Incidence Of Pericarditis Research Articles

PO-02-204 COLCHICINE USAGE FOR PREVENTION OF POST ATRIAL FIBRILLATION ABLATION PERICARDITIS IN PATIENTS UNDERGOING HIGH POWER SHORT DURATION ABLATION

Radiofrequency ablation (RFA) for atrial fibrillation (AF) can be associated with up to 10% incidence of post-operative pericarditis, suspected to be more prevalent with the advent of high-power short duration (HPSD) ablation. This has led to widespread use of colchicine, an anti-inflammatory medication, for prevention of post-AF ablation pericarditis. However, the utility of preventative colchicine remains unproven. To evaluate the efficacy of a routine post-operative colchicine regimen for prevention of post-ablation pericarditis in patients (pts) undergoing HPSD ablation for AF. We retrospectively evaluated consecutive single-operator HPSD AF ablation procedures at our institution from June 2019 to July 2022. A colchicine protocol was introduced in June 2021 for prevention of post-ablation pericarditis. None of the pts before this date received preventative colchicine while all consecutive pts after this date received routine colchicine 0.6 mg twice daily for 14 days starting on the procedure day. Pts were divided into colchicine and non-colchicine groups (gps). We recorded the incidence of post ablation chest pain, emergency room (ER) visit for chest pain, pericardial effusion, pericardiocentesis, any ER visit, hospitalization, AF recurrence and cardioversion (CV) for AF within the first 30 days post-ablation. We also recorded colchicine-related side effects and medication compliance. Out of 225 consecutive procedures, 20 were excluded for lack of follow-up data, yielding 101 pts in the colchicine gp and 104 pts in the non-colchicine gp. Both gps were well-matched for demographic and procedural parameters (Table 1). There was no significant difference in post-ablation chest pain (9.9% vs 8.6%, p = 0.7), pericardial effusion (2.9% vs 0.9%, p = 0.1), ER visits (11.9% vs 12.5%, p = 0.2), 30-day hospitalization for AF recurrence (0.9% vs 0.96%,p = 0.3) and 30-day need for CV for AF (3.9 % vs 5.7%, p = 0.2) (Table 1). 15 pts had severe colchicine-related diarrhea, out of which 12 discontinued it prematurely (Figure 1). In this single-operator retrospective analysis, preventative colchicine was not associated with any significant reduction in the incidence of pericarditis, pericardial effusion, ER visits or AF recurrence within the first 30 days after HPSD ablation for AF. Colchicine usage was associated with significant diarrhea affecting patient compliance. Our findings argue against routine use of colchicine for prevention of post AF-ablation pericarditis.

PO-02-068 REAL WORLD COLCHICINE USE FOR PREVENTION OF PERICARDITIS AFTER ABLATION FOR ATRIAL FIBRILLATION

Colchicine is a commonly used anti-inflammatory medication for the treatment of acute pericarditis. The incidence of pericarditis after atrial fibrillation (AF) ablation has been estimated at up to 10%. Over the last decade, colchicine has been increasingly used for prevention of pericarditis after AF ablation. However, there are no established guidelines for preventative colchicine, no accepted dosage protocol, and no data regarding compliance with colchicine use. To estimate the usage of and compliance with colchicine for prevention of post-AF ablation pericarditis in real-world electrophysiology practices. The REAL-AF registry is the largest physician-driven registry of AF ablation in the United States, with a combined annual AF ablation volume of around 10,000 procedures by 80 operators. We circulated a Colchicine Use survey among all REAL-AF registry participants to estimate preventive colchicine usage as well as the dosage protocol and patient compliance. Sixty one (75%) registry participants responded to the survey. The majority (91.8%) used high power short duration (HPSD) ablation with 40-50 Watts in the left atrium (LA). Only 12 (21%) respondents had a pre-specified protocol for pericarditis prevention for all patients while another 12 (21%) operators used a selective protocol dependent upon extent of LA ablation beyond pulmonary veins. Colchicine was part of the preventive protocol for only 14 (24.1%) operators while another 10 (16.7%) used it selectively. Colchicine dosage varied between 0.3 mg BID (30.8%), 0.6 mg daily (38.4%) and 0.6 mg BID (38.4%), with duration of prescription varying widely from 1-4 weeks (Figure 1). As many as 44% of operators estimated that at least a third of their patients were unable to comply with complete colchicine protocol (Figure 1). Despite a general aura of regular use for prevention of post-AF ablation pericarditis, colchicine is actually used for this purpose by less than a third of high-volume operators in a real-world registry, with extreme variation in colchicine dosage protocol and a relatively high prevalence of patient non-compliance. The utility of preventive colchicine needs to be studied in a systematic manner to establish a universal usage recommendation.

