28 Constrictive pericarditis Constrictive pericardial physiology may exist among those with significant pericardial inflammation and edema, resulting in pericardial constraint. Fibrotic constrictive pericarditis is thought to be an infrequent complication of recurrent inflammatory pericarditis. As a result, constrictive pericardial physiology should prompt further evaluation looking for pericardial inflammation, which may be responsive to anti-inflammatory therapy. Although inflammatory markers may have normalized, CMR provides an invaluable tool in the assessment of pericardial inflammation as a potential cause for constrictive pericardial physiology. Careful attention should be paid to the presence of T2 weighted edema sequence hyperenhancement and significant delayed gadolinium enhancement. Where pericardial inflammation is present, an initial trial of anti-inflammatory therapy, including either NSAIDs or corticosteroid or IL-1 receptor blockade, is warranted to determine if therapy results in resolution of constrictive pericardial physiology. In those patients, refractory to medical therapy, surgical pericardiectomy should be considered. Pericarditis and COVID-19 vaccination There have been rare reports of myocarditis and pericarditis triggered by vaccination against SARS-CoV-2 with messenger RNA (mRNA)-based vaccines and the Novavax protein-subunit vaccine.89 Most cases appear to affect boys and young men (age <40 years) within 7 days of dosing and typically occur after the second dose.90 However, a history of pericarditis or myocarditis due to a vaccine unrelated cause does not appear to be associated with an increased risk of this complication. Therefore patients with a history of previous vaccine unrelated pericarditis should be vaccinated as normal, provided they are currently in remission.89 An episode of pericarditis or myocarditis occurring >3 weeks after vaccination is unlikely to be related. Although most cases of vaccine-associated myocarditis and pericarditis occur within 7 days of exposure, the CDC advises that any case occurring within 3 weeks should be considered as potentially associated as a precaution.89 Where it is suspected a case is vaccinerelated, current advice is to avoid further dosing. If further dosing is considered, e.g., where it is unclear whether an episode is vaccine-associated, or where the individual is at significantly increased risk of SARS-CoV2-infection and complications or will be immunosuppressed heightening such risks, further dosing should only take place after complete resolution of symptoms and signs pericarditis/ myocardial inflammation, and only after a careful individualized risk assessment.89 Where a case of pericarditis is thought to be due to SARS-CoV2 infection itself, vaccination should only be considered after full recovery and should be deferred for 90 days post-symptom onset or testing positive based on: • Low likelihood of reinfection within the 90-day window. • Likely better immune response to the vaccine with increased interval between infection and vaccination.89 As this is an area of evolving evidence, all practitioners should consult the CDC website for the latest guidance and advice for all scenarios.
RkJQdWJsaXNoZXIy MjI2NjI=