Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 12  |  Issue : 3  |  Page : 45-48

Tamponade-like picture caused by pericardial cyst


Department of Cardiothoracic Anesthesia, Freeman Hospital, Newcastle Upon Tyne, UK

Date of Submission10-Dec-2018
Date of Acceptance10-Jan-2019
Date of Web Publication24-May-2019

Correspondence Address:
Mostafa Eladawy
Department of Cardiothoracic Anesthesia, Freeman Hospital, Newcastle Upon Tyne
UK
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejca.ejca_17_18

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  Abstract 

Pericardial cysts are rare entities, they have an incidence rate of 1:100,000 which constitutes about 7.6% of all mediastinal masses (6). The differential diagnosis includes other solid tumors and cysts of the mediastinum, diaphragmatic hernia or tumors, aneurysms of the heart or great vessels (1).
Although TTE can differentiate many of the causes of mediastinal masses, loculated pericardial effusion with a similar clinical picture can be difficult to differentiate on transthoracic echocardiography (8). Radiological examination with CT or MRI has been described to differentiate in difficult cases. In emergency situations, TEE examination could be a useful option as it can help differentiating a malignant from a benign pericardial cyst, check the extent of involvement of underlying myocardium or adjacent structures and assess the anatomical abnormalities or effects on different heart chambers.
In our case we describe a case of a huge pericardial cyst which had affected the patient haemodynamics in a tamponade like picture, the intra-operative TEE assessment helped appreciating the compression effect on the right heart chambers and the intravascular resuscitation needed to counteract the external pressure of the pericardial cyst. The echocardiography also helped the decision making of performing the procedure on CPB.

Keywords: pericardial cyst, tamponade, TOE


How to cite this article:
Eladawy M, Varghese A. Tamponade-like picture caused by pericardial cyst. Egypt J Cardiothorac Anesth 2018;12:45-8

How to cite this URL:
Eladawy M, Varghese A. Tamponade-like picture caused by pericardial cyst. Egypt J Cardiothorac Anesth [serial online] 2018 [cited 2019 Aug 18];12:45-8. Available from: http://www.ejca.eg.net/text.asp?2018/12/3/45/258995

Cysts in pericardium are not an uncommon finding. It has been reported to constitute 6% of mediastinal masses and 33% of mediastinal cysts. Although many are associated with congenital lesions, isolated findings have also been reported. Many are discovered as part of routine evaluation as a shadow in chest radiography, but symptomatic cysts are also not uncommon, warranting intervention [1],[2].

A 58-year-old man with previous history of hypertension, coronary artery disease with stenting to right coronary artery 9 years ago, and osteoarthritis but otherwise fit and active was referred to our cardiothoracic unit with complaints of chest tightness, increasing shortness of breath, and worsening unexplained hypoxia. Preliminary computed tomography (CT) to rule out pulmonary embolus found a loculated pericardial effusion compressing right heart chambers including the outflow tract. The content was more dense than normal fluid with visible strands indicating either hemorrhagic or proteinaceous inflammation.

A transthoracic echocardiogram (TTE) showed moderate compression of right ventricle and severe compression of the right atrium and strands inside the fluid in the pericardium. The oxygen saturation was 78%, even with 15 l of oxygen support via face mask; lactate was 2.6 mmol/l; and venous pressure measured around 16 mmHg. The differential diagnosis was right atrial mass, cyst, or malignant effusion causing tamponade.

The patient was listed for emergency sternotomy with cardiopulmonary bypass (CPB) standby.

All routine monitoring was used. An arterial line was inserted before induction. Induction of anesthesia was done using fentanyl, etomidate, and atracurium. Airway was secured with an endotracheal tube. A transesophageal echocardiography (TEE) probe was inserted for intraoperative monitoring that confirmed the preoperative TTE findings. Immediately following sternotomy, there was a rapid improvement in the saturation to high 90 s.

On opening the pericardium away from the visible bulge, it was found to be a pericardial cyst, and as it was thought to be dangerously adherent to the underlying myocardium, CPB was instituted with central cannulation of the right atrium and aorta.

The cyst was excised, and the patient was weaned off pump uneventfully without any cardiovascular support. Following hemostasis and chest closure, the patient was shifted to intensive care for an early respiratory wean. After 12 h of intensive care monitoring, the patient was shifted to the ward and discharged after 4 days.

The pathology study of the mass revealed nonspecific active pericarditis with focal acute inflammation and evidence of malignancy; unfortunately, 3 months later, he developed mediastinal lymphadenopathy, which was found to be nondifferentiated epithelioid tumor ([Figure 1],[Figure 2],[Figure 3],[Figure 4]).
Figure 1 Bicaval view TOE picture of RA compressed by the cyst. RA, right atrium, TOE, transoesophageal echocardiography.

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Figure 2 Bulging of the interatrial septum into the left atrium.

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Figure 3 The right atrial cavity is almost completely effaced, and right coronary artery is seen to the left of the cyst/abnormality, supporting that it is extracardiac/causing compression.

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Figure 4 Compression of RA and RV by the cyst. RA, right atrium, RV, right ventricle.

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  Discussion Top


Pericardial cysts are rare entities; when they are diagnosed, they have an incidence rate of 1 : 100 000, which constitutes approximately 7.6% of all mediastinal masses [3]. Pericardial cysts are most commonly found at the right (51–70%) or left cardiophrenic angle (28–38%) and less commonly in other mediastinal locations [4],[5]. They usually present in the third or fourth decade, with equal incidence in males and females. Most cyst are believed to be congenital in origin (failure of fusion of one of the mesenchymal lacunae) [6], though acquired causes have also been described (usually asymptomatic and are diagnosed either incidentally or when they develop complications. Symptoms related to pericardial cysts are nonspecific and are more related to the complication it develops [7],[8],[9],[10].

