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Case Studies /

Pericardial Mass

Noninvasive Assessment of a Pericardial Mass

Virginia Workman, M.D., M.Sc.​ Clinical Fellow
Department of Cardiovascular Medicine. Yale University

A 53-year-old man with history of alcoholic cirrhosis, refractory ascites, s/p peritoneovenous shunt placement, chest X-ray, suggested pericardial calcifications and enlargement of the cardiomediastinal silhouette. He was referred for cardiac MRI.

Cardiac MRI Cine sequence  
4-chamber view.

Magnetic resonance imaging demonstrated a large heterogeneous anterior pericardial mass measuring 13 x 7.5, and a right atrial catheter-associated thrombus.

Septal bounce is noted, which suggests constrictive physiology.

Subcostal view. Dilated  inferior vena cava.

2-dimensional echocardiography demonstrated dilated, noncompressible IVC and tricuspid valve inflow variation, supporting a diagnosis of pericardial constriction.

Cardiac MRI First-pass perfusion sequence in short axis view, mid-ventricular level.

There is no clear evidence of communication of flow from the right ventricle into the pericardial-based mass. However, the heterogeneous appearance and density are consistent with possible thrombus/hematoma. Differential diagnosis includes contained RV rupture given his history of chronic indwelling venous catheter placement. 

Apical 4 chamber view, pulse-wave doppler through tricuspid valve demonstrating significant inflow velocity variation.
Cardiac CT 
Mid-ventricular short axis view.

Computed tomography sequences with retrospective ECG gating were constructed to rule out a communication between the right ventricle and the pericardial-based mass. No clear communication between the RV and mass was visualized. 

Cardiac CT ​RA inflow view.

A rim of calcium suggests the mass is chronic. The IVC is markedly dilated. Contrast stasis suggests compressive effects of the right atrial thrombus, which appears to extend into SVC and IVC on this study.

Clinical Course and Final Diagnosis
  • Unfortunately patient expired secondary to septic shock.

  • Autopsy demonstrated a large thin-walled calcified pericardial cyst, with evidence of acute and chronic inflammation and recent hemorrhage. 

  • The final cause of his refractory ascites was determined to be portal hypertension due to constrictive pericarditis secondary to congenital pericardial cyst. 

Pericardial Cysts
  • Prevalence of pericardial cysts is estimated to be approximately 1 in 100,000.

  • The majority of cases are diagnosed between the third and fifth decades of life.

  • Etiologies include infectious (echinococcal), traumatic, and postsurgical, but the vast majority of cases are thought to be congenital in origin.​​

  • Congenital cases are caused by herniation through structural defects in the pericardial sac early in embryonic development, with most cysts presenting in the right or left cardiophrenic angle. Pericardial cysts and diverticula are thought to have a common embryologic origin, with cysts occurring due to loss of communication between the cyst and pericardial space.

  • The majority of cases are incidentally noted on imaging studies and asymptomatic at diagnosis, though the most common presenting symptoms are chest pain (22% of patients) and dyspnea (10% of patients).

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Imaging Modalities

Echocardiography is generally recommended as the initial test of choice given its wide availability, low cost, and safety profile. Further imaging with either cardiac CT or cardiac MRI is indicated to evaluate the exact size, location, and relation to surrounding anatomical structures for surgical planning or to further guide the decision to pursue resection.

 

  • Echocardiogram
    Cyst interior is anechoic. As the most common cyst location is in the R anterior cardiophrenic angle, parasternal echocardiography windows may be obtained with no lung attenuation in most patients.

 

  • Cardiac CT
    Simple cysts demonstrate the same attenuation as water (characteristic Hounsfield unit range 0-20 HU). Cysts do not take up contrast.

 

  • Cardiac MRI
    Cysts generally demonstrate a low signal intensity on T1-weighted images and a homogeneous high signal intensity on T2-weighted STIR images or fat-suppressed images. Cysts with highly proteinaceous contents may have high-intensity signal on T1-weighted images. Cysts do not enhance with gadolinium on late gadolinium enhancement sequences.

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Management
  • Small, asymptomatic cysts are generally observed with serial echocardiography examination. Cysts that are large, symptomatic, or deemed high-risk for complication are managed with surgical resection. VATS is the most common approach, but mediastinoscopy or thoracotomy may be required based on location.

 

  • Echo or CT-guided percutaneous aspiration with or without ethanol sclerosis may be pursued in patients waiting for surgery or who are not surgical candidates, but recurrence rates are high.

 

  • Complications requiring resection include:

    • right heart failure

    • secondary infection with erosion into surrounding myocardium

    • rapid growth due to hemorrhage in setting of trauma

    • conduction system infiltration and heart block

    • rupture into pericardial sac with tamponade

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References
  1. Le Roux BT. Pericardial Coelomic Cysts. Thorax 14 (1959):27-35.
     

  2. Feigin DS, Fenoglio JJ, McAllister HA, and Madewell JE. Pericardial Cysts: A Radiologic-Pathologic Correlation and Review. Radiology 125 (1977):15-20.
     

  3. Kar SK, Ganguly T. Current Concepts of Diagnosis and Management of Pericardial Cysts. Indian Heart J 69 (2017):364-370.
     

  4. Lambert AV. Etiology of Thin-Walled Thoracic Cysts. J Thorac Surg 10 (1940):1-7.
     

  5. Lillie WI, McDonald JR, and Clagett OT. Pericardialcelomic Cysts and Pericardial Diverticula; a concept of etiology and report of cases. J Thorac Surg 20 (1950):494-504.
     

  6. Verhaert D, Gabriel RS, Johnston D, Lytle BW, Desai MY, Klein AL. The Role of Multimodality Imaging in the Management of Pericardial Disease. Circ Cardiovasc Imaging 3 (2010):333-343.
     

  7. Wang ZJ, Reddy GP, Gotway MB, Yeh BM, Hetts SW, and Higgins CB. CT and MR Imaging of Pericardial Disease. RadioGraphics 23 (2003):S167-S180.
     

  8. Martins IM, Fernandes, JM, Gelape CL, Baulio R, Silva VC, and Nunes MCP. A Large Pericardial Cyst Presenting with Compression of the Right-Side Cardiac Chambers. Braz J Cardiovasc Surg 26 (2011):504-507.
     

  9. Chopra PS, Duke DJ, Pellett JR, Rahko PS. Pericardial Cyst with Partial Erosion of the Right Ventricular Wall. Ann Thorac Surg 51 (1991):840-841.
     

  10. Temizkan V, Burak O, Kaan I, Alper U, and Yilmaz AT. Hemorrhage Into a Pericardial Cyst and Associated Right Ventricular Compression After Blunt Chest Trauma. Ann Thorac Surg 89 (2010):1292-1295.
     

  11. Fredman CS, Parsons SR, Aquino TI, and Hamilton WP. Sudden Death After a Stress Test in a Patient with a Large Pericardial Cyst. Am Heart J 127 (1994):946-950.
     

  12. Tanoue Y, Fujita S, Kanaya Y, and Tominaga R. Acute Cardiac Tamponade Due to a Bleeding Pericardial Cyst in a 3-Year-Old Child. Ann Thorac Surg 84 (2004):282-284.

Case Studies /

Pericardial Mass