo sternotomy 5 years after bypass grafting and pericardial reconstruction afforded the opportunity to explant the bioscaffold and examine it histologically. Consistent with preclinical evidence, pathology results showed that the bioscaffold had remodeled into viable, fully cellularized, vascularized, non-fibrotic connective tissue similar to native pericardium.

Concepts: Bone, Muscle, Histopathology, Biology, Anatomical pathology, Pericardium, Histology, Blood

1

Chylopericardium effusion is characterized by the accumulation of milky effusion in the pericardium. It is often idiopathic but it can be secondary to trauma, chest radiation, tuberculosis and malignancy. If cardiac tamponade ensues, it becomes life-threatening. Herein we describe chylopericardium tamponade in a child with IgA nephropathy. To the best of our knowledge, this is the first reported case of chylopericardium tamponade in IgA nephropathy.

Concepts: Immunoglobulin A, Report, Greatest hits, Greatest hits albums, Pericardium, Medical terms, Cardiac tamponade, Heart

1

Disorders of the pericardium represent a diverse range of conditions that traditionally may not have received the same level of attention by cardiologists and physicians, owing partly to a lack of research into advanced diagnostic modalities, and limited, evidence-based treatment options. In recent years, there has been a timely resurgence of interest in pericardial diseases, in particular pericarditis. This is attributable to advances in multi-modality cardiovascular imaging, in particular cardiac magnetic resonance (CMR), which may help guide treatment decisions for patients with pericardial syndromes. Additionally, increased research and understanding of the pathophysiological basis of pericarditis have shed light on the role of inflammation in pericarditis. This knowledge may help identify potential specific treatment targets. This article aims to provide a practical review of the role of multimodality cardiovascular imaging (echocardiography, multidetector cardiac computed tomography (MDCT), CMR) in pericardial conditions, focusing on the strengths and potential limitations of each imaging modality.

Concepts: The Canon of Medicine, Avicenna, Pericarditis, Heart, Cardiac tamponade, Medical imaging, Cardiology, Pericardium