Unveiling the Spectrum of Pericardial Diseases: Insights, Novelties, and Future Directions

Welcome to this special issue of the Canadian Journal of Cardiology dedicated to exploring the multifaceted realm of pericardial diseases. As the editors of this unique collection, we are thrilled to present a diverse array of manuscripts that delve into the etiology, diagnosis, management, and prognosis of pericardial diseases. We aim to shed light on this complex field and stimulate further research and advancements in understanding and treating these conditions. In this editorial, we provide an overview of the manuscripts included in this special issue and highlight key themes and emerging trends. Isidoro et al. explore the emerging understanding of immune cell populations within the pericardium and their significance in cardiovascular health.1Isidoro C.A. Deniset J. Pericardial immune cells and their evolving role in cardiovascular pathophysiology.Can J Cardiol. 2023; 39: 1078-1089Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar The authors highlight the distinct function and phenotype of pericardial immune cells compared with other immune cells in the body. These cells have been found to play critical roles in various conditions, including myocardial infarction, pericarditis, and post–cardiac surgery complications. They emphasise the importance of investigating the immune components within the pericardium for a comprehensive understanding of cardiovascular diseases. Reddy et al. provide an insightful overview of the changing patterns of pericardial disease epidemiology and the various causative factors involved.2Reddy P. Kane G.C. Oh J.K. Luis S.A. The evolving etiologic and epidemiologic portrait of pericardial disease.Can J Cardiol. 2023; 39: 1047-1058Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar They highlight that idiopathic pericarditis remains the most common cause globally, while tuberculous pericarditis is prevalent in developing countries. They also discuss the emerging understanding of immune pathophysiology and its impact on the reclassification of some idiopathic cases. Ntsekhe highlights the unique challenges and characteristics of pericardial disease in developing regions.3Ntsekhe M. Pericardial disease in the developing world.Can J Cardiol. 2023; 39: 1059-1066Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar He emphasises that effusive and constrictive syndromes contribute significantly to the burden of acute and chronic heart failure in those places. The prevalence of Mycobacterium tuberculosis as a cause of pericarditis is particularly high, resulting in substantial morbidity and mortality. Resource constraints, such as limited access to advanced imaging and hemodynamic assessment, influence diagnostic and treatment approaches, ultimately affecting outcomes. Dr Ntsekhe highlights the importance of considering the specific context of developing countries when addressing pericardial diseases and underscores the need for tailored approaches to diagnosis and management in these settings. Sheridan et al. present a comprehensive review of rare congenital pericardial disorders that are frequently misdiagnosed because of their similarity to more common conditions.4Sheridan J.A. Noga M. Mackie A.S. Congenital disorders of the pericardium.Can J Cardiol. 2023; 39: 1140-1144Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar The article focuses on the partial or complete absence of the pericardium, pericardial cysts, and diverticula. The authors highlight cardiac magnetic resonance imaging (CMR) as the criterion standard for pericardial imaging. Although limited evidence exists for treatment guidance, the authors shed light on these rare congenital pericardial disorders, aiding in accurate diagnosis and appropriate management decisions. Conte et al. focus on the growing role of cardiac computed tomography (CCT) and CMR in pericardial diseases.5Conte E. Agalbato C. Melotti E. et al.The contemporary role of cardiac computed tomography and cardiac magnetic resonance imaging in the diagnosis and management of pericardial diseases.Can J Cardiol. 2023; 39: 1111-1120Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar In particular, the value of CMR in identifying pericardial inflammation provides both diagnostic and prognostic value in recurrent and chronic pericarditis. And CCT enables accurate assessment of pericardial calcification, aiding in the diagnosis of constrictive pericarditis and planning for pericardiectomy. The authors also emphasise the need for specialised expertise in evaluating and interpreting imaging. Lazaros et al. present a comprehensive and standardised approach in their review on managing chronic pericardial effusions.6Lazaros G. Imazio M. Tsioufis P. et al.Chronic pericardial effusion: causes and management.Can J Cardiol. 2023; 39: 1121-1131Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar They highlight the significance of C-reactive protein, CCT, and CMR in identifying the underlying causes of pericardial effusions. And they provide detailed technical insights into performing pericardiocentesis and percutaneous drain placement effectively. Treatment is based on individual patient evaluation and overall prognosis, which is closely linked to the underlying causes. Notably, the authors’ recent findings support a watchful waiting strategy for asymptomatic, idiopathic, chronic, and large pericardial effusions. Serati et al. provide valuable insights into managing pericardial diseases during pregnancy.7Serati L. Mardigyan V. Dominioni C.C. et al.Pericardial diseases in pregnancy.Can J Cardiol. 