Diagnostic utility of CYFRA 21-1 and CEA assays in pericardial fluid for the recognition of neoplastic pericarditis

A positive cytology result in pericardial fluid is the gold standard for recognition of malignant pericardial effusion. Unfortunately, in 30-50% of patients with malignant pericardial effusion cytological examination of the pericardial fluid is negative. Tumor marker assessment in pericardial fluid may help to recognize malignant pericardial effusion. The aim of our study was to estimate the value of CYFRA 21-1 and CEA measurement in pericardial fluid for the recognition of malignant pericardial effusion. To our knowledge this is the first study on CYFRA 21-1 assessment in pericardial effusion. The examined group consisted of 50 patients with malignant pericardial effusion and 34 patients with non-malignant pericardial effusion. Median CEA concentrations in malignant pericardial effusion and non-malignant pericardial effusion were 80 ng/mL (0-317) and 0.5 ng/mL (0-18.4), respectively (p<0.001). Median CYFRA 21-1 concentrations in malignant pericardial effusion and non-malignant pericardial effusion were 260 ng/mL (5.3-10080) and 22.4 ng/mL (1.87-317.6), respectively (p<0.001). The optimal cutoff value for CYFRA 21-1 in pericardial effusion was 100 ng/mL. CYFRA 21-1 >100 ng/mL or CEA >5 ng/mL were found in 14/15 patients with malignant pericardial effusion and negative pericardial fluid cytology. We therefore strongly recommend the use of CYFRA 21-1 and/or CEA in addition to pericardial fluid cytology for the recognition of malignant pericardial effusion.     

Animal model of acute pericarditis and its progression to pericardial fibrosis and adhesions: ultrastructural studies

To study the evolution of pericardial inflammation, we have developed a model of pericarditis in sheep by surgically injecting heat-killed staphylococci and Freund's adjuvant into the pericardial cavity under sterile conditions. The pericarditis evolved through the following phases: 1) inflammatory response, 2) mesothelial cell injury and desquamation, and 3) fibrotic phase. At 3-24 hr there was increased microvascular permeability, which resulted in the exudation of fluid, neutrophils, macrophages, and fibrin into the pericardial cavity and the pericardial interstitium. By 72 hr, large numbers of inflammatory cells were aggregated on the mesothelial surfaces and dispersed throughout the pericardial cavity, either as free-floating cells or located between strands of fibrin. At 6 days, fibrinolysis was apparent along the mesothelial surfaces; and newly formed collagen fibrils were deposited throughout the interstitial spaces and among the aggregated cells. These fibrils provided a matrix for the growth of new blood and lymphatic vessels into new connective tissue on both parietal and visceral pericardial surfaces. At 2 weeks, intrapericardial fibrosis had produced focal adhesions between the pericardial surfaces. At 1 month, extensive areas of the pericardial cavity were obliterated. By 9 months, there was a marked reduction in the numbers of cells and blood vessels and increased deposition of collagen and elastic fibers. The intrapericardial injection of heat-killed staphylococci and adjuvant provides a reproducible animal model to study the time course of pericardial inflammation.     

Surgical properties and survival of a pericardial window via left minithoracotomy for benign and malignant pericardial tamponade in cancer patients

ABSTRACT: BACKGROUND: Surgical drainage is a rapid and effective treatment for pericardial tamponade in cancer patients. We aimed to investigate the effectiveness of pericardial window formation via minithoracotomy for treating pericardial tamponade in cancer patients, and to evaluate clinical factors affecting long-term survival. METHODS: Records of 53 cancer patients with pericardial tamponade treated by pericardial window formation between 2002 and 2008 were examined. Five patients were excluded due to insufficient data. Kaplan-Meier and Cox regression analysis were used for analysis. RESULTS: Forty-eight patients (64.7% male), with a mean age of 55.20 +/- 12.97 years were included. Patients were followed up until the last control visit or death. There was no surgery-related mortality and the 30-day mortality rate was 8.33%; all died during postoperative hospitalization. Morbidity rate was 18.75%. Symptomatic recurrence rate was 2.08%. Cancer type and nature of the pericardial effusion were the major factors determining long-term survival (P <0.001 and P <0.004, respectively). Overall median survival was 10.41 +/- 1.79 months. One- and 2-year survival rates were 45 +/- 7% and 18 +/- 5%, respectively. CONCLUSION: Pericardial window creation via minithoracotomy was proven to be a safe and effective approach in surgical treatment of pericardial tamponade in cancer patients. Cancer type and nature of pericardial effusion were the main factors affecting long-term survival.     

