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Primary cardiac tumors are rare. The cardiac sarcomas are the most common malignant cardiac tumors. These tumors have a dismal prognosis with an overall median survival of 25 months. Clinical features include dyspnea, arrhythmias, pericardial effusions, heart failure, and sudden cardiac death. The diagnosis is often challenging. Therefore, the cardiac imaging workup plays a central role in addition to a high clinical suspicion in the setting of atypical presentations that do not respond to standard therapies. The echocardiography, computed tomography, and cardiac MRI are crucial in clinching the diagnosis. Multimodal treatment with surgery, chemotherapy, and radiotherapy has been shown to improve outcomes, as opposed to using either of these modalities alone. We describe the case of a 30-year-old gentleman with COVID-19 infection who developed recurrent hemorrhagic pericardial effusions refractory to standard treatment and was eventually diagnosed as a case of pericardial angiosarcoma after his biopsy revealed the diagnosis and staging was performed using PET-CT-FDG scan. Our case re-emphasizes the importance of considering a malignant etiology early in the course of the disease presentation, especially in recurrent hemorrhagic effusions despite an inflammatory cytologic diagnosis of fluid. It also highlights the place for cardiac CT and MRI to ascertain the location and spread and to plan the further course of treatment. If diagnosed early, the estimated survival time can be prolonged by instituting a multimodal approach.

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Background Pericardial diseases manifest in various clinical forms, including acute pericarditis, constrictive pericarditis, pericardial effusion, and cardiac tamponade, with acute pericarditis being the most prevalent. These conditions significantly contribute to mortality rates. Therefore, this article aimed to analyze mortality trends in the Brazilian population based on age and sex, shedding light on the impact of pericardial diseases on public health outcomes. Methods  This is a retrospective time-series analysis of pericardial disease mortality rates in Brazil (2000-2022). Data was obtained from the Department of Informatics of the Unified Health System (DATASUS), and the 10th edition of the International Classification of Diseases (ICD-10) codes: I30, I31, and I32 were included for analysis. We gathered population and demographic data categorized by age range and sex from the Brazilian Institute of Geography and Statistics (IBGE). Subsequently, we computed the age-standardized mortality rate per 100,000 individuals and assessed the annual percentage changes (APCs) and average annual percentage changes (AAPCs) using joinpoint regression, along with their corresponding 95% confidence intervals (CIs). Results  In terms of mortality trends based on sex, overall mortality rates remained stable for males and combined sexes over the study period. However, there was a notable increase in mortality rates among females (AAPC=1.18), particularly between 2020 and 2022, with a significant APC of 27.55. Analyzing pericardial diseases across different age groups (20 to 80 years and above), it wasobserved that mortality rates significantly increased in the 70-79 and 80 years and above age groups throughout the study period (AAPC=1.0339 and AAPC=3.4587, respectively). These two age groups experienced the highest significant rise in mortality between 2020 and 2022. Other age groups did not exhibit a significant change in AAPC. Conclusions  This comprehensive analysis spanning two decades (2000-2022), examined the mortality trends of pericardial diseases in Brazil and revealed relative stability overall. Males exhibited an overall higher mortality number due to pericardial diseases; however, females showed the most significant increase in mortality trend throughout the whole period. In the first segment (2000-2015), mortality rose across all cohorts, which was attributed to substandard healthcare facilities and infectious diseases like tuberculosis. The second segment (2016-2020) saw a decline in mortality, likely due to improved healthcare, particularly the increased availability of echocardiograms. However, the third segment (2020-2022) witnessed a sharp rise in mortality, coinciding with the COVID-19 pandemic, with post-COVID-19 symptoms, particularly pericarditis. Pericarditis-related death rates declined compared to pericardial effusion, and mortality rates correlated directly with age, with older cohorts experiencing higher mortality due to increased comorbidities, and decline in health and immunocompetency.