Cardiac Tamponade Caused by Cutibacterium acnes: An Updated and Comprehensive Review of the Literature.

Bacterial pericarditis is a critical diagnosis caused by a wide range of organisms including Streptococcus pneumoniae and other anaerobic organisms like Cutibacterium acnes which has been gaining more importance as a causative organism. Cutibacterium species are Gram-positive microaerophilic rods that constitute part of the normal flora of skin and mucosal membranes. The incidence of pericarditis caused by this organism is underreported as it is often dismissed as a skin flora contaminant. However, if left untreated, Cutibacterium acnes can cause pericarditis with serious complications. In this paper, we present a comprehensive review of the literature regarding pericarditis caused by Cutibacterium acnes along with a case presentation from our institution. In our institution, a 20-year-old man with history of atrial septal defect presented with chest pain radiating to the back along with symptoms of upper respiratory tract infection including headaches and myalgia. Electrocardiogram was remarkable for diffuse low-voltage waves. Echocardiography revealed a large pericardial effusion with tamponade features. Pericardiocentesis drained 1.2 L of milky fluid. Pericardial fluid analysis grew Cutibacterium acnes after being cultured for 8 days. The patient received 3 weeks of IV penicillin followed by 3 weeks of oral amoxicillin along with nonsteroidal anti-inflammatory agents and colchicine with no recurrence. Pericarditis caused by Cutibacterium acnes requires a high clinical suspicion since isolation of this organism can be dismissed as a skin flora contaminant. Literature review reveals that this infection may be underdiagnosed and underreported. Prompt diagnosis may lead to timely initiation of antibiotics which can help prevent devastating complications like constrictive pericarditis. Prospective studies are needed to evaluate the true incidence and prevalence of this disease.

Cardiac manifestations of Han Chinese patients with systemic lupus erythematosus: a retrospective study

ObjectiveTo investigate cardiac manifestations and the risk factors in Han Chinese patients with systemic lupus erythematosus (SLE).MethodsSeven hundred fifty SLE patients who were hospitalized at our department were recruited in the present study. The patients were divided into two groups—those with or without cardiac manifestations. Cardiac manifestations in those SLE patients, such as pericarditis, myocarditis, heart valve disease, arrhythmia, were analyzed. The risk and protective factors of cardiac diseases in patients with SLE, as well as the predictors of mortality, were assessed, respectively.ResultsIn all 750 SLE patients, there were 339 (45.20%) patients suffered from one or more cardiac manifestations, involving pericarditis in 9.5%, myocarditis in 5.7%, heart valve disease in 15.6%, arrhythmia in 16.67%, and cardiovascular diseases (CVD) in 14%. 15.7% of SLE patients were accompanied with pulmonary arterial hypertension (PAH), of which 13.7% were mild, 1.2% were moderate, and 0.8% were severe. No significant differences were found between the two groups in age, disease duration, gender, antibody, and Systemic Lupus Erythematosus Disease Activity Index (SLEDAI). The incidence of pericarditis, heart valve disease, arrhythmia, and PAH was positively correlated with age. The incidence of arrhythmia, CVD, and PAH was correlated with SLEDAI. PAH and myocarditis were the risk factors of mortality in SLE patients with disease duration ≤ 10 years (P = 0.034 and 0.001, respectively).ConclusionCardiac involvement is common in Han Chinese SLE patients and associated with age and disease activity. PAH and myocarditis are the risk factors of mortality in SLE.