Lysozyme in the pericardial complex of Manduca sexta

The pericardial cell-heart complex (pericardial complex) of fifth instar Manduca sexta larvae has been shown to contain, to synthesize and to release lysozyme. Lysozyme activity was present in homogenates of pericardial complex. Immunocytochemical analysis demonstrated that lysozyme in the pericardial complex was located in pericardial cells. Injection of peptidoglycan elicitors, which markedly increase levels of hemolymph lysozyme, also elevated lysozyme activity in homogenates of pericardial complex, but only moderately. Lysozyme synthesis in the pericardial complex was demonstrated in vitro by the incorporation of [³H]leucine into immunoprecipitable lysozyme. This tissue did exhibit an increase in the release of a variety of newly synthesized proteins but not a selective increase in the synthesis and release of lysozyme after peptidoglycan stimulation.In similar experiments, cultured fat body from naive larvae incorporated [³H]leucine into secreted, immunoprecipitable lysozyme at a rate 100-fold greater than that observed for pericardial complex and exhibited a selective increase in lysozyme synthesis and release to 6.5 times its basal level when stimulated with peptidoglycan.We conclude that, of these two tissues, fat body is the primary source of hemolymph lysozyme. On the other hand, pericardial cell lysozyme may function in the intracellular, lysosomal degradation of pinocytosed fragments of bacterial invaders.     

Podocytes in bivalve molluscs: Morphological evidence for ultrafiltration

Summary In representatives from a survey of three major taxa of bivalves the pericardial glands were found in two distinct positions. In protobranches (Acila castrensis) and filibranch bivalves (Glycymeris subobsoleta, Chlamys hastata, Pecten caurinus, Placopecten magellanicus, Mytilus edulis andMytilus californianus) the pericardial glands are located on the auricular surface. In heterodonts (Mercenaria mercenaria, Clinocardium nuttallii andMya arenaria) the pericardial glands are found in an anterodorsal position to the pericardial cavity.The sites of ultrafiltration are described. They consist of podocytes with basally extending pedicels forming an interdigitating network apposed to a basal lamina. Other characteristics of this ultrafiltration barrier described are anionic sites on the basal lamina and presence of substructural components within the ultrafiltration slits between pedicels.The pathway for the ultrafiltrate in protobranchs and filibranchs is from the hemocoel through the basal lamina, through the ultrafiltration slits of the pedicel network, into the urinary spaces between the podocyte cell bodies and into the pericardial cavity. The pathway for the ultrafiltrate in heterodonts is from the hemocoel through the basal lamina, through the ultrafiltration slits of the pedicel network, into urinary spaces between the podocyte cell bodies, into the lumen of the pericardial gland tubules and into the pericardial cavity.All podocyte cells have electron dense granules, Golgi apparatus and vacuoles associated with their cytoplasm. Heterodont species have microvilli on the cell surfaces of the podocytes apposed to urinary spaces.In all cases the morphological sites of ultrafiltration were associated with the pericardial glands of the heart-pericardial complex.     

A case report of a 24-year-old male with a large hemorrhagic pericardiai effusion

Although bloody pericardial effusion often suggests neoplasia,such an event is not rare in tuberculosis (TB),especially in those countries with a high TB disease burden.Meanwhile,TB accounts for 50％ and greater than 90％ of large pericardial effusions in human immunodeficiency virus (HIV)-negative and HIV-positive patients,respectively.Here we report a case of a 24-year-old HIV-negative male who presented with fever and hemorrhagic pericardial effusion.The patient was given presumptive anti-TB treatment before diagnosis was established.Eventually the patient responded well to the anti-TB treatment at the last follow-up and the diagnosis was confirmed by aspirated pericardial fluid culture on LowensteinJensen (LJ) medium.     