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Resumo Fundamento: A triagem do câncer é absolutamente necessária em pacientes com derrame pericárdico, pois o câncer é uma das doenças mais graves em sua etiologia. Estudos anteriores indicaram que o índice de inflamação imunológica sistêmica (IIS), o índice prognóstico nutricional (PNI) e o escore de hemoglobina, albumina, linfócitos e plaquetas (HALP) podem ser escores relacionados ao câncer. Objetivos: Este estudo foi iniciado considerando que esses sistemas de pontuação poderiam prever o câncer na etiologia de pacientes com derrame pericárdico. Métodos: Os pacientes submetidos à pericardiocentese entre 2006 e 2022 foram analisados retrospectivamente. A pericardiocentese foi realizada em um total de 283 pacientes com derrame pericárdico ou tamponamento cardíaco de moderado a grande no período especificado. Os índices de HALP, PNI e IIS foram calculados do sangue venoso periférico retirado antes do procedimento de pericardiocentese. O nível de significância estatística foi aceito em p<0,05. Resultados: O escore HALP foi de 0,173 (0,125-0,175) em pacientes com câncer. Detectou-se que em pacientes não oncológicos o escore foi de 0,32 (0,20-0,49; p<0,001). O escore de PNI foi de 33,1±5,6 em pacientes com câncer. Detectou-se que em pacientes não oncológicos o escore foi 39,8±4,8 (p<0,001). Conclusão: Os escores HALP e PNI são testes de triagem de câncer fáceis e rápidos que podem prever metástases de câncer na etiologia de pacientes com derrame pericárdico.

Abstract Background: Cancer screening is absolutely necessary in patients with pericardial effusion, given that cancer is one of the most serious diseases in the etiology of pericardial effusion. In previous studies, it was stated that the systemic immune-inflammation index (SII); the prognostic nutrition index (PNI); and the hemoglobin, albumin, lymphocyte, platelet (HALP) score can produce scores related to cancer. Objectives: This study began considering that these scoring systems could predict cancer in the etiology of patients with pericardial effusion. Methods: This study produced a retrospective analysis of patients who underwent pericardiocentesis between 2006 and 2022. Pericardiocentesis was performed in a total of 283 patients with moderate-to-large pericardial effusion or pericardial tamponade within the specified period. HALP, PNI, and SII scores were calculated according to the peripheral venous blood taken before the pericardiocentesis procedure. The statistical significance level was set at p<0.05. Results: The HALP score proved to be 0.173 (0.125-0.175) in cancer patients and 0.32 (0.20-0.49) in non-cancer patients (p<0.001). The PNI score proved to be 33.1±5.6 in cancer patients and 39.8±4.8 in non-cancer patients (p<0.001). Conclusion: The HALP score and PNI proved to be easy and fast cancer screening tests that can predict cancer metastasis in the etiology of patients with pericardial effusion.

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Abstract Primary cardiac tumors are rare. The cardiac sarcomas are the most common malignant cardiac tumors. These tumors have a dismal prognosis with an overall median survival of 25 months. Clinical features include dyspnea, arrhythmias, pericardial effusions, heart failure, and sudden cardiac death. The diagnosis is often challenging. Therefore, the cardiac imaging workup plays a central role in addition to a high clinical suspicion in the setting of atypical presentations that do not respond to standard therapies. The echocardiography, computed tomography, and cardiac MRI are crucial in clinching the diagnosis. Multimodal treatment with surgery, chemotherapy, and radiotherapy has been shown to improve outcomes, as opposed to using either of these modalities alone. We describe the case of a 30-year-old gentleman with COVID-19 infection who developed recurrent hemorrhagic pericardial effusions refractory to standard treatment and was eventually diagnosed as a case of pericardial angiosarcoma after his biopsy revealed the diagnosis and staging was performed using PET-CT-FDG scan. Our case re-emphasizes the importance of considering a malignant etiology early in the course of the disease presentation, especially in recurrent hemorrhagic effusions despite an inflammatory cytologic diagnosis of fluid. It also highlights the place for cardiac CT and MRI to ascertain the location and spread and to plan the further course of treatment. If diagnosed early, the estimated survival time can be prolonged by instituting a multimodal approach.

