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Ann Thorac Surg 1997;63:845-847
© 1997 The Society of Thoracic Surgeons

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Case Reports

Acute Right-Sided Heart Failure Due to Hemorrhage Into a Pericardial Cyst

Division of Pneumology, Medical Department I; Division of Thoracic Surgery, Department of Abdominal and Visceral Surgery; and Institute for Pathology, Medical School (Charité) of the Humboldt-University Berlin, Berlin, Germany

Accepted for publication October 15, 1996.

	Abstract

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This is a description of a rare complication of a pericardial cyst with spontaneous internal hemorrhage and following tamponade. The noninvasive diagnosis was done by transesophageal echocardiography and computed thoracic tomography. The cyst was thoracoscopically removed and pathologically examined. This case demonstrates a rare but important and life-threatening complication of mostly asymptomatic pericardial cysts.

	Introduction

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Pericardial cysts are rare and are mostly located at the right costophrenic angle, unilocular, and filled with clear liquid [1–6]. Pericardial cysts are usually symptomless and cause no physical findings. They usually come to medical attention as an unexpected finding of a round mass along the right cardiac border on a chest radiograph [6]. Previous long-term follow-up studies have demonstrated that most of the patients are without any symptoms [1, 5].

The purpose of this article is to present a case of symptomatic pericardial cyst due to a very rare life-threatening complication and the need for emergency removal by thoracoscopic operation. The following case describes acute right heart decompensation occurring in a middle-aged man due to spontaneous bleeding into a large pericardial cyst, without any previous symptoms.

A 66-year old man was admitted to our hospital because of sudden and persistent chest pain and dyspnea. The patient had enjoyed excellent health before. He had smoked one pack of cigarettes daily for 35 years. There was no history of arthralgia, rash, fever, or weight loss.

The patient demonstrated the signs of right-sided heart failure with rapid, weak pulse with paradox, distended jugular veins accentuated during inspiration (positive Kussmaul's sign), hepatomegaly, peripheral edema, and distant heart sounds; within the next 2 hours severe dyspnea and orthopnea also developed. The lungs were clear, and the neurologic examination was normal. The temperature was 36.8°C, the pulse was 112 beats/min, and the respiration rate was 22/min. The blood pressure was 110/65 mm Hg. The prothrombin and partial thromboplastin times were normal. Cardiac enzymes and other laboratory findings were also within the normal range. A radiograph of the chest showed an enlarged cardiac silhouette and a spherical area of increased density at the right side of the heart and right anterior cardiophrenic angle with a size of 6 x 4 cm.

An electrocardiogram revealed a sinus rhythm at a rate of 118 beats/min with normal intervals and an elevation of less than 1 mm in the ST segments in leads 1, 2, and aVF. The electrocardiogram demonstrated low QRS voltage, generalized T-wave flattening, and left atrial abnormalities suggestive of P mitrale.

Because of lung interposition a transthoracic echocardiogram was obtained without sufficient diagnostic impact, and a transesophageal two-dimensional echocardiogram was performed in the emergency room. The transesophageal echocardiogram disclosed a 11 x 4 x 7-cm complex, echogenic, round mass with compression of the right atrium and right ventricle, with clear delineation of the right ventricular wall and the mass (Fig 1). The right and left ventricular systolic function and the morphology and function of the heart valves appeared normal without regional dyskinesia. The compression of the right atrium and right ventricle, the restrictive pattern of the transtricuspid flow with increase of early maximal velocity demonstrated the cause of the right heart decompensation. Computed tomographic scans of the chest showed a large (11 x 4 x 7-cm) cyst adherent to the right-sided pericardium with complex density, an attenuation value ranging from -0.3 to 12 Houndsfield units and without contrast medium enhancement.

View larger version (128K): [in this window] [in a new window]   Fig 1. . Transesophageal echocardiogram demonstrating the large pericardial cyst ( c) with compression of the right atrium (RA) and ventricle (RV).

Postoperative transesophageal echocardiography showed a small right-sided pericardial effusion and the echogenic rest of the posterior cyst wall. Right and left ventricular function were normal, and there was no evidence of valve dysfunction (Fig 2).

View larger version (79K): [in this window] [in a new window]   Fig 2. . Postoperative transesophageal echocardiogram showing the rest of the posterior wall of the cyst and right-sided pericardial effusion without hemodynamic consequences. ( RA = right atrium; RV = right ventricle.)

	Comment

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Chest pain may occur in rare cases owing to torsion of the cyst. Echocardiography and computed tomography are able to distinguish the cyst from a solid tumor or aneurysm in most cases [4]. The differential diagnosis includes foramen of Morgagni diaphragmatic hernia, large right pericardial fat pad, mediastinal or diaphragmatic tumors, and tumors of the heart or pericardium. It is important to distinguish pericardial cysts from solid tumors, which is possible by two-dimensional and three-dimensional transesophageal echocardiography [5]. Pericardial cysts can also be accurately diagnosed and treated by percutaneous aspiration and cyst injection under fluoroscopic guidance with no evidence of recurrence of the cysts upon 3-year follow-up [2]. Most of the patients can be treated conservatively without surgical intervention. In rare cases there are complications of pericardial cysts like sudden death after a stress test [6] and atrial fibrillation resulting from the pericardial cyst, which was treated by removal of the cyst [7, 8].

We have known this complication of hemorrhage before in renal, ovarian, and hepatic cysts, but this is the first case we have seen of a spontaneous hemorrhage into a large pericardial cyst, followed by right-sided heart failure and treated successfully with thoracoscopic removal. In pericardial cysts computed tomography, echocardiographically or fluoroscopically guided puncture, aspiration, and injection is in most of the cases an ideal combination of diagnosis and treatment; only in rare cases with unclear differential diagnosis or very large or symptomatic cysts is surgical treatment necessary, as demonstrated in this case report.

	Footnotes

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Address reprint requests to Dr Borges, Division of Pneumology, Medical Department I, Schumannstr 20-21, 10117 Berlin, Germany.

	References

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1. Roober P, Maisin J, Lacquet A. Congenital pleural pericardial cysts. Thorax 1963;18:146–50.
2. Feigin DS, Fenoglio JJ, McAllister HA, Madewell JE. Pericardial cysts, a radiologic-pathologic correlation and review. Radiology 1977;125:15–20.[Abstract]
3. Lam CR. Pericardial celomic cysts. Radiology 1947;48:239–43.
4. Unverferth DV, Wooley CF. The differential diagnosis of paracardiac lesions: pericardial cysts. Cathet Cardiovasc Diagn 1979;5:31–40.[Medline]
5. Borges AC, Witt C, Bartel T, Müller S, Konertz W, Baumann G. Preoperative two- and three-dimensional transesophageal echocardiography in heart tumors. Ann Thorac Surg 1996;61:1163–7.[Abstract/Free Full Text]
6. Fredman CS, Parson SR, Aquino TI, Hamilton WP. Sudden death after a stress test in a patient with a large pericardial cyst. Am Heart J 1994;127:946–50.[Medline]
7. Vlay SC, Hartman AR. Mechanical treatment of atrial fibrillation: removal of pericardial cyst by thoracoscopy. Am Heart J 1994;127:616–8.
8. Scully RE, Mark EJ, McNeely WE, Ebeling SH. Case report of the Massachusetts General Hospital—case 5—1996. N Engl J Med 1996;335:452–8.

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Borges, A. C. Articles by Witt, C. Search for Related Content PubMed PubMed Citation Articles by Borges, A. C. Articles by Witt, C.