Myocarditis and pericardial diseases are no longer regarded as isolated entities. The new ESC 2025 Guidelines merge them into a common clinical framework—IMPS—recognizing the anatomical and pathophysiological continuum between the myocardium and pericardium, where inflammatory processes frequently coexist.

This document adopts a contemporary, evidence-based and pragmatic perspective, offering structured algorithms for diagnosis, risk stratification and treatment. For the first time, clinical care pathways are aligned from initial suspicion to functional recovery, emphasizing the role of the multidisciplinary IMPS team, which includes cardiologists, cardiac surgeons, intensivists and infectious disease specialists.

From a surgical standpoint, the guidelines incorporate key practical elements: refined indications for pericardial drainage and pericardiectomy, strengthened recommendations for short-term mechanical circulatory support in fulminant myocarditis (primarily VA-ECMO or temporary ventricular assist devices), and greater emphasis on early surgical involvement in critical scenarios.

1. From entity-based diagnosis to syndromic concept (IMPS)

The guidelines group myocarditis, pericarditis and overlapping forms under the term IMPS. This reclassification aims to streamline clinical decision-making, avoid fragmented diagnoses and encourage specialized multidisciplinary care.

Any patient presenting with cardiac inflammation should be assessed comprehensively—heart and pericardium are considered a single functional unit.

2. Non-invasive diagnosis: the era of advanced CMR

Cardiac magnetic resonance (CMR) is consolidated as the principal non-invasive diagnostic tool. The updated Lake Louise 2.0 criteria require at least one marker of edema (T2-based techniques) and, ideally, one marker of myocardial injury (T1-based mapping or late gadolinium enhancement). Elevated troponin levels without imaging evidence of myocardial involvement are no longer sufficient to diagnose myocarditis.

3. Endomyocardial biopsy (EMB): when it should and should not be performed

EMB is recommended only when it may influence therapeutic decisions—such as in suspected fulminant myocarditis, chronic inflammatory cardiomyopathy or when specific immunosuppressive therapy is considered.

The optimal timing is within the first 14 days from symptom onset.

4. Updated clinical algorithms: three main entry points

The guidelines define three primary diagnostic scenarios:

1. Acute chest pain mimicking an acute coronary syndrome
2. Acute heart failure
3. Ventricular arrhythmias or aborted sudden cardiac death

Each pathway includes stepwise evaluation, exclusion of coronary artery disease and clinical risk stratification. Rapid triage in the early phase reduces unnecessary hospital admissions and prevents therapeutic delays in fulminant cases.

5. Management of fulminant myocarditis: urgency and circulatory support

Short-term mechanical circulatory support is reinforced as a central element of treatment in fulminant myocarditis, particularly using VA-ECMO or temporary assist devices. Intra-aortic balloon pump therapy is removed from the algorithms. Early implantation of mechanical support in SCAI stage C–D improves survival, facilitates myocardial recovery and may serve as a bridge to transplantation.

6. Acute pericarditis: diagnosis and treatment

Diagnosis continues to rely on classic clinical criteria (pericardial chest pain, friction rub, ECG changes and pericardial effusion), now supported by inflammatory markers and imaging evidence.
High-sensitivity troponin elevation alone is not enough to classify a case as myopericarditis; CMR must confirm myocardial involvement.

Treatment continues to be based on nonsteroidal anti-inflammatory drugs and colchicine. Corticosteroids remain second-line therapy due to their association with recurrence and should only be used in refractory or contraindicated cases.

7. Recurrent and incessant pericarditis: new therapeutic sequences

The guidelines introduce a structured escalation strategy:

• First line: NSAIDs + colchicine
• Second line: low-dose corticosteroids
• Third line: immunomodulators or biologics such as anakinra or rilonacept, which have demonstrated efficacy in reducing recurrence and shortening symptom duration

Early referral to expert centers is advised in steroid-dependent or treatment-refractory cases.

8. Pericardial effusion and cardiac tamponade: surgical relevance

Pericardiocentesis is the first-line approach in hemodynamically significant effusions or tamponade. Surgical pericardial window is indicated in recurrent or loculated effusions, purulent pericarditis or when percutaneous drainage is unsafe or ineffective.

From a surgical perspective, the document stresses meticulous planning, especially in postoperative or neoplastic effusions, as well as careful management of anticoagulated patients.