MRI-determined left ventricular "crescent effect": a consequence of the slight deviation of contents of the pericardial sack from the constant-volume state

During one cardiac cycle, the volume encompassed by the pericardial sack in healthy subjects remains nearly constant, with a transient +/-5% decrease in volume at end systole. This "constant-volume" attribute defines a constraint that the longitudinal versus radial pericardial contour dimension relationship must obey. Using cardiac MRI, we determined the extent to which the constant-volume attribute is valid from four-chamber slices (two-dimensional) compared with three-dimensional volumetric data. We also compared the relative percentage of longitudinal versus radial (short-axis) change in cross-sectional area (dimension) of the pericardial contour, thereby assessing the fate of the +/-5% end-systolic volume decrease. We analyzed images from 10 normal volunteers and 1 subject with congenital absence of the pericardium, obtained using a 1.5-T MR scanner. Short-axis cine loop stacks covering the entire heart were acquired, as were single four-chamber cine loops. In the short-axis and four-chamber slices, relative to midventricular end-diastolic location, end-systolic pericardial (left ventricular epicardial) displacement was observed to be radial and maximized at end systole. Longitudinal (apex to mediastinum) pericardial contour dimension change and pericardial area change on the four-chamber slice were negligible throughout the cardiac cycle. We conclude that the +/-5% end-systolic decrease in the volume encompassed by the pericardial sack is primarily accounted for by a "crescent effect" on short-axis views, manifesting as a nonisotropic radial diminution of the pericardial/epicardial contour of the left ventricle. This systolic drop in cardiac volume occurs primarily at the ventricular level and is made up during the subsequent diastole when blood crosses the pericardium in the pulmonary venous Doppler D wave during early rapid left ventricular filling.     

Pericardial and pericardioperitoneal canal relationships to cardiac function in the white sturgeon (Acipenser transmontanus)

Sturgeons are primitive bony fishes and their hearts have structural features found in other primitive fishes. Sturgeons have a pericardioperitoneal canal (PPC), a one-way conduit into the peritoneum. A PPC also occurs in elasmobranchs (sharks and rays) and studies with that group demonstrate that pericardial pressure and pericardial fluid loss via the PPC affect stroke volume. A study of white sturgeon (Acipenser transmontanus) heart function was conducted to test for a comparable PPC and pericardial effects. White sturgeon-elasmobranch heart-function similarities include biphasic ventricular filling, a comparable operational pericardial pressure (-0.03 kPa), and a strongly negative pressure (-0.2 to -0.6 kPa) with complete pericardial fluid withdrawal. Differences include the white sturgeon's relatively smaller atrium and ventricle but a larger conus arteriosus. Although white sturgeon heart size is also smaller, its pericardial volume is disproportionately less (2.4 to 2.7 vs. 3.5 to 5.4 ml kg(-1) in elasmobranchs), meaning it has less scope for increasing stroke volume upon PPC fluid release. These differences may reflect the phylogenetic progression from the less complex operation of the elasmobranch heart, which lacks sympathetic innervation and has a mechanically mediated (PPC) stroke volume, to the condition in the more derived bony fishes which have sympathetic and parasympathetic regulation of both stroke volume and heart rate.     

A case report of a 24-year-old male with a large hemorrhagic pericardial effusion

Although bloody pericardial effusion often suggests neoplasia, such an event is not rare in tuberculosis (TB), especially in those countries with a high TB disease burden. Meanwhile, TB accounts for 50% and greater than 90% of large pericardial effusions in human immunodeficiency virus (HIV)-negative and HIV-positive patients, respectively. Here we report a case of a 24-year-old HIV-negative male who presented with fever and hemorrhagic pericardial effusion. The patient was given presumptive anti-TB treatment before diagnosis was established. Eventually the patient responded well to the anti-TB treatment at the last follow-up and the diagnosis was confirmed by aspirated pericardial fluid culture on Lowenstein-Jensen (LJ) medium.     