Cardiac Tamponade: An Uncommon Presentation of Granulomatosis With Polyangiitis

SESSION TITLE: Pulmonary Manifestations of Systemic Disease Case Report Posters SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM INTRODUCTION: Cardiac tamponade is a life-threatening condition requiring pericardial drainage to restore hemodynamic balance. We describe a case of tamponade as the presenting manifestation of granulomatosis with polyangiitis (GPA). CASE PRESENTATION: A 58 year-old farmer acutely developed chest pain and dyspnea. He was tachycardic, tachypneic and diaphoretic. He described a productive cough, recurrent sinusitis, malaise, polyarthralgias, night sweats and a 50 pound weight loss. On examination he appeared ill. Jugular venous pulsations were elevated, heart tones were distant and trace pretibial pitting edema was present. Labs demonstrated leukocytosis, anemia, thrombocytosis and normal renal function. Troponin-T was negative. Electrocardiogram revealed sinus tachycardia. Computed tomography ruled out pulmonary embolism but showed a pericardial effusion [image 1] with pericardial enhancement. Irregular nodules were noted in the right lung [image 2], as well as a left pleural effusion and mediastinal lymphadenopathy. Echocardiogram revealed right ventricular and atrial collapse and respirophasic flow reversal in the inferior vena cava, consistent with tamponade. Pericardiocentesis yielded 500 mL of sero-sanguineous fluid. Further studies revealed microscopic hematuria, erythrocyte sedimentation rate of 130 mm/hr, C-reactive protein of 203 mg/L, cytoplasmic anti-neutrophil cytoplasmic antibodies (c-ANCA) titer of 1:256 and markedly elevated proteinase (PR-3). Pericardial cytology and cultures were negative. Treatment for GPA was initiated with prednisone and cyclophosphamide, in addition to colchicine and indomethacin. Four months after diagnosis he is in remission. DISCUSSION: The reported frequency of cardiac involvement with GPA ranges from 6-44% (1); the largest GPA case series found a 10% overall incidence of pericarditis (2). To our knowledge this is the first description of tamponade leading to the diagnosis of GPA, though four cases of tamponade in the setting of established GPA have been previously described. This patient was successfully treated with pericardiocentesis and immunosuppression. CONCLUSIONS: Pericarditis is not uncommon in GPA and can rarely result in tamponade. Reference #1: Grant et al. Wegener's granulomatosis and the heart. Br Heart J. 1994 Jan;71(1):82-6. Reference #2: Hoffman et al. Wegener granulomatosis: an analysis of 158 patients. Ann Intern Med. 1992 Mar 15;116(6):488-98. Reference #3: Schiavone et al. Unusual cardiac complications of Wegener's granulomatosis. Chest. 1985 Nov;88(5):745-8. DISCLOSURE: The following authors have nothing to disclose: Erin Sullivan, Rodrigo Cartin-Ceba, Fabien Maldonado No Product/Research Disclosure Information

Cardiac Perforation and Lead Dislodgement after Implantation of a MR‐Conditional Pacing Lead: A Single‐Center Experience

The purpose of our study was to determine if the rate of lead-related complications was increased with the Medtronic CapSureFix MRI™ SureScan™ 5086 MRI pacing lead (5086; Medtronic Inc., Minneapolis, MN, USA) compared to the previous generation of Medtronic CapSureFix Novus™ 5076 pacing lead (5076). The 5086 lead is a newly introduced active-fixation pacemaker lead designed to be used conditionally in a magnetic resonance (MR) scanner. This lead has specific design changes compared to the previous generation of 5076 pacing leads. This study was a retrospective case control study of 65 consecutive patients implanted with two 5086 leads compared to 92 consecutive control patients implanted with two 5076 leads over a 14-month period at a high-volume tertiary care hospital. Pericarditis, pericardial effusion, cardiac tamponade, or death within 30 days of implant were seen in eight patients from the 5086 cohort and two from the 5076 cohort (odds ratio 6.3, 95% confidence interval 1.3-30.8, P = 0.02). Lead dislodgement occurred in four of the 5086 patients and in none of the 5076 patients (P < 0.03). In a high-volume center, the incidence of pericarditis, cardiac perforation, tamponade, death, and lead dislodgement was significantly higher with the MR-conditional Medtronic 5086 lead when compared to the previous generation Medtronic 5076 lead.