Pericardial cysts are typically located at the right cardiophrenic angle (51–70%) or left cardiophrenic angle (28–38%) and rarely in other mediastinal locations.

Asymptomatic cysts need only follow-up, and intervention is warranted only if it develops complications. The differential diagnosis includes other solid tumors and cysts of the mediastinum, diaphragmatic hernia or tumors, and aneurysms of the heart or great vessels [7].

Although TTE can differentiate many of the causes of mediastinal masses, loculated pericardial effusion with a similar clinical picture can be difficult to differentiate on TTE [11]. Radiological examination with CT or MRI has been described to differentiate in difficult cases. In our patient, owing to hemodynamic instability, MRI scan was not possible and CT scan was inconclusive.

In emergency situations, TEE examination could be a useful option as it can help in differentiating a malignant from a benign pericardial cyst, can be used to check the extent of involvement of underlying myocardium or adjacent structures, and can be used to assess the anatomical abnormalities or effects on different heart chambers.

Asymptomatic cysts can be kept under follow-up [7],[12]. Treatment for symptomatic pericardial cyst is surgical excision with a variety of techniques described by several authors, for example, echocardiographically guided percutaneous aspiration, video-assisted thoracoscopic surgery, thoracotomy, and excision [5],[7],[8],[11],[12].

Several complications have been associated with pericardial cyst − sudden death, cardiac tamponade, cyst rupture, right ventricular outflow obstruction, pulmonary stenosis, erosion of the cyst into the superior vena cava and right ventricular wall, mitral valve prolapse, congestive heart failure, atrial fibrillation, pericarditis, and obstruction of the right main bronchus [11].

Any of the aforementioned approaches can be adapted with excellent results as described by the authors, if the diagnosis is confirmed before surgery. However, in cases of diagnostic dilemmas, it is prudent to adopt a safer approach in this benign condition but prone for grave complications.

In our case, we describe a case of a huge pericardial cyst which had affected the patient’s hemodynamics in a tamponade-like picture. The intraoperative TEE assessment helped appreciate the compression effect on the right heart chambers and the intravascular resuscitation needed to counteract the external pressure of the pericardial cyst.

The echocardiography also helped in the decision making of performing the procedure on CPB as the cyst was found to be very adherent to the right heart chambers causing compression effect, and the danger of damaging these chambers during dissection was beyond acceptable.

Hence, we concurred to proceed with CPB, as neither TTE nor CT was able to conclusively differentiate the origin of the lesion. After establishing CPB and draining the heart, we were better able to differentiate the lesion and proceed with excision without damaging the surrounding structures. Thus, although a rare lesion, pericardial cyst should be a differential diagnosis of every case of mediastinal mass. Surgery with CPB should be an option in the armamentarium of clinicians dealing with mediastinal masses.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Parmar YJ, Kronzon I. Congenital abnormalities of the pericardium. Cardiol Clin 2017; 16:821–827.  Back to cited text no. 1
    
2.
Zhou W, Srichai MB. Multi-modality imaging assessment of pericardial masses. Curr Cardiol Rep 2017; 19:32.  Back to cited text no. 2
    
3.
Seo GW, Seol SH, Jeong HJ, Seo MG, Song PS, Kim DK et al. A large pericardial cyst compressing the left atrium presenting as a pericardiopleural efussion. Heart Lung Circ 2014; 23:e273–e275.  Back to cited text no. 3
    
4.
Patel J, Park C, Michaels J, Rosen S, Kort S. Pericardial cyst: case reports and a literature review. Echocardiography 2004; 21:269–272.  Back to cited text no. 4
    
5.
Kutlay H, Yavuzer I, Han S, Cangir AK. Atypically located pericardial cysts. Ann Thorac Surg 2001; 72:2137–2139.  Back to cited text no. 5
    
6.
Kar SK, Ganguly T. Current concepts of diagnosis and management of pericardial cysts. Indian Heart J 2017; 69:364–370.  Back to cited text no. 6
    
7.
Martins IM, Fernandes JM, Gelape CL, Braulio R, Silva Vde C, Nunes Mdo C. A large pericardial cyst presenting with compression of the right-side cardiac chambers. Rev Bras Cir Cardiovasc 2011; 26:504–507.  Back to cited text no. 7
    
8.
Ilhan E, Altin F, Ugur O, Özkara S, Kayacioglu I, Aydemir NA, Tayyareci G. An unusual presentation of pericardial cyst: recurrent syncope in a young patient. Cardiol J 2012; 19:188–191.  Back to cited text no. 8
    
9.
Borges AC, Gellert K, Dietel M, Baumann G, Witt C. Acute right-sided heart failure due to hemorrhage into a pericardial cyst. Ann Thorac Surg 1997; 63:845–847.  Back to cited text no. 9
    
10.
Komodromos T, Lieb D, Baraboutis J. Unusual presentation of a pericardial cyst. Heart Vessels 2004; 19:49–51.  Back to cited text no. 10
    
11.
Najib MQ, Chaliki HP, Raizada A, Ganji JL, Panse PM, Click RL. Symptomatic pericardial cyst: a case series. Eur J Echocardiogr 2011; 12:E43.  Back to cited text no. 11
    
12.
Maisch B, Seferović PM, Ristić AD, Erbel R, Rienmuller R, Adler Y et al. Task Force on the diagnosis and management of pericardial diseases of the European Society of Cardiology. Guidelines on the diagnosis and management of pericardial diseases executive summary; the task force on the diagnosis and management of pericardial diseases of the european society of cardiology. Eur Heart J 2004; 25:587–610.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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