Ann Thorac Surg 2009;88:1010-1012. doi:10.1016/j.athoracsur.2009.01.049
© 2009 The Society of Thoracic Surgeons
Case Reports
Video-Assisted Mediastinoscopic Drainage of a Bronchogenic Cyst Presenting With Cardiac Dysfunction
Muhammad I. Aslam, MRCS,
Haitham Abunasra, FRCS,
Michael Klimatsidas, MS,
David A. Waller, FRCS(CTh)*
Department of Thoracic Surgery, University Hospitals of Leicester, Glenfield Hospital, Leicester, United Kingdom
Accepted for publication January 19, 2009.
* Address correspondence to Dr Waller, Thoracic Surgery Unit, Glenfield Hospital, Groby Rd, Leicester, LE3 9QP, United Kingdom (Email: david.waller{at}uhl-tr.nhs.uk).
 |
Abstract
|
|---|
Bronchogenic cysts originate from the anomalous development of the ventral foregut. The usual presentation of bronchogenic cyst in the mediastinum is related to cyst infection or tracheobronchial compression. We describe a case of bronchogenic cyst presenting with cardiac dysfunction and hemodynamic compromise in a 23-year-old man with chest pain and progressive dyspnea. A high body mass index and respiratory dysfunction increased the risk of open surgery. Therefore, video-assisted cervical mediastinoscopy was performed and de-roofing of the cyst achieved resolution of his cardiovascular dysfunction and symptoms.
|
Introduction
|
|---|
Bronchogenic cysts originate from the anomalous development of the ventral foregut. The usual presentation of bronchogenic cyst in the mediastinum is related to cyst infection or tracheobronchial compression. Subcarinal cysts may cause compression of the airway and very rarely present with compression of the posterior wall of the left atrium, reducing left ventricular pre-load and hemodynamic compromise. We describe a case of bronchogenic cyst presenting with cardiac dysfunction and hemodynamic compromise.
A 23-year-old man presented as an emergency with gradual onset of central chest discomfort and dyspnea, which was worst when prone. His body mass index was 32, and his arterial blood gas analysis showed a degree of type 2 respiratory failure (PaO
2 = 7.8 kPa, PaCO
2 = 6.4 kPa). A computed tomographic pulmonary angiogram was performed to exclude a pulmonary embolus and reconstructed three-dimensional computed tomographic images revealed a 78 x 63 mm, well-defined subcarinal cystic mass with peripheral calcification, causing significant compression of the posterior wall of the left atrium and the carina (Fig 1). A transthoracic echocardiogram revealed large global pericardial effusion, with 3 cm maximum rim of fluid around the right ventricle, collapsed right atrium, and significantly reduced stroke volume. The patient underwent echocardiographic-guided drainage of his pericardial effusion, but this failed to show a significant improvement in his cardiac function. The patient proceeded to the drainage of the mediastinal cyst under general anesthesia with intraoperative transesophageal echocardiography. Video-assisted cervical mediastinoscopy was performed through a cervical incision, and after dissection in the pre-tracheal plane, the cystic swelling was visualized in the subcarinal space (Fig 2). Using transesophageal echocardiographic assistance, the superior margin of the cyst was identified in the subcarinal area, dissected and carefully separated from the posterior left atrial wall and aspirated (Fig 3), with resultant immediate improvement in the cardiac function. De-roofing of the superior aspect of the cyst was performed to prevent recurrence. The patient made a swift uncomplicated postoperative recovery and was discharged 2 days later.
View larger version (78K):
[in this window]
[in a new window]
|
Fig 1. Cyst splaying the carina and causing extrinsic compression of main bronchi, especially the left main bronchus and right lower bronchus.
|
|
Three months later, a repeat computed tomographic scan showed no compression of the trachea or great vessels of the heart (Fig 4). The patient remained symptom-free and retained his full functional capacity at follow-up.
View larger version (91K):
[in this window]
[in a new window]
|
Fig 4. Postoperative computed tomographic scan shows no compression of trachea and pulmonary vessels also showing a small fluid collection at operative site.
|
|
|
Comment
|
|---|
Bronchogenic cysts are lesions of congenital origin derived from the primitive foregut [1]. A majority of these cysts are lined by columnar-ciliated epithelium and rarely communicate with the airway. Most bronchogenic cysts originate in the mediastinum, but they can be found in the lung parenchyma and many atypical locations, both below and above the diaphragm [2]. Although some bronchogenic cysts are asymptomatic and are found incidentally on radiologic investigations, the majority of cysts are symptomatic. The most frequent symptoms are cough, fever, pain, and dyspnea [3]. In children, tracheobronchial compression and respiratory distress are relatively more common due to their soft tracheobronchial tree [4]. Subcarinal cysts may cause compression of the airway and very rarely present with compression of the posterior wall of the left atrium [5], reducing left ventricular pre-load and hemodynamic compromise, as seen in this case. If a subcarinal bronchial cyst enlarges, it may become adherent to the left atrium and there may be an increased risk of bleeding, acute cardiovascular collapse, and difficulty in dissection [6]. Video-assisted mediastinoscopic cyst drainage has the advantage of reduced morbidity compared with open removal through a median sternotomy or thoracotomy. Some surgeons believe that removal of the endothelium is necessary to prevent recurrence but de-roofing also prevents recurrence. The total excision of the cyst wall might not be achieved [7], but removal of more than 50% of the cyst wall [8] will help the surrounding tissues to absorb the small amount of fluid secreted by the remnant cyst wall and will prevent recurrence. Video-assisted mediastinoscopy offers a minimally invasive option, especially for those patients who are at high operative risk due to cardiovascular compromise and may be considered as an initial option in all such patients.
|
References
|
|---|
- Aktogu S, Yuncu G, Halilcolar H, Ermete S, Buduneli T. Bronchogenic cysts: clinicopathological presentation and treatment Eur Respir J 1996;9:2017-2021.[Abstract/Free Full Text]
- Alpay Sarper, Arife Ayten, Ilhan Golbasi, et al. Bronchogenic cyst Tex Heart Inst J 2003;30:105-108.[Medline]
- St. Georges R, Deslauriers J, Duranceau A, et al. Clinical spectrum of bronchogenic cysts of the mediastinum and lung in the adult Ann Thorac Surg 1991;52:6-13.[Abstract/Free Full Text]
- Ramenofsky ML, Leape LL, McCauley RG. Bronchogenic cyst J Pediatr Surg 1979;14:219-224.[Medline]
- Tohru Mawatari, Toshiro Itoh, Yoshikazu Hachiro, et al. Large bronchial cyst causing compression of the left atrium Ann Thorac Cardiovasc Surg 2003;9:261-263.[Medline]
- Fratellone PM, Coplan N, Friedman M, Stelzer P. Hemodynamic compromise secondary to a mediastinal bronchogenic cyst Chest 1994;106:610-612.[Abstract/Free Full Text]
- Smythe WR, Bavaria JE, Kaiser LR. Mediastinoscopic subtotal removal of mediastinal cysts Chest 1998;114:614-617.[Abstract/Free Full Text]
- Burjonrappa SC, Taddeucci R, Arcidi J. Mediastinoscopy in the treatment of mediastinal cysts JSLS 2005;9:142-148.[Medline]
This article has been cited by other articles:
|
|
|
|
 
J. Lesaffer, B. Heremans, P. De Leyn, and D. Van Raemdonck
Video-assisted mediastinoscopic resection of a large symptomatic bronchogenic cyst
Interact CardioVasc Thorac Surg,
June 1, 2011;
12(6):
1071 - 1073.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
