Post-Cardiac Injury Syndrome

Figures

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  Central Illustration. Pathophysiology of Post-Cardiac Injury Syndrome Pericardial injury leads to the release of damage- and pathogen-associated molecular patterns (DAMPs/PAMPs), activating nuclear factor kappa-light-chain enhancer of activated B cells (NF-κB signaling), which upregulates inflammatory mediators and cytokines essential for inflammasome assembly. The inflammasome then facilitates the release of IL-1β and IL-18, amplifying the inflammatory cascade. Additionally, NF-κB promotes phospholipase A2 synthesis, driving the arachidonic acid pathway and producing prostaglandins and thromboxanes. IL-1α and IL-1β, acting through the IL-1 receptor (IL-1R), further propagate pericardial inflammation, with IL-1α serving as an early alarmin and IL-1β enhancing the immune response.25,33, 34, 35 Abbreviation as in Figure 6.

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  Figure 1. PCIS Imaging Modalities Overview of the strengths of echocardiography, CCT, and CMR in PCIS evaluation and treatment. CCT = cardiac computed tomography; IVC = inferior vena cava; LGE = late gadolinium enhancement; PCIS = post-cardiac injury syndrome; T2-STIR = T2-Weighted Short-TI Inversion Recovery.

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  Figure 2. Case Presentation #1 A 50-year-old male who underwent a 4-vessel coronary artery bypass grafting which was complicated by Dressler syndrome. The upper left echo image shows a large PEff on a postoperative transthoracic echocardiogram apical 4-chamber view (red asterisk marks the PEff). The upper right echo image reveals the same TTE view with resolution of that PEff after treatment with aspirin and colchicine. The bottom image again shows the PEff on echocardiogram along with respiratory variation across the mitral valve on Doppler inflow pattern. Exp = expiration; Insp = inspiration; PEff = pericardial effusion; TTE = transthoracic echocardiogram.

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  Figure 3. Case Presentation #2 A 66-year-old female diagnosed with pericarditis post pacemaker implantation. Figure A is a short-axis slice of cardiac magnetic resonance imaging showing severe late gadolinium enhancement (arrows). Figure B is repeat imaging in the same patient 1 year later with improved inflammation after completion of treatment with NSAIDs and colchicine. NSAIDs = nonsteroidal anti-inflammatory drug.

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  Figure 4. Case Presentation #3 A 53-year-old female with a history of hypertrophic cardiomyopathy who developed recurrent pericarditis following pericardiotomy (septal myectomy). The image on the left is a short-axis slice of cardiac magnetic resonance imaging showing late gadolinium enhancement suggestive of inflammation (arrows). The image on the right is repeat imaging in the same patient 1 year later with improved enhancement after completion of treatment with NSAIDs, colchicine, and prednisone. Abbreviation as in Figure 3.

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  Figure 5. Case Presentation #4 A 66-year-old female who developed recurrent pericarditis after a coronary perforation during a percutaneous coronary intervention of her left anterior descending artery. The image on the left is a short-axis slice of cardiac magnetic resonance imaging showing late gadolinium enhancement, edema, and pericardial thickening (arrows). The image on the right is repeat imaging of the same patient 1 year later after completion of treatment with aspirin, colchicine, and prednisone noting significant improvement.

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  Figure 6. Ongoing Clinical Trials in Recurrent Pericarditis Emerging therapies for recurrent pericarditis under investigation in ongoing clinical trials. IL= interleukin.