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Diseases of the pericardium commonly manifest in one of three ways: acute pericarditis, pericardial effusion and constrictive pericarditis. In the developed world, the most common cause of acute pericarditis is viral or idiopathic disease, while in the developing world tuberculous aetiology, particularly in subSaharan Africa, is commonplace owing to the high prevalence of HIV. This article provides an approach to the diagnosis, investigation and management of these patients.

Post-pulmonary tuberculosis complications in South Africa and a potential link with pulmonary hypertension: Premise for clinical and scientific investigations To the Editor: The magnitude of the pulmonary tuberculosis (TB) epidemic in South Africa (SA) and globally [1] has received increased attention. Efforts have been made to explore new and improved diagnostic [2] and treatment strategies, [3] but the story does not end with treatment, and TB frequently results in long-term lung damage. This may include chronic airflow obstruction, reduced lung function (forced vital capacity) and destruction of the pulmonary vascular bed in cases of advanced lung disease. [4,5] This destruction of the vascular bed is attributed to parenchymal abnormalities that lead to reduced cross-sectional area of the pulmonary vasculature. [6] We highlight the fact that long-term consequences of advanced destruction of the pulmonary vasculature may occur in the absence of significant parenchymal damage, and that this is another post-TB complication that remains largely unexplored. Few previous reports [7-9] and our clinical experience suggest that there is an association between post-TB lung disease and pulmonary hypertension (PHT). Although a proportion of patients with current TB do present with PHT, [7,8,10] the strength of this association remains largely undefined. [9,10] In addition, the prevalence of PHT among individuals who have been treated for pulmonary TB but who have minimal fibrotic parenchymal disease is also not known. We have noticed a paucity of literature listing TB as a potential cause of pulmonary vascular disease, or demonstrating an association between TB and PHT. Furthermore, the literature and PHT guideline documents rarely mention TB among the list of causes of group 3 PHT. [11] We therefore propose that a discordance may exist between our clinical reality and the literature on post-TB pulmonary vascular disease and PHT. This discordance is difficult to explain, and may in part be due to a low TB incidence in countries currently researching PHT. It is possible that in their setting they do not frequently observe patients with TB progressing to advanced lung destruction, like we do here in SA. This highlights many important unanswered questions, that include: What is the strength of the association between pulmonary TB and PHT, across the spectrum of parenchymal abnormality in TB patients? Why does the degree of right heart failure correlate so poorly with the degree of radiological changes? [8] Does the degree of right heart failure correlate with the degree of airway obstruction/ restriction regardless of the degree of radiological changes? What is the time of onset of PHT in patients who were successfully treated for TB? Lastly, do other co-factors, such as smoking, drug use or HIV, have a modifying role in the development of PHT? Considering that in SA there were an estimated 438 000 cases of tuberculosis in 2016 alone, [1] we highlight that further clinical investigation and research into this disease associa...

Background Cardiovascular magnetic resonance (CMR) is considered the reference imaging modality in providing a non-invasive diagnosis of acute myocarditis (AM), as it allows for the detection of myocardial injury associated with AM. However, the diagnostic sensitivity and pattern of CMR findings appear to differ according to clinical presentation. Methods This is a retrospective cross-sectional study. Consecutive adult patients presenting to a single tertiary centre in South Africa between August 2017 and January 2022 with AM confirmed on endomyocardial biopsy (EMB) were enrolled. Patients with infarct-like symptoms, defined as those presenting primarily with chest pain syndrome with associated ST-T wave changes on electrocardiogram, or heart failure (HF) symptoms, defined as clinical signs and symptoms of HF without significant chest discomfort, were compared using contrasted CMR and parametric techniques with EMB confirmation of AM as diagnostic gold standard. Results Forty-one patients were identified including 23 (56%) with infarct-like symptoms and 18 (44%) with HF symptoms. On CMR, the infarct-like group had significantly higher ejection fractions of both ventricles (LVEF 55.3 ± 15.3% vs. 34.4 ± 13.5%, p < 0.001; RVEF 57.3 ± 10.9% vs. 42.9 ± 18.2%, p = 0.008), without significant differences in end diastolic volumes (LVEDVI 82.7 ± 30.3 ml/m2 vs. 103.4 ± 35.9 ml/m2, p = 0.06; RVEDVI 73.7 ± 22.1 ml/m2 vs. 83.9 ± 29.9 ml/m2, p = 0.25). Myocardial oedema was detected more frequently on T2-weighted imaging (91.3% vs. 61.1%, p = 0.03) and in more myocardial segments [3.0 (IQR 2.0–4.0) vs. 1.0 (IQR 0–1.0), p = 0.003] in the infarct-like group. Despite the absence of a significant statistical difference in the prevalence of late gadolinium enhancement (LGE) between the two groups (95.7% vs. 72.2%, p = 0.07), the infarct-like group had LGE detectable in significantly more ventricular segments [4.5 (IQR 2.3–6.0) vs. 2.0 (IQR 0–3.3), p = 0.02] and in a different distribution. The sensitivity of the original Lake Louise Criteria (LLC) was 91.3% in infarct-like patients and 55.6% in HF patients. When the updated LLC, which included the use of parametric myocardial mapping techniques, were applied, the sensitivity improved to 95.7% and 72.2% respectively. Conclusion The pattern of CMR findings and its diagnostic sensitivity appears to differ in AM patients presenting with infarct-like and HF symptoms. Although the sensitivity of the LLC improved with the addition of parametric mapping in the HF group, it remained lower than that of the infarct-like group, and suggests that EMB should be considered earlier in the course of patients with clinically suspected AM presenting with HF.