9. Pericardiectomy: when to refer to surgery

Pericardiectomy remains the definitive treatment for chronic constrictive pericarditis. The guidelines underline:

• Total pericardiectomy is preferred to partial resection
• Early surgery is associated with better symptomatic relief and long-term survival
• Referral to high-volume centers is strongly recommended due to the technical complexity and risk of right ventricular injury

10. Therapeutic innovations and multidisciplinary IMPS team

The guidelines endorse a collaborative care model involving cardiologists, imaging specialists, cardiac surgeons, intensivists and infectious disease experts.

New therapeutic strategies include:

• Targeted immunosuppression in biopsy-proven immune-mediated myocarditis
• Early mechanical circulatory support in fulminant cases
• Better use of pericardial interventions guided by advanced imaging

This multidisciplinary approach improves timing, decision-making and outcomes.

The 2025 ESC Guidelines on myocarditis and pericardial disease mark a profound conceptual shift: they move beyond viewing these as separate pathologies and adopt an integrated perspective centered on inflammatory myopericardial syndrome (IMPS). This framework enables faster, more consistent, and multidisciplinary assessment of patients with cardiac inflammation, improving diagnostic precision and therapeutic decision-making.

The authors emphasize three pillars for care: early CMR-based diagnosis, clinical risk stratification, and collaboration within specialized IMPS teams. They also recommend centralizing the most complex scenarios—fulminant myocarditis, constrictive pericarditis, or refractory recurrences—in centers with established expertise in mechanical circulatory support and cardiac surgery.

Finally, they stress that implementation of these guidelines is intended not only to improve prognosis but also to optimize healthcare resources by integrating clinical, interventional, and surgical perspectives within a single coordinated workflow.

COMMENTARY:

The 2025 ESC Guidelines on myocarditis and pericardial diseases represent a significant step forward. The IMPS concept helps streamline clinical practice, dismantles the artificial myocardium–pericardium boundary and reminds us that the heart behaves as a single functional entity. However, the document still carries a predominantly “medical” bias: the role of the cardiac surgeon is less prominent than real-world clinical practice would require. For this reason, several surgical considerations should be highlighted:

1) A new language… with surgical gaps
Grouping myocarditis, pericarditis and their overlap phenotypes under IMPS is a useful approach: it unifies protocols, accelerates decision-making and improves multidisciplinary coordination. Nevertheless, the guidelines offer limited details on when and how to intervene surgically beyond pericardial drainage or delayed pericardiectomy. In daily practice, the surgeon is also involved in inflammatory shock, in selecting and timing mechanical circulatory support and in the early indication of complete pericardiectomy.

2) Fulminant myocarditis: time is measured in hours
The guidelines endorse short-term mechanical circulatory support in fulminant myocarditis (mainly VA-ECMO or temporary assist devices), with a very limited role for intra-aortic balloon pump. The crucial point is timing: once cardiac output drops and lactate rises, the therapeutic window is counted in hours.
Although the document does not specify types of devices or escalation strategies, the experience of transplant centers such as ours (CHUAC) shows that early initiation of support—and, when appropriate, transition from ECMO to an axial or continuous-flow device—may shorten support duration, reduce hemolysis and promote myocardial recovery. The guidelines do not standardize which device to use or when; in this setting, the expertise and coordination of the shock team remain key.
Current evidence indicates that cardiogenic shock secondary to fulminant myocarditis has higher survival and ventricular recovery rates than ischemic or dilated cardiomyopathy, provided that support is established early and in experienced centers. Timely recognition and prompt activation of the dedicated team are decisive for survival and meaningful recovery.

3) Cardiac tamponade: indicate, choose the approach and perform it correctly
In cardiac tamponade, the guidelines are clear: urgent drainage is required in the presence of hemodynamic instability (hypotension, marked pulsus paradoxus), diastolic collapse of right-sided chambers, respiratory variation >25% in Doppler inflow, dilated inferior vena cava without collapse or equalization of left- and right-sided filling pressures.
• Percutaneous image-guided drainage (echocardiography or fluoroscopy) with continuous drainage for 24–48 hours remains the standard. Pericardial fluid must always be sent for microbiological and cytological analysis (Gram stain, cultures, ADA if tuberculosis is suspected, cytology if malignancy is considered).
• Surgical drainage (subxiphoid window or sternotomy) is indicated when free-wall rupture post-myocardial infarction, acute aortic dissection, postoperative hemopericardium with clots or recurrent malignant effusion is suspected.
• Post-drainage, clinicians should monitor for effusive–constrictive pericarditis, especially if congestion persists or Doppler shows respiratory discordance.