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INTRODUCTION: Pericardial effusion is a common complication without a standard postoperative effusion treatment after cardiac surgery. The grooved negative pressure drainage tube has many advantages as the emerging alternative for drainage of pericardial effusion, such as it changes the structure of the traditional side hole, uses the capillary function to ensure drainage smooth, etc. The purpose of this study was to assess the feasibility and effectiveness of transthoracic color Doppler ultrasound-guided grooved negative pressure drainage tube implantation in pericardial effusion after cardiac surgery. METHODS: All patients with pericardial effusion after cardiac surgery who underwent transthoracic color Doppler ultrasound-guided grooved negative pressure drainage tube implantation between January 2019 and December 2021 were retrospectively analyzed. Treatment results (including clinical symptoms, effusion volume, color Doppler ultrasonography, and computed tomography scan) were investigated to evaluate the effectiveness and safety of this method. RESULTS: A total of 20 patients successfully underwent transthoracic color Doppler ultrasound-guided grooved negative pressure drainage tube implantation. After the operation, their symptoms (chest tightness, shortness of breath, etc.) were all relieved, and dark red or light red drainage fluid (> 200 ml) appeared in the newly placed drainage bottle. Color Doppler ultrasonography showed that the volume of pericardial effusion decreased significantly. CONCLUSION: The transthoracic color Doppler ultrasound-guided grooved negative pressure drainage tube is a safe and effective method for the treatment of postoperative pericardial effusion with less trauma, faster recovery, shorter in-hospital stay, and fewer complications.

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Recurrent pericardial effusion is commonly encountered in neoplastic and infective disorders. Intervention is compulsory in patients with unstable hemodynamics and tamponading effusion. Surgical options include: pericardiocentesis, subxiphoid pericardiostomy, and pericardial window. The latter has proved to have lower incidence of recurrence; however, the technique has been continuously refined to improve the recurrence-free survival and decrease postoperative morbidity. We herein present a novel simple modification to minimize recurrence by anchoring the free edges of pericardial fenestration overlying the superior vena cava and right atrium to the chest wall. Follow-up showed no recurrence compared to 3.5% in the conventional procedure.

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ABSTRACT Introduction: Pericardial effusion is a common complication without a standard postoperative effusion treatment after cardiac surgery. The grooved negative pressure drainage tube has many advantages as the emerging alternative for drainage of pericardial effusion, such as it changes the structure of the traditional side hole, uses the capillary function to ensure drainage smooth, etc. The purpose of this study was to assess the feasibility and effectiveness of transthoracic color Doppler ultrasound-guided grooved negative pressure drainage tube implantation in pericardial effusion after cardiac surgery. Methods: All patients with pericardial effusion after cardiac surgery who underwent transthoracic color Doppler ultrasound-guided grooved negative pressure drainage tube implantation between January 2019 and December 2021 were retrospectively analyzed. Treatment results (including clinical symptoms, effusion volume, color Doppler ultrasonography, and computed tomography scan) were investigated to evaluate the effectiveness and safety of this method. Results: A total of 20 patients successfully underwent transthoracic color Doppler ultrasound-guided grooved negative pressure drainage tube implantation. After the operation, their symptoms (chest tightness, shortness of breath, etc.) were all relieved, and dark red or light red drainage fluid (> 200 ml) appeared in the newly placed drainage bottle. Color Doppler ultrasonography showed that the volume of pericardial effusion decreased significantly. Conclusion: The transthoracic color Doppler ultrasound-guided grooved negative pressure drainage tube is a safe and effective method for the treatment of postoperative pericardial effusion with less trauma, faster recovery, shorter in-hospital stay, and fewer complications.