2023; 39: 1067-1077Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Their review highlights the benign nature of pericardial effusion, which typically resolves without treatment after delivery. The authors emphasise the importance of medical therapy for acute pericarditis during pregnancy and pre-pregnancy counselling as crucial for women with recurrent pericarditis to ensure optimal planning and review of appropriate therapy. The authors discuss the cautious use of medications such as aspirin, nonsteroidal antiinflammatory drugs, and prednisone during pregnancy and lactation. They also emphasise the compatibility and continued use of colchicine as a preventive measure, and recommend a multidisciplinary team to ensure favourable outcomes for both mother and fetus. Imazio et al. provide a comprehensive review of the latest advancements in managing recurrent pericarditis.8Imazio M. Mardigyan V. Andreis A. et al.New developments in the management of recurrent pericarditis.Can J Cardiol. 2023; 39: 1104-1110Abstract Full Text Full Text PDF Scopus (1) Google Scholar They highlight the high prevalence of recurrent pericarditis and the challenges associated with its pathogenesis. They focus on recent therapeutic developments, such as the use of colchicine and anti–interleukin-1 (IL-1) agents (eg, anakinra and rilonacept), which suggests an autoinflammatory mechanism for recurrences with an inflammatory phenotype. The authors emphasises the importance of a personalised approach to treatment, recommending colchicine and anti–IL-1 agents as second-line therapy (avoiding prednisone) for patients with an inflammatory phenotype. At the same time, low to moderate doses of corticosteroids are suggested for those without evidence of systemic inflammation. Imazio et al. also discuss the consideration of other treatments in case of corticosteroid failure. Aldajani, Imazio, et al. highlight the challenges associated with treating refractory pericarditis with IL-1 antagonists.9Aldajani A. Imazio M. Klein A. Mardigyan V. How to use interleukin-1 antagonists in patients with pericarditis.Can J Cardiol. 2023; 39: 1103-1110Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar They provide a focused guide, offering practical tips to assist clinicians in appropriately using these agents in patients with pericarditis. Castro-Varela et al. discuss the surgical management of pericardial disease.10Castro-Varela A. Schaff H.V. The surgical management of pericardial disease.Can J Cardiol. 2023; 39: 1136-1139Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar They highlight the preference for complete pericardiectomy with the removal of both anterior and diaphragmatic pericardium for most patients. They describe the different categories of patients with pericardial diseases that require surgical intervention and discuss the outcomes of the surgery, both in the early and late stages. They also address the special challenges of tricuspid valve regurgitation and radiation-induced pericardial constriction. Hassanabad et al. explore the link between pericardial inflammatory mediators and postoperative atrial fibrillation (POAF) development in cardiac surgery patients.11Hassanabad A.F. Deniset J.F. Fedak P.W.M. Pericardial inflammatory mediators that can drive postoperative atrial fibrillation in cardiac surgery patients.Can J Cardiol. 2023; 39: 1090-1102Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar POAF is a common complication that poses significant challenges in patient management and often prolongs hospitalisation. Hassanabad et al. explore the clinical relevance of the link between pericardial inflammation and atrial fibrillation by providing evidence for pericardial-specific treatments, including posterior left pericardiotomy, to reduce the pericardial inflammation and POAF. Aldajani, Bérubé, et al. emphasise the significance of pericardial diseases and their impact on the health care system.12Aldajani A. Bérubé M. Mardigyan V. How and why to set up a pericardial disease clinic.Can J Cardiol. 2023; 39: 1149-1151Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar They identify the lack of structured and timely follow-up as a major issue, leading to increased health care burden and costs, particularly for recurrent or refractory cases. They suggest the establishment of nurse-led clinics as a potential solution to improve care and outcomes, drawing from positive experiences with other cardiovascular conditions. Finally, we pay tribute to the life and accomplishments of John Tyberg.13Smiseth O.A. Belenkie I. ter Keurs H.E.J. Smith E.R. In memoriam: John Victor Tyberg, MD, PhD.Can J Cardiol. 2023; 39: 1041-1043Abstract Full Text Full Text PDF Scopus (1) Google Scholar A highly respected researcher and educator, Tyberg’s work encompassed various areas of cardiac function. His contributions include elucidating the role of the pericardium in ventricular constraint and its impact on ventricular preload, as well as advancing our understanding of the physiology of the ventricular septum and ventricular interaction. In addition, Tyberg delved into exploring models to explain the propagation of the arterial waveform. Known for his humility and passion for literature, history, and music, Tyberg’s legacy lives on through his mentees and his enduring contributions to the field of cardiology. This special issue of the Canadian Journal of Cardiology is a comprehensive resource, bringing together clinical perspectives from international world experts on pericardial diseases. Through this collection of manuscripts, we hope to inspire collaboration, stimulate further research, and ultimately improve the care and outcomes of patients affected by these conditions. We encourage the development of American College of Cardiology/American Heart Association guidelines on pericardial disease. We extend our heartfelt appreciation to all of the authors for their valuable contributions and to the readers for their continued engagement in advancing the field of pericardial diseases. The authors have no funding sources to declare.