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Ann Thorac Surg 1997;63:1147-1148
© 1997 The Society of Thoracic Surgeons

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Case Report

Pericardial Cyst Causing Right Ventricular Outflow Tract Obstruction

Section of Thoracic Surgery, Department of Surgery, University of Chicago Hospitals, Pritzker School of Medicine, Chicago, Illinois

Accepted for publication October 30, 1996.

	Abstract

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Pleuropericardial cysts are rare. Rarer still are cardiopulmonary complications caused by their presence. We report the case of a pericardial cyst producing high-grade right ventricular outflow tract obstruction and its subsequent management. The clinical importance of transesophageal echocardiography is highlighted.

	Introduction

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Pleuropericardial cysts represent 5% to 7% of all mediastinal tumors [1]. They are thought to result from failure of fusion of one of the mesenchymal lacunae that normally fuse to form the pericardial sac and usually come to lie in the region of the anterior cardiophrenic angle. The natural history of the pericardial cyst is generally benign. Most authorities recommend its removal if diagnosis is in doubt or if symptoms are present. We report the case of a giant pericardial cyst that produced right ventricular outflow tract obstruction and that presented as heart failure.

The patient is a 66-year-old man with a history of hypertension who had generally been active and in good health his entire life. Several months earlier he had noted intermittent chest discomfort that was unrelated to exertion. More recently, peripheral edema began to develop, and the patient was given increasing doses of diuretic. Due to the resistant nature of his edema, an echocardiogram was performed. Notably, in 1982, a chest radiograph identified mild cardiomegaly with extensive pericardial calcification. He had rheumatic fever as a child. He denied a history of tuberculosis, exposure to fungal disease, radiation, or recent overseas travel.

On examination, he appeared in no distress. The blood pressure was 150/70 mm Hg, and the heart rate was 80 beats/min and regular. He was afebrile. There was no jugular venous distention. There was a grade 3/4 systolic ejection murmur. The lungs were clear. The liver was of normal span. Bilateral 2+ pitting pedal edema was noted.

Routine laboratory values were unremarkable. An electrocardiogram revealed a right bundle-branch block without evidence of right ventricle hypertrophy. A chest radiograph showed extensive anterior pericardial calcifications, mild cardiomegaly, and no pulmonary vascular congestion. Purified protein derivative of tuberculin testing was equivocal.

Transthoracic two-dimensional echocardiography showed an abnormal anterior mass compressing the right ventricular free wall. Transesophageal echocardiography demonstrated the mass to be extrinsic, confined to the pericardium, and extending to compress the main pulmonary artery (Fig 1A). A 1 m/s outflow tract gradient was demonstrated. No significant valvular abnormalities were identified. Magnetic resonance imaging demonstrated an irregular mass measuring 10 by 6 cm (Fig 2). Relative T1/T2 weighting revealed a complex mass of muscle density. As the mass was symptomatic and the diagnosis remained in question, the patient was referred for operative exploration.

View larger version (120K): [in this window] [in a new window]   Fig 1. . Long-axis view on transesophageal echocardiography demonstrates the right ventricular (RV) outflow tract (A) before (arrow) and (B) after (arrowhead) pericardial cyst resection. Transesophageal echocardiography was used preoperatively and intraoperatively. (AO = aorta; LA = left atrium; LV = left ventricle; PA = pulmonary artery.)

View larger version (132K): [in this window] [in a new window]   Fig 2. . In cross-section, magnetic resonance imaging demonstrates a well-delineated mass anterior to the right ventricle (arrow).

Microbiologic stains and cultures were unremarkable. Hyphal forms were noted in a single culture bottle, but mycotic cultures failed to identify an organism. Histologic study revealed a fibrovascular cyst wall with evidence of chronic inflammation and extensive necrosis most consistent with a necrotic mesothelial cyst. Notably there were no giant cells, granulomata, acid-fast bacilli, or fungi identified.

The patient was seen in follow-up approximately 1 month after his discharge. At that time, he was well with no cardiac murmur on auscultation and near-complete resolution of his pedal edema. A follow-up transthoracic echocardiogram demonstrated no right ventricular outflow tract obstruction and a mildly hypokinetic right ventricular free wall.

	Comment

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Although pericardial cysts are rare, they are the most common benign pericardial tumor. The majority of such cysts are discovered post mortem or as an incidental finding on routine chest radiograph. Most authorities do not favor their removal if the diagnosis can be reasonably established by the classic position and configuration of the cyst.

A chest radiograph typically demonstrates the cyst occupying the anterior cardiophrenic angle, more often the right than the left side. On the lateral projection, a teardrop configuration is seen as the cyst tends to conform to the medial aspect of the pulmonary fissure. Needle aspiration of clear, watery fluid confirms the diagnosis. Resection is indicated if the diagnosis is in doubt, symptoms are present, or complications arise. The most common presenting symptoms are vague chest pain and dyspnea. Reported complications include cardiac compression [2, 3], cyst infection with or without cardiac erosion [4], and cyst rupture [5]. No cases of malignant degeneration have been reported.

This case serves to illustrate several important concerns regarding the management of such cysts. The majority of pericardial cysts may be removed safely without the use of cardiopulmonary bypass. However, cardiopulmonary bypass should be available on standby, especially if there is concern that cardiac compression may render the induction of anesthesia potentially treacherous, if erosion of the right ventricular free wall has taken place, or if resection will require extensive cardiac manipulation. Magnetic resonance imaging allowed characterization of cyst contents and established a plane between the cyst and the epicardium. Transesophageal echocardiography allowed preoperative quantification of hemodynamic compromise. Moreover, transesophageal echocardiography helped to guide the extent of resection and to document the relief of obstruction.

	Footnotes

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Address reprint requests to Dr Ng, Department of Surgery, Cooper Hospital/University Medical Center, 3 Cooper Plaza, Camden, NJ 08103.

	References

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1. McAllister HA Jr. Primary tumors and cysts of the heart and pericardium. Curr Probl Cardiol 1979;4:1–51.
2. Shaver VC, Bailey WR, Marrangoni AG. Acquired pulmonic stenosis due to external cardiac compression. Am J Cardiol 1965;16:256–61.[Medline]
3. Koch PC, Kronzon I, Winer HE, Adams P, Trubek M. Displacement of the heart by a giant mediastinal cyst. Am J Cardiol 1977;40:445–8.[Medline]
4. Chopra PS, Duke DJ, Pellet JR, Rahko PS. Pericardial cyst with partial erosion of the right ventricular wall. Ann Thorac Surg 1991;51:840–1.[Abstract]
5. King JT, Crosby I, Pugh D, Reed W. Rupture of a pericardial cyst. Chest 1971;60:611–2.[Abstract/Free Full Text]

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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 Author home page(s): Arthur F. Ng Jemi Olak Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ng, A. F. Articles by Olak, J. Search for Related Content PubMed PubMed Citation Articles by Ng, A. F. Articles by Olak, J.