Myopericarditis and Pericarditis in the Deployed Military Member: A Retrospective Series

In this study, we investigated the incidence and etiology of pericarditis and myopericarditis of military members deployed to Iraq and Kuwait from 2004 through 2008. The importance of acute pericarditis and myopericarditis in the deployed military service member has resurfaced with the reintroduction of the smallpox vaccination by the U.S. Department of Defense in 2002. There are limited epidemiologic data on acute pericarditis and myopericarditis in the general population. As a primary evacuation node for cardiology patients between 2004 and 2008, the United States Military Hospital Kuwait cardiology clinic was uniquely situated to reliably extrapolate epidemiologic data for U.S. Armed Service Members serving in the Middle East. Between these years, approximately 721,600 service members served in Kuwait and Iraq. A total of 70 cases of pericarditis and 9 cases of myopericarditis were diagnosed. This yields an estimated incidence of 7.4 and 0.95 cases per 100,000 per year for pericarditis and myopericarditis, respectively. A total of eleven patients had received the smallpox vaccine 4 to 30 days before being diagnosed with pericarditis or myopericarditis. Four of the eleven patients (36.3%) had pericarditis, with a mean duration of 28.3 days since vaccination. Seven of these eleven (63.6%) patients had myopericarditis, with a mean duration of 13.7 days since smallpox vaccination. The incidence of pericarditis and myopericarditis was lower than previously reported incidence rates in the population. In all cases of myopericarditis and pericarditis, smallpox vaccination was preferentially related to myopericarditis versus pericarditis.

Fraction Size and Dose Parameters Related to the Incidence of Pericardial Effusions

Purpose: The influence of treatment parameters, such as (a) fraction size and (b) average and maximum dose (as derived from three-dimensional (3D) distributions), on the incidence of pericarditis was analyzed. To understand and predict the dose and volume effect on the pericardium, a normal tissue-complication probability model was tested with these complication data. Methods and Materials: Patients ( n = 57) entered in 3 consecutive University of Michigan protocols of combined modality for treatment of localized esophageal carcinoma, and having 3D treatment planning for radiation therapy were the subject of this study. Univariate and multivariate analyses were performed to determine the significance of the effect of fraction size and dose parameters on the development of any grade of pericarditis. Dose distributions were corrected for the biological effect of fraction size using the linear-quadratic method. Normal tissue complication probability (NTCP) was calculated with the Lyman model. Results: Nonmalignant pericardial effusions occurred in 5 of the 57 patients; all effusions were in patients who received treatment with 3.5 Gy daily fractions. On multivariate analysis, no dose factor except fraction size predicted pericarditis, until the dose distributions were corrected for the effect of fraction size (“bio”-dose). Then, both “bio-average” and “bio-maximum” dose were significant predictive factors ( p = 0.014). NTCPs for the patients with pericarditis range from 62% to 99% for the calculations with the “bio”-dose distributions vs. 0.5% to 27% for the uncorrected distributions. Discussion: A normal tissue complication probability (NTCP) model predicts a trend towards a high incidence of radiation pericarditis for patients who have high complication probabilities. It is important to correct the dose distribution for the effects of fractionation, particularly when the fraction size deviates greatly from standard (2.0 Gy) fractionation.

Experimental studies on the pathogenesis of damage in the heart.

Radiation-induced heart disease has been observed in a significant number of patients following mediastinal radiotherapy of Hodgkin’s disease or postoperative radiotherapy of breast cancer. Following higher radiation doses and especially following treatments delivering a particularly high dose to the anterior pericardium, a reversible exudative pericarditis can occur within the first 2–3 years (Pierce et al. 1969; Byhardt et al. 1975; Gottdiener et al. 1983; Greenwood et al. 1974; Applefeld and Wiernik 1983). A compilation of clinical data has shown that the incidence of pericarditis rises sharply with radiation dose to the anterior pericardium (Schultz-Hector 1991a). Since modern radiation techniques achieve a more homogeneous dose distribution, pericarditis has become a rare event and is no longer a major clinical concern (Carmel and Kaplan 1976; Watchie et al. 1987; Morgan et al. 1985). With increasing survival times, particularly in Hodgkin patients, late radiation effects on myocardial function have been observed. In a significant number of patients, left ventricular ejection fractions were reduced at 5–25 years postirradiation (Morgan et al. 1985; Burns et al. 1983; Savage et al. 1990; Gomez et al. 1983). Although these patients were asymptomatic, one has to assume that the cardiac reserve capacity, i.e., the ability to compensate for cardiac stress of other origin, is reduced in these patients. We therefore developed an animal model to study the pathogenesis of radiation-induced myocardial dysfunction.