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Resumo Fundamento A janela pericárdica, além de promover a drenagem pericárdica, também pode fornecer amostras do pericárdio para exame anatomopatológico. No entanto, a contribuição dessas biópsias para a elucidação da etiologia do derrame pericárdico tem sido debatida. Objetivo Analisar o valor diagnóstico da biópsia pericárdica não guiada obtida de procedimentos de janela pericárdica. Métodos Foram revisados retrospectivamente dados de 80 pacientes submetidos a biópsia pericárdica parietal de 2011 a 2020. A significância estatística foi considerada quando p < 0,05. Resultados Cinquenta pacientes eram do sexo masculino (62,5%) e 30 do sexo feminino (37,5%). A mediana de idade foi de 52 anos (intervalo interquartil: 29 a 59) e 49 anos (intervalo interquartil: 38 a 65), respectivamente (p = 0,724). A etiologia suspeita do derrame pericárdico foi neoplásica em 31,3%, incerta em 25%, tuberculose em 15%, autoimune em 12,5%, síndrome edemigênica em 7,5% e outras condições diversas em 8,8%. A abordagem mais frequente para drenagem pericárdica e biópsia foi a subxifoide (74%), seguida pela videotoracoscopia (22%). Em 78,8% das biópsias, os achados histopatológicos foram compatíveis com inflamação inespecífica, e apenas 13,7% de todas as biópsias produziram um diagnóstico histopatológico conclusivo. Aqueles que sofriam de câncer e derrame pericárdico apresentaram maior proporção de achados histopatológicos conclusivos (32% apresentavam infiltração neoplásica pericárdica). A taxa de mortalidade hospitalar foi de 27,5% e 54,5% dos pacientes que morreram no hospital tinham câncer. Nenhuma morte foi atribuída ao tamponamento cardíaco ou ao procedimento de drenagem. Conclusão Nossos resultados mostraram que a janela pericárdica é um procedimento seguro, mas teve pouco valor para esclarecer a etiologia do derrame pericárdico e nenhum impacto na terapia planejada para o diagnóstico primário além da descompressão cardíaca.

Abstract Background Pericardial window, in addition to promoting pericardial drainage, can also provide samples of the pericardium for anatomopathological examination. However, such biopsies' contribution to clarifying the etiology of pericardial effusion has been debated. Objective To analyze the diagnostic value of non-targeted pericardial biopsy obtained from pericardial window procedures. Methods Data from 80 patients who had undergone parietal pericardial biopsies from 2011 to 2020 were retrospectively reviewed. Statistical significance was considered if p < 0.05. Results Fifty patients were male (62.5%,) and 30 were female (37.5%). The median age was 52 years (interquartile range: 29 to 59) and 49 years (interquartile range: 38 to 65), respectively (p = 0.724). The suspected etiology of pericardial effusion was neoplastic in 31.3%, unclear in 25%, tuberculosis in 15%, autoimmune in 12.5%, edemagenic syndrome in 7.5%, and other miscellaneous conditions in 8.8%. The most frequent approach for pericardial drainage and biopsy was subxiphoid (74%), followed by video-assisted thoracoscopy (22%). Overall, in 78.8% of the biopsies, the histopathologic findings were compatible with nonspecific inflammation, and only 13.7% of all biopsies yielded a conclusive histopathological diagnostic. Those suffering from cancer and pericardial effusion had a higher proportion of conclusive histopathologic findings (32% had pericardial neoplastic infiltration). The hospital mortality rate was 27.5%, and 54.5% of the patients who died in the hospital had cancer. No deaths were attributed to cardiac tamponade or the drainage procedure. Conclusion Our results showed that pericardial window is a safe procedure, but it had little value to clarify the pericardial effusion etiology and no impact on the planned therapy for the primary diagnosis besides the cardiac decompression.