Beyond technical criteria, it is worth reflecting on who should perform pericardiocentesis. In our institution, cardiac surgeons perform the procedure in nearly 100% of cases, generating a substantial burden during on-call hours. However, modern intensive care units include physicians highly skilled in echocardiography and invasive procedures who could assume a more active role.
Delegating this procedure to trained intensivists or cardiologists in critical care not only is safe but also expedites care and allows surgeons to focus on complex scenarios (hemopericardium, recurrent effusions or extended surgical drainage), where their presence is truly decisive.

4) Effusive–constrictive pericarditis: avoid indefinite waiting
If constrictive physiology persists after drainage and does not resolve following 2–4 weeks of anti-inflammatory therapy (with or without colchicine, low-dose steroids or anti-IL-1 agents in refractory cases), early planning of pericardiectomy is reasonable. Excessive delay usually worsens the surgical risk profile and postoperative outcomes.

5) Constrictive pericarditis: indication, timing and surgical technique
Surgical candidates are those with limiting symptoms (NYHA III–IV), persistent constrictive hemodynamics despite medical therapy, pericardial thickening or calcifications on CT/CMR, or established chronic constriction. If CMR shows T2 edema or late gadolinium enhancement in the pericardium with elevated CRP, transient constriction may be present. In such cases, a short trial of anti-inflammatory therapy with close reassessment is appropriate. If no reversal occurs, surgery is indicated.
Although the guidelines do not mandate a specific approach, contemporary practice supports complete pericardiectomy in experienced centers. Median sternotomy allows wide “phrenic-to-phrenic” resection, liberation of the atrioventricular groove and diaphragmatic surface, and provides standby cardiopulmonary bypass in cases of massive calcification or postsurgical adhesions. Increasing evidence supports cardiopulmonary bypass use to maintain hemodynamic stability while extending the pericardiectomy to the posterior AV groove or the entire lateral wall of the left ventricle. Partial or subxiphoid resections leave constricting pericardium behind, leading to worse hemodynamics and higher mortality. Not only low-pressure chambers and great veins should be liberated; removing calcified “eggshell” pericardium adherent to the myocardium is also desirable. In this setting, devices such as CUSA may be especially useful.

6) Expectations and postoperative care after pericardiectomy
In expert hands, mortality for complete pericardiectomy is approximately 3–8% (higher in radiation-induced disease, advanced tuberculosis or in patients with cachexia). When well indicated, functional improvement is the rule. In the immediate postoperative period, special attention should be given to transient right ventricular failure after sudden release of constriction: careful preload management, selective inotropes, pulmonary vasodilators if needed and aggressive diuresis are essential. When inflammatory activity existed, tapering of anti-inflammatory treatment should be adjusted based on CRP values and/or imaging findings.

7) What already changes daily practice
Two guideline contributions directly impact clinical care:
• CMR as the diagnostic cornerstone and EMB only when it modifies management—both strategies reduce misdiagnosis and standardize decision-making.
• Anti-IL-1 therapy (anakinra, rilonacept) for recurrent or corticosteroid-dependent pericarditis (IIa) finally provides an effective and durable immunomodulatory option; it should be prioritized over prolonged steroid dependence.

8) Real IMPS teams, not just protocols
The guideline rightly promotes IMPS teams and a hub-and-spoke model. The real challenge lies in implementation: refer early, decide early and intervene thoroughly when indicated. Surgeons must be involved from the outset (during shock, drainage or constrictive phases), because in severe cardiac inflammation time remains the primary determinant of outcome, and surgery—when applied appropriately—is the definitive tool to restore function in the inflamed heart.

REFERENCE:

Schulz-Menger J, Collini V, Gröschel J, Adler Y, Brucato A, Christian V, et al.; ESC Scientific Document Group. 2025 ESC Guidelines for the management of myocarditis and pericarditis. Eur Heart J. 2025 Aug 29:ehaf192. doi: 10.1093/eurheartj/ehaf192.