Factors Influencing the Severity of Escherichia coli and Avian Adenovirus Group II Infections in Chickens

Chickens from lines selectively bred for either a high (HH) or low (LL) antibody response to sheep erythrocytes were challenged intravenously with avian adenovirus group II (AA). Spleen size was determined 6 days later. In some experiments the responses of chickens to AA and Escherichia coli infections were compared. The level of corticosterone in the feed (15 mg/kg) which resulted in the lowest incidence of pericarditis in response to E. coli resulted in the greatest incidence of large spleens in response to AA infection. Incidence of enlarged spleens in response to AA infection was increased in fasted chickens and reduced in socialized LL-line chickens. Among ignored chickens harshly treated for 2 weeks before challenge, LL-line chickens had a higher incidence of enlarged spleens than HH-line chickens. Socialized HH-line chickens subjected to social stress 1 day before challenge had more severely affected spleens than socialized LL-line chickens. The HL cross was more severely affected by AA than the LH cross but was less severely affected by E. coli. Antibody responsiveness to sheep erythrocytes did not affect the severity of AA infection. Factors that increased the severity of AA infection seemed to result in a decreased severity of E. coli infection.

Symptomatic radiation-induced pericarditis in Hodgkin's disease

This is a retrospective review of 193 evaluable patients treated with radiation therapy to the mediastinum for Stages 1, II and III-A Hodgkin's disease. Eligible patients were those receiving 3000 rad or more to the mediastinum and no chemotherapy prior to the radiation. During the study period, 13 patients developed symptomatic pericarditis. The interval post treatment to the development of symptoms was six to 34 months. The incidence of pericarditis was studied as a function of: (1) the was studied as a function of: (1) thedose of radiation at a depth of 2 cm, 5 cm and the midplane of the mediastinum; (2) the ratio of anterior to posterior weighting of dose; (3) the presence or absence of intrathoracic tumor; (4) the size of the tumor when present; and (5) the fraction of the heart exposed to the radiation beam. There was a significant increase in the incidence of significant increase in the incidence of pericarditis with an increased dose of radiation at 2 cm, 5 cm and midplane depths and also with the presence of a large intrathoracic tumor. A reduction in mediastinal dose is recommended.

Imaging the inflammatory response to acute myocardial infarction in man using indium-111-labeled autologous platelets.

The feasibility of imaging the inflammatory response to acute transmural myocardial infarction in man using biologically active indium-111 (111In)-labeled autologous leukocytes was assessed in 36 patients. Indium-111 leukocytes (approximately 500 microCi) were injected i.v. 18-112 hours after the onset of chest pain. Cardiac imaging was performed 24 hours later with a mobile gamma camera. Twenty-one patients had positive images and 15 had negative images. The percent of positive images increased as the interval between infarction and 111In-leukocyte injection shortened; all patients injected within 24 hours of infarction had positive images. Patients with positive images were injected with 111In leukocytes earlier after infarction (mean +/- SEM, 43 +/- 4 vs 63 +/- 7 hours; p less than 0.05) and were younger (53 +/- 2 vs 65 +/- 3 years; p less than 0.05) than those with negative images. Several other parameters that could possibly have affected the imaging results were examined and were not significantly different in patients with positive and negative images. These included peak serum creatine kinase, location of infarction, incidence of pericarditis, use of antiinflammatory drugs (aspirin and indomethacin) or membrane-active antiarrhythmic drugs (lidocaine and procainamide), peripheral leukocyte count and cell labeling efficiency. The function of the labeled cell was similar in patients with positive and negative images. Six patients with acute infarction serving as controls and given free 111In oxine and six patients with stable coronary artery disease given 111In leukocytes all had negative cardiac images.

