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Ann Thorac Surg 1998;66:607-608
© 1998 The Society of Thoracic Surgeons

Correspondence

Reply

Adrian C. Borges, MDa, Christian Witt, MDa, Gert Baumann, MDa

a Medical Department I, Medical School (Charité) of the Humboldt-University Berlin, Schumannstr 20-21, 10117 Berlin, Germany

To the Editor

Pericardial cysts and diverticula are not uncommon, but they rarely cause symptoms or life-threatening complications [1]. Pericardial cysts may present from childhood to old age. Some tumors of the pericardium such as lipoma, hemangioma, or lymphangioma may simulate the clinical, sonographic, and radiologic picture of pericardial cysts. The pericardium may be involved by metastatic neoplasms much more frequently than by primary neoplasms (sarcoma, mesothelioma) [2].

Shabb and colleagues note that cystic hydatid disease should be included in the differential diagnosis of the pericardial mass, especially in endemic areas. Essentials of diagnosis include (1) history of exposure to dogs associated with livestock in a hydatid-endemic region; (2) avascular cystic tumors of liver, lung, or less frequently other organs; and (3) positive serologic tests (we would prefer the immunoblot test given its 98% specificity and 91% sensitivity; enzyme-linked immunosorbent assay, indirect hemagglutination, and immunofluorescence are useful for screening) [3]. Ultrasound and computed tomographic scan are the modalities used most commonly to delineate pericardial cysts. Nearly pathognomonic of a hydatid cyst is the presence of daughter cysts within the main cystic cavity. Surgical treatment can be difficult in view of the need to sterilize and remove the cyst contents without spillage.

We agree with Shabb and associates that contrast-enhanced computed tomography can be useful to demonstrate adipose tissue between the cyst and the right ventricular free wall. In our experience, transesophageal echocardiography can also delineate a tissue plane between the cyst wall and the ventricular wall because of the very good spatial resolution of this method. However, in the case we described previously, we were unable to exclude a malignant neoplasm either by computed tomography or transesophageal echocardiography because hemorrhage into the cyst had created a complex mass with both solid and liquid components. Tissue diagnosis was necessary. Furthermore, aspiration was not a clinical option because of the solid components within the cyst. We found thoracoscopy, with partial cyst removal and intraoperative histologic examination, to be the most effective and least invasive method of acute and definitive treatment. For those cases in which the diagnosis is certain, the treatment of choice for the symptomatic cyst should be percutaneous drainage and sclerosis guided by computed tomography, echocardiography, or fluoroscopy. This procedure yields a very low recurrence rate on follow-up [2]. Magnetic resonance imaging is for some authors the method of choice for diagnosis and monitoring of pericardial cysts and for differential diagnosis of malignant mediastinal cystic tumors with solid components. The advantages of echocardiography are convenience, speed, and the possibility to perform the procedure at bedside in the emergency ward or operating room [4].

References

  1. Klatte E.C., Yune Y. Diagnosis and treatment of pericardial cysts. Radiology 1972;104:541-544.[Abstract/Free Full Text]
  2. McAllister H.A., Buja L.M., Ferrans V.J. Pericardial disease. In: Willerson J.T., ed. Cardiovascular medicine. New York: Churchill Livingstone, 1995:1009-1011.
  3. Kammerer W.S., Schantz P.M. Echinococcal disease. Infect Dis Clin North Am 1993;7:605-608.[Medline]
  4. Vinee P., Stover B., Sigmund G., et al. MR imaging of the pericardial cyst. J Magn Reson Imaging 1992;2:593-596.[Medline]




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