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Pericardial diseases only affect a small proportion of patients with heart disease. But their diagnosis and differential diagnosis is, though too often neglected by cardiologists and internists, extremely important for the individual patient and of therapeutic and prognostic relevance in the differential diagnosis of cardiac symptoms [1, 2]: An excellent example for precordial pain is acute pericarditis, which should be differentiated from aortic dissection, myocardial infarction, pneumonia or pleuritis, pulmonary embolism, pneumothorax, costochondritis (Da Costa syndrome), gastroesophageal reflux or neoplasm and herpes zoster. In the spectrum of heart failure syndromes, it is pericardial constriction that causes dyspnoea and peripheral edema. Seferovic et al. particularly address these issues in their contribution, which was designed to update the 2004 guidelines of the European Society of Cardiology [3]. These guidelines are still the only guidelines worldwide on the management of pericardial diseases. Interventional pericardiologists nowadays use intrapericardial endoscopy and biopsy together with classic cytology to establish an etiologically based diagnosis [4, 5] by making use of techniques that have been accepted and applied to diagnose inflammatory cardiomyopathies [6] or tumors or rheumatic diseases since several decades. Pericardial access has become a vital interest for electrophysiologists, who now also ablate epicardial foci and reentry sites to treat malignant ventricular tachycardia [7, 8]. Pericardial access is also discussed for localized pharmacological treatment [9], even for stem cells or cocktails with growth factors [10]. Devices for locomotion on the epicardial surface have been designed and applied in preclinical settings [10, 11]. Apart from the patient’s symptoms, echocardiography remains the mainstay of imaging of acute pericardial syndromes but also of constrictive pericarditis, effusive–constrictive pericarditis, pericardial effusion, tamponade, absence of the pericardium and cysts or tumors. The remarkable progress, which has been made in echocardiography in the last years, is very well described by Veress, Feng and Oh from the Mayo-Clinic. Progress in cardiac tissue Doppler analysis, strain and strain rate imaging by speckle tracking imaging and three-dimensional echocardiography, the assessment of early diastolic annulus velocity and annulus reversus by TDI improves the differentiation of constriction from restrictive myocardial disease and is in the focus of their contribution. Threedimensional echocardiography may come up as a useful method for the precise assessment pericardial masses as it provides incremental value to 2D echocardiography by detecting anatomical and pathological structures with higher accuracy. Of particular interest are their contributions and that of others on effusive–constrictive pericarditis [12–14] and on the differential diagnosis of constrictive pericarditis to restrictive cardiomyopathy [15]. Syed and coworkers in this issue point out that effusive– constrictive pericarditis is best characterized in patients with tamponade who continue to have elevated intracardiac pressure after removal of pericardial fluid. The underlying causes are pericardial inflammation in conjunction with the presence of pericardial fluid under pressure, whereby the etiology is diverse. Alter et al. add valuable information on imaging by reviewing MRI and CT [16, 17] as well as scintigraphic Bernhard Maisch: Former Director of the University Hospital of Internal Medicine and Cardiology.

Pericardial diseases in the era of imaging, biomarkers and molecular diagnosis