Procainamide-induced lupus erythematosus pericarditis encountered during coronary bypass surgery

Procainamide is probably the most common offending drug responsible for the drug-induced lupus erythematosus syndrome today. Pericarditis has been reported to occur in from 14 to 18 per cent of the cases of procainamide-induced lupus erythematosus, and occasional reports of massive pericardial effusion, pericardial tamponade and constrictive pericarditis have appeared in the literature. We describe a patient who presented with features of procainamide induced lupus erythematosus without any clinical evidence of pericarditis. He underwent coronary bypass surgery 12 days after administration of the drug was stopped and was found to have a significant pericardial effusion at the time of surgery; histologic examination of pericardial tissue and pericardial fluid confirmed that the pericardial effusion was related to the procainamide-induced lupus syndrome. The incidence of pericarditis in procainamideinduced lupus erythematosus may be higher than presently accepted figures would indicate. Symptoms and signs related to procainamide-induced lupus pericarditis may cause diagnostic confusion with common postoperative bypass complications; the full implications of this disease entity to the patient undergoing coronary bypass are unknown.

Treatment of Uremic Pericarditis

To the Editor.— The use of polyethylene catheter in pericardial drainage 1 also found application in the treatment of uremic pericarditis in the early part of this decade, 2-4 when it was also used to inject steroids and was left in place up to 26 days. Buselmeier et al 5 have published numerous articles from 1973 through the present (240:1358, 1978) reporting their experience with this technique. Although the incidence of pericarditis occurring in the well-dialyzed patient during three months seems to be on the decline, this technique seems to have helped reduce, if not make unnecessary, subjecting these patients to pericardiectomies. Two items regarding the report of Buselmeier et al require comment. None of our patients required pericardiectomies, whether or not indomethacin 6 was used. During the past four years, only one patient in my care required a pericardiocentesis, which yielded about 800 mL of serosanguineous fluid. The occurrence

RADIATION-INDUCED HEART DISEASE: Clinical and Experimental Aspects

The heart traditionally was considered to be radioresistant; however, careful analysis of a large number of patients treated at Stanford Medical Center has revealed examples of radiation-induced heart disease. In Hodgkin's disease, the incidence was 6.6 per cent and in breast carcinoma 4.5 per cent. The pathology of radiation-induced heart disease is distinctive but by no means specific. The hallmark of the late lesions in the pericardium and myocardium is fibrosis. On clinical grounds, we have attempted to classify syndromes, realizing that there is considerable overlap in the course of many patients. Particularly, either of the late pericardial syndromes, acute pericarditis or chronic pericardial effusion, may progress to cardiac tamponade or constriction. It is of utmost importance to remain alert to the occurrence of radiation-induced pericardial disease because it is often satisfactorily treatable. The signs and symptoms accompanying radiation pericarditis often are similar to those produced by advancing neoplasm within the thorax, but careful clinical study will reveal the correct diagnosis in the majority of cases. Our policy of treatment has been conservative because in approximately half the patients we have seen pericarditis has cleared spontaneously. Pericardiocentesis may be urgently indicated in the presence of tamponade, and several patients have been cured by pericardiectomy. The occurrence of late radiation pericarditis is related to the dose of radiation, its fractionation, and also to the volume of heart irradiated. When large volumes of the heart must be treated, pericardial tolerance is approximately 1500 rets fractionated radiation. If only a small volume is included, pericardial tolerance is approximately 1850 rets. Pancarditis, the most severe form of radiation-induced heart disease, will be rare if these tolerance limits are not exceeded. In planning radiation therapy, as much of the cardiac silhouette as possible should be excluded by careful treatment planning and port shielding. Although the incidence of pericarditis is related to dose, one must guard against a systematic policy of reduced dosage insufficient to control the neoplasm. Our animal studies have added helpful information concerning the nature of radiation-induced heart disease and have shown that pericarditis is a dose-related phenomenon which does not depend on underlying malignancy for its production. The sharp rise in incidence with increasing dose is similar to that observed in humans. Therefore, the concept of pericardial tolerance developed from the clinical data appears validated in the animal model. Our experiments revealed that the pathogenesis of the myocardial fibrosis is related to capillary endothelial cell injury, leading to a quantitative loss of capillaries, failure of the microcirculation, and ischemia.