The pericardium and cardiac transmural filling pressure in the fetal sheep

Fetal pericardial physiology may be important for understanding normal and abnormal circulatory states. Right atrial, pericardial, thoracic, and amniotic fluid pressures were measured simultaneously in chronically-instrumented, near-term fetal sheep. Fourteen experiments were performed in 8 fetuses 4-21 days after surgery. The pressure gradient from the right atrium to the amniotic fluid and its components (transatrial, transpericardial and transthoracic pressures) were measured during control and with rapid infusion and withdrawal of blood. Under control conditions, right atrial minus amniotic pressure was 3.2 +/- 1.8 (SD) torr, right atrial minus pericardial pressure 2.5 +/- 1.7, pericardial minus thoracic pressure 0.6 +/- 0.7, and thoracic minus amniotic pressure 0.1 +/- 1.4. At right atrial pressures above control, pericardial minus thoracic pressure rose linearly with right atrial minus thoracic pressure. The average regression coefficient was 0.50 with an intercept of -1.5 torr. Administration of dextran-saline solution (121% of estimated blood volume) over 2-4 hs in 10 experiments did not reduce the pericardial minus thoracic to right atrial minus thoracic pressure relationship. Fluid added to the pericardium of three lambs progressively shifted the pericardial minus thoracic to right atrial minus thoracic pressure relationship up and to the left. The pericardial minus thoracic to right atrial minus thoracic pressure relationship was unaffected by fetal growth. Thus, the fetal pericardium affects cardiac filling pressures. The affect of the pericardium is increased markedly by pericardial liquid but is unchanged during growth.     

Influence of involvement of anterior leaflet versus posterior leaflet on residual regurgitation as assessed by transesophageal echocardiography in patients undergoing valve repair for mitral regurgitation due to mitral valve prolapse

Cardiac tamponade is the phenomenon of hemodynamic compromise caused by a pericardial effusion. Following a myocardial infarction, the most common causes of pericardial fluid include early pericarditis, Dressler's syndrome, and hemopericardium secondary to a free wall rupture. On transthoracic echocardiography, pericardial fluid appears as an echo-free space in between the visceral and parietal layers of the pericardium. Pericardial fat has a similar appearance on echocardiography and it may be difficult to discern the two entities. We present a case of a post-MI patient demonstrating pseudo tamponade physiology in the setting of excessive pericardial fat.     

Pericardial fat amount is an independent risk factor of coronary artery stenosis assessed by multidetector-row computed tomography: the Korean Atherosclerosis Study 2

Pericardial fat surrounding the heart and coronary arteries might aggravate vessel wall inflammation and stimulate the progression of coronary atherosclerosis. However, there has been little comprehensive evaluation of the effects of pericardial fat on coronary artery disease (CAD). We investigated the relationship between pericardial fat volume and the severity of coronary artery stenosis assessed by computed tomography and angiography among patients with suspected CAD. Participants from the cohort of the Korean Atherosclerosis Study 2 (n = 402, mean age of 54 years, 57.0% men) underwent 64-slice multidetector-row computed tomography (MDCT) to assess pericardial fat amount, coronary artery calcium score (CACS), severity of coronary artery stenosis, and plaque characteristics. Patients with atherosclerotic lesion had significantly larger volume of pericardial fat than patients without atherosclerosis (308 ± 96 cm(3) vs. 251 ± 93 cm(3); P < 0.01). In a multivariate regression analysis adjusting for age, gender and BMI, subjects with more pericardial fat had a higher risk for significant (>50%) stenosed coronary vessels (odds ratio (OR) = 1.012; 95% confidence interval (CI) 1.001-1.030; P = 0.017). This association remained after adjusting for hypertension, diabetes, smoking status, and lipid profiles (OR = 1.007; 95% CI 1.001-1.014; P = 0.042). In conclusion, an increased pericardial fat volume was an independent risk factor for stenotic CAD and could be helpful in assessing subclinical CADs.     

