Chronic pericardial effusion: current concepts and emerging trends

ABSTRACT

Introduction

Pericardial effusion (PEF) is a common and challenging pericardial syndrome with a variety of clinical manifestations ranging from asymptomatic, incidentally uncovered small PEFs, to life-threatening cardiac tamponade.

Areas covered

This review focuses on the pathophysiology, epidemiology, aetiology, classification, clinical findings, diagnostic work-up, management, and outcome of PEFs. Particular emphasis has been given on the most recent evidence concerning the contribution of imaging for the detection, differential diagnosis, and evaluation of the haemodynamic impact of PEFs on the diastolic filling of the heart. Moreover, simplified algorithms for PEF triage and management have been included.

Expert opinion

The management of patients with PEFs is mainly based on four parameters, namely, haemodynamic impact on diastolic function, elevation of inflammatory markers, presence of a specific underlying condition known to be associated with PEF, and finally size and duration of the effusion. Novel data have contributed to change our view towards large, asymptomatic, ‘idiopathic’ PEFs and dictated a rather conservative approach in most cases. It is also stressed that there is a compelling need for additional research, which is essential for tailored treatments aiming at the improvement of quality of life and containment of health care costs.

KEYWORDS:

• pericardial effusion
• pericarditis
• cardiac tamponade
• pericardial drainage
• outcome

Article highlights

• PEF is a common pericardial syndrome (incidence 3%, prevalence 5.7-9%) which may be observed either in the setting of acute infectious pericarditis or as a manifestation of a specific cause.

• Diagnostic work-up for the investigation of PEFs includes medical history, chest X-ray, ECG, echocardiography, and a clinically oriented blood work. In doubtful cases, additional investigation including second level imaging is recommended.

• Clinical findings depend on the underlying etiology and include a broad spectrum of manifestations ranging from asymptomatic, incidentally unveiled PEFs to life-threatening cardiac tamponade.

• Pericardial drainage is recommended in cases of cardiac tamponade or suspicion of purulent-neoplastic pericarditis. In cases with CRP elevation, anti-inflammatory treatment is advised whereas in the absence of overt inflammation a specific cause should be ruled-out. Chronic idiopathic effusions should be treated conservatively if asymptomatic.

• Prognosis of PEFs largely depends on the underlying cause. After checking for stability, small effusions do not require specific monitoring whereas in moderate and large effusions, clinical and echocardiographic assessment every 3-6 months is recommended.

Disclosure statement

A peer reviewer on this manuscript has received a travel grant from Kiniksa Pharmaceuticals Ltd. and has received honoraria from Effetti Srl. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Abbreviations

CMR	=	Cardiac Magnetic Resonance
COVID-19	=	Coronavirus Disease 19
CRP	=	C-reactive protein
CT	=	Computed Tomography
ECG	=	Electrocardiography
ESC	=	European Society of Cardiology
FMF	=	Familial Mediterranean Fever
HIV	=	Human Immunodeficiency Virus
IL-1	=	Interleukin-1
PEF	=	Pericardial Effusion
NSAIDs	=	Nonsteroidal anti-inflammatory drugs
PET	=	Positron Emission Tomography
SARS-CoV-2	=	Severe Acute Respiratory Syndrome Coronavirus 2
STIR	=	T2-weighted short-tau inversion recovery
TRAPS	=	Tumor Necrosis Factor Receptor Associated Periodic Syndrome
VATS	=	Video-Assisted Thoracoscopic Surgery

Additional information

Funding

This paper was not funded..