ObjectivesTo determine the prevalence and types of viral pathogens in the myocardium of patients presenting with clinically suspected myocarditis in South Africa.MethodThis is a prospective cross-sectional study. Consecutive adults presenting to a single tertiary centre in South Africa between August 2017 and January 2021 who fulfilled the European Society of Cardiology’s diagnostic criteria for clinically suspected myocarditis and who had undergone the appropriate investigations, including cardiac MRI (CMR) and endomyocardial biopsy (EMB), were included.ResultsOne hundred and two patients with clinically suspected myocarditis were enrolled. Acute myocarditis (AM) was confirmed by CMR or EMB in 82 (80.39%) patients. Viral genomes were detected by PCR in EMB specimens of 50 patients with AM. Parvovirus B19 (PVB19) was the most frequently detected virus, in 37 as monoinfection and 4 as coinfection. This was followed by Epstein-Barr virus (n=6), human herpesvirus 6 (n=2) and human bocavirus (n=1). PVB19 was also detected in 9 patients with no evidence of AM on CMR or EMB.ConclusionViral myocarditis is the most common form of myocarditis in South Africa. Local viral prevalence appears to be similar those of the developed world. The clinical significance and pathogenic role of PVB19 remains questioned, and its local background prevalence will have to be further investigated.

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To determine whether the routine use of real‐time transthoracic echocardiographic (TTE) guidance in addition to fluoroscopy would ensure the safety of right ventricular endomyocardial biopsy (RV EMB) in a low‐volume center. RV EMB is a valuable tool and plays an important role in the diagnosis and management of patients with myocardial diseases. However, it has yet to gain widespread acceptance due to its perceived low diagnostic yield and concerns regarding its invasive nature and potential complications. Although the safety of EMB when performed by experienced operators in high‐volume centers is well established, the complication rate in low‐volume centers is less well defined but appears to be higher. This is a retrospective single‐center cross‐sectional study. Consecutive adult patients who underwent RV EMB procedures at Tygerberg Hospital (Cape Town, South Africa) between August 2017 and December 2020 were included. RV EMB was successfully performed in 85 patients. No major complications were reported. Five (5.88%) patients experienced minor complications: three transient right bundle branch blocks and two hemodynamically stable ventricular tachycardia. A definitive biopsy diagnosis was made in 37 (43.54%) patients. The average procedural time was 27.06 min, which equated to 4.09 min per specimen taken. The routine use of real‐time TTE guidance in addition to fluoroscopy ensured the safety of RV EMB in a low‐volume center without unnecessarily prolonging procedural time.

Background Transradial catheterization has become the preferred access site for coronary angiography. The transradial approach is however not without challenges and complications. Cannulation is technically challenging and may require multiple cannulation attempts or access may fail. Local access site complications may occur postprocedurally. Purpose To explore the use of prolonged occlusion flow mediated dilatation (PO-FMD) to dilate the radial artery prior to cannulation to reduce puncture attempts, increase cannulation success and reduce access site complications in transradial coronary angiography. Methods 1156 patients undergoing transradial coronary angiography were randomized into PO-FMD and sham PO-FMD groups. PO-FMD was achieved by a 10 minute inflation of a blood pressure cuff on the arm to above systolic pressure, followed by deflation with resultant radial artery dilation. In the sham PO-FMD group the cuff was not inflated. The operators were blinded to the intervention. Results 580 patients were randomized to the sham PO-FMD group and 576 to the PO-FMD group. The number of puncture attempts were reduced with the use of PO-FMD, with a median number of attempts of 1 in the PO-FMD group and 2 in the sham PO-FMD group (p<0.001). Cannulation failure was reduced with PO-FMD FMD with cannulation failure rates of 2.7% in the PO-FMD group and 5.8% in the sham PO-FMD group (p=0.01). Radial artery pulsation loss (RAPL) was reduced with PO-FMD with 1.4% in the PO-FMD group and 3.8% in the sham PO-FMD group (p=0.02). Conclusion PO-FMD decreases puncture attempts, reduces cannulation failure rates and decreases RAPL during transradial coronary angiography.