Ann Thorac Surg 2003;75:1629-1631
© 2003 The Society of Thoracic Surgeons
Case report
Chronic expanding hematoma in the pericardial cavity after cardiac surgery
Shinji Hirai, MDa*,
Yoshiharu Hamanaka, MDa,
Norimasa Mitsui, MDa,
Mitsuhiro Isaka, MDa,
Taira Kobayashi, MDa
a Department of Thoracic and Cardiovascular Surgery, Hiroshima Prefecture Hospital, Hiroshima, Japan
Accepted for publication October 27, 2002.
* Address reprint requests to Dr Hirai, Department of Thoracic and Cardiovascular Surgery, Hiroshima Prefecture Hospital, 1-5-54, Ujinakanda, Minami-ku, Hiroshima 734-8530, Japan.
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Abstract
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We report the successful surgical treatment of a rare case of chronic expanding hematoma in the pericardial cavity that developed into a very large mass over a long period. The patient, who had a history of cardiac surgery for a double-outlet right ventricle 14 years previously and for tricuspid regurgitation 8 years ago, noticed a slowly growing mass near the left atrium and ventricle 5 years ago. The mass, which comfirmed a diagnosis of chronic expanding hematoma, was resected by left thoracotomy.
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Introduction
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Hematomas caused by surgery or trauma usually resolve without sequelae. However, a chronic expanding hematoma can sometimes develop into a very large mass over a long period of time. An expanding hematoma can be difficult to distinguish from malignant tumors. Although chronic expanding hematoma in the chest is known as a specific type of chronic empyema or chronic pleurisy [1, 2] chronic expanding hematoma in the pericardial cavity after cardiac surgery is very rare. The mechanism of expansion of such hematomas is still incompletely understood. The irritation releases vasoactive substances and induces capsule formation, while repeated inflammation seems to result in effusion and new bleeding from damaged microvessels beneath the capsule. We describe a pericardial chronic expanding hematoma that had developed into a very large mass over a long period of time after several cardiac operations and report the successful surgical treatment of this rare case.
A 63-year-old woman was admitted with cough and chest discomfort on inspiration. She had no treatment history of tuberculosis but she had a history of cardiac surgery for a double-outlet right ventricle 14 years previously and for tricuspid regurgitation 8 years previously. A small mass near the left atrium and ventricle had been detected 5 years earlier by chest roentgenography and cardiac ultrasonography. The mass had gradually increased to 88 x 66 mm in size. Chest computed tomography (CT) revealed an encapsulated tumor with calcification that compressed the heart and the left lower lung field. On magnetic resonance imaging (MRI), T1-weighted images demonstrated a high-intensity area and T2-weighted images demonstrated a mixture of nonhomogeneous hypointense areas and high-intensity areas surrounded by a low-intensity rim (Fig 1).
As we could not rule out a pericardial or mediastinal tumor with bleeding, the mass was resected by left thoracotomy. At operation a firm mass was covered by a thickened pericardium and it appeared to be a well-circumscribed organized hematoma (Fig 2).
Pathology examination showed fresh and old hematomas including small blood vessels and no malignant change was observed. It confirmed a diagnosis of chronic expanding hematoma. The patient’s postoperative course and recovery were uneventful.
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Fig 1. Magnetic resonance T1-weighted images (left) demonstrated a high-intensity area and T2-weighted images (right) demonstrated a mixture of nonhomogeneous hypointense areas and high-intensity areas surrounded by a low-intensity rim.
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Fig 2. (Left) Operative findings showed a firm mass that was covered by a thickened pericardium. (Right) It appeared to be a well-circumscribed organized hematoma (arrow) that was covered by thickened pericardium (arrowheads).
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Comment
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Hematoma caused by surgery or trauma usually resolves without sequelae but chronic expanding hematoma can develop into a very large mass over a long period. Chronic expanding hematoma can potentially occur at various locations [3]. Chronic expanding hematoma in the pericardial cavity after cardiac surgery as in our case is very rare, however. In previous reports chronic expanding hematoma of the chest has been described as a specific type of chronic empyema, ie, so-called organizing empyema caused by thoracoplasty or tuberculous pleurisy [1, 2, 4]. Chronic expanding hematoma has no associated evidence of bacterial infection and consists of an organizing hematoma surrounded by dense fibrous tissue.
The mechanism of expansion of such hematomas is still imcompletely understood. Labadie and associates [5] have shown that the self-perpetuating expanding nature of these lesions may be related to an inflammatory reaction stimulated by the irritant effect of blood and its breakdown products. The irritation releases vasoactive substances and induces capsule formation while repeated inflammation seems to result in effusion and new bleeding from damaged microvessels beneath the capsule. Clinically the trigger of expansion is still unknown. We suppose that in the present case it might have originated from recurrent pericarditis caused by repeated cardiac surgery.
The best diagnostic procedures for chronic expanding hematoma include CT and MRI. We recommend MRI as the diagnostic procedure of choice because the findings on T1- and T2-weighted images have characteristics, including high-intensity areas, similar to those found in a hemangioma owing to the presence of fresh and old hematoma. Nonetheless it is said that chronic expanding hematoma is difficult to differentiate from mlignant tumors such as malignant lymphoma, soft tissue sarcoma, and squamous cell carcinoma and that only resection can make a definitive diagnosis. The management of such hematomas should be complete surgical resection at an early stage before cardiac and mediastinal compression or extrathoracic protrusion occur in the late stage. We conclude that chronic expanding hematoma remains a rare disease but should be considered when an expanding mass is found in the chest after cardiac surgery.
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References
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- Uramoto H., Nakanishi R., Eifuku H., et al. Chronic expanding hematoma in the chest. J Cardiovasc Surg 2000;41:143-146.[Medline]
- Hanagiri T., Muranaka H., Hashimoto M., et al. Chronic expanding hematom in the chest. Ann Thorac Surg 1997;64:559-561.[Abstract/Free Full Text]
- Ried J.D., Kommareddi S., Lankerani M., Park M.C. Chronic expanding hematomas. A clinicopathologic entity. JAMA 1980;244:2441-2442.[Abstract/Free Full Text]
- Nomori H., Horino H., Kobayashi R., Morinaga S. Expanding intrathoracic hemorrhagic lesion penetrating the thoracic wall: a rare complication of chronic tuberculous pleurisy. Thorac Cardiovasc Surg 1995;43:358-360.[Medline]
- Labadie E.L., Glover D. Physiopathogenesis of subdural hematomas. Part 1: Histological and biochemical comparisons of subcutaneous hematoma in rats with subdural hematoma in man. J Neurosurg 1976;45:382-392.[Medline]
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Abstract
Introduction