Viral Communities Associated with Human Pericardial Fluids in Idiopathic Pericarditis

Pericarditis is a common human disease defined by inflammation of the pericardium. Currently, 40% to 85% of pericarditis cases have no identified etiology. Most of these cases are thought to be caused by an infection of undetected, unsuspected or unknown viruses. In this work, we used a culture- and sequence-independent approach to investigate the viral DNA communities present in human pericardial fluids. Seven viral metagenomes were generated from the pericardial fluid of patients affected by pericarditis of unknown etiology and one metagenome was generated from the pericardial fluid of a sudden infant death case. As a positive control we generated one metagenome from the pericardial fluid of a patient affected by pericarditis caused by herpesvirus type 3. Furthermore, we used as negative controls a total of 6 pericardial fluids from 6 different individuals affected by pericarditis of non-infectious origin: 5 of them were sequenced as a unique pool and the remaining one was sequenced separately. The results showed a significant presence of torque teno viruses especially in one patient, while herpesviruses and papillomaviruses were present in the positive control. Co-infections by different genotypes of the same viral type (torque teno viruses) or different viruses (herpesviruses and papillomaviruses) were observed. Sequences related to bacteriophages infecting Staphylococcus, Enterobacteria, Streptococcus, Burkholderia and Pseudomonas were also detected in three patients. This study detected torque teno viruses and papillomaviruses, for the first time, in human pericardial fluids.     

A study on the cytoplasmic granules of the pericardial gland cells of some bivalve molluscs

The pericardial glands of three bivalve molluscs are composed of convoluted epithelium that appears as pouches on the auricles of Mytilus and as tubules in the connective tissue at the anterior-lateral sides of the pericardial cavity of Mercenaria and Anodonta. The pericardial gland cells are attached to each other by many randomly placed desmosome-like cell junctions and gap junctions. Belt-desmosomes that are characteristic of epithelial cells were not observed. The basal membrane of these cells is invaginated producing complex interdigitating cytoplasmic processes and filtration slits. The pericardial gland cells stain for the presence of iron with Prussian blue stain. Electron-dense and electron-lucent granules of various diameters are present in the cytoplasm. Many electron-dense granules contain ferritin-like particles in which the presence of iron has been demonstrated by microanalysis. It is suggested that these particles are the iron storage protein ferritin since they contain iron, and are water soluble, heat stable, and morphologically similar to mammalian ferritin. Ferritin particles are probably both synthesized and broken down by the pericardial gland cells; thus the pericardial gland cells may be involved in iron homeostasis in these molluscs.     

Intrathoracic pressures and left ventricular configuration with respiratory maneuvers

In 12 dogs, we examined the correspondence between esophageal (Pes) and pericardial pressures over the anterior, lateral, and inferior left ventricular (LV) surfaces. Pleural pressure was decreased by spontaneous inspiration, Mueller maneuver, and phrenic stimulation and increased by intermittent positive pressure ventilation (IPPV) and positive end-expiratory pressure (PEEP). To separate effects due to blood flow, we analyzed beating and nonbeating hearts. In beating hearts, there were no significant differences between changes in Pes and pericardial pressures. In arrested hearts, increasing LV pressure by 8 Torr increased pericardial pressures by only 3.6 Torr. With IPPV and PEEP, increases in Pes and pericardial pressures were equal in live hearts and in low-volume arrested hearts (LV pressure = 4 Torr). In high-volume arrested hearts (LV pressure = 12 Torr), the increase in pericardial pressure over the anterior LV surface was less than Pes, whereas that over the lateral and inferior LV surfaces was the same as Pes. At high LV volume, in arrested hearts pericardial pressures decreased less than Pes during negative pressure maneuvers. In another six dogs, external LV configuration and volume were measured. In beating hearts during spontaneous inspiration, Mueller maneuver, and phrenic stimulation (endotracheal tube open), septal-lateral dimension and LV volume decreased by approximately 3% (P less than 0.05). This was also true for PEEP. In arrested hearts, septal-lateral dimension and LV volume decreased only with PEEP. We conclude that 1) the relationship between Pes and pericardial pressures is complex and depends on LV volume, local pericardial compliance, and the means by which Pes is changed, 2) changes in measured pericardial pressures did not completely explain changes in LV configuration, and 3) during different respiratory maneuvers, different forces account for the same observed changes in LV volume and configuration.     

Ventricular Tachycardia Caused by Mesothelial Cyst

A 27 year-old- lady was evaluated due to recurrent ventricular tachycardia. After performing echocardiography and cardiac MRI, she was found to have large pericardial cyst. Pathologic examination confirmed it as mesothelial pericardial cyst. Up to our knowledge it is the first presentation of simple pericardial cyst as ventricular a tachycardia.     

A novel protein that binds juvenile hormone esterase in fat body tissue and pericardial cells of the tobacco hornworm Manduca sexta L

Juvenile hormone esterase degrades juvenile hormone, which acts in conjunction with ecdysteroids to control gene expression in insects. Circulating juvenile hormone esterase is removed from insect blood by pericardial cells and degraded in lysosomes. In experiments designed to characterize proteins involved in the degradation of juvenile hormone esterase, a pericardial cell cDNA phage display library derived from the tobacco hornworm moth Manduca sexta L. was constructed and screened for proteins that bind juvenile hormone esterase. A 732-base pair cDNA encoding a novel 29-kDa protein (P29) was isolated. Western and Northern analyses indicated that P29 is present in both pericardial cell and fat body tissues and is expressed in each larval instar. In immunoprecipitation experiments, P29 bound injected recombinant juvenile hormone esterase taken up by pericardial cells and native M. sexta juvenile hormone esterase in fat body tissue, where the enzyme is synthesized. Binding assays showed that P29 bound juvenile hormone esterase more strongly than it did a mutant form of the enzyme with mutations that perturb lysosomal targeting. Based on these data, we propose that P29 functions in pericardial cells to facilitate lysosomal degradation of juvenile hormone esterase.     

Featured Article: Induction of heme oxygenase with hemin improves pericardial adipocyte morphology and function in obese Zucker rats by enhancing proteins of regeneration

Oxidative stress and inflammation are implicated in tissue remodeling, hypertrophy, and organ malfunction. Since heme-oxygenase (HO) is a cytoprotective enzyme with effects against oxidative stress and inflammation, we investigated the effects of upregulating HO with hemin on adipocyte hypertrophy, proteins of repair/regeneration including beta-catenin, Oct3/4 and Pax2 as well as pro-fibrotic/remodeling proteins like osteopontin and transforming growth factor-beta (TGF-β) in pericardial adipose tissue from obese Zucker rats (ZRs). Treatment with hemin significantly reduced pericardial adipose tissue inflammation/oxidative stress, suppressed osteopontin and TGF-β, and attenuated pericardial adipocyte hypertrophy in obese ZRs. These were associated with enhanced expression of the stem/progenitor-cell marker cKit; the potentiation of several proteins of regeneration including beta-catenin, Oct3/4, Pax2; and improved pericardial adipocyte morphology. Interestingly, the amelioration of adipocyte hypertrophy in hemin-treated animals was accompanied by improved adipocyte function, evidenced by increased levels of pericardial adipose tissue adiponectin. Furthermore, hemin significantly reduced hypertriglyceridemia and hypercholesteromia in obese ZRs. The protective effects of hemin were accompanied by robust potentiation HO activity and the total antioxidant capacity, whereas the co-administration of hemin with the HO inhibitor, stannous mesoporphyrin abolished the effects of hemin. These data suggest that hemin improves pericardial adipocyte morphology and function by enhancing proteins of repair and regeneration, while concomitantly abating inflammatory/oxidative insults and suppressing extracellular-matrix/profibrotic and remodeling proteins. The reduction of hypertriglyceridemia, hypercholesteromia, pericardial adiposity, and pericardial adipocyte hypertrophy with corresponding improvement of adipocyte morphology/function in hemin-treated animals suggests that HO inducers may be explored for the design of novel remedies against cardiac complications arising from excessive adiposity.