A pericardial cyst is one of the rare causes of mediastinal masses. Most of the cases are secondary to congenital incomplete fusion of the pericardial sac. More than two-thirds of the cases are present in the right cardiophrenic angle, and the left cardiophrenic angle is the second most common location. In our study, we illustrated an incidental finding of the pericardial cyst in a patient who presented with nonspecific symptoms and was found to have a left-sided cardiophrenic pericardial cyst, which is only found in about 20% of the cases. A CT scan and echocardiogram confirmed the diagnosis of a 4.39-centimeter cyst with no signs of complications like tamponade or pericarditis. As the patient's symptoms resolved, outpatient follow-up with serial echocardiogram was advised. Through this report, we aim to raise awareness of the importance of further investigation for nonspecific symptoms like atypical chest tightness and differentiating simple pericardial cysts from other pericardial lesions. Based on the symptoms, size, and compression effect of the cyst, management may vary from serial echocardiogram to aspiration or surgical resection.
Introduction:
Penetrating Aortic Ulcer (PUA) is an atherosclerotic lesion with ulceration that penetrates the internal elastic lamina and allows hematoma formation within the medial layer of the aortic wall. As per our literature review, only one case of PUA causing hemopericardium has been reported.
Case Presentation
66-year-old male with an unknown past medical history was bought in by the emergency medical services following a cardiac arrest. Initial rhythm was pulseless electrical activity and return of spontaneous circulation was achieved after ten mins of cardio-pulmonary resuscitation on the field. Initial echocardiogram was significant for a 4.6 cm ascending aorta with large hemopericardium causing tamponade physiology. CT chest with contrast revealed an ectatic ascending aorta with mild irregularity along the posteromedial wall, concerning for aortic leak secondary to a penetrating aortic ulcer (as indicated by the yellow arrow in the image below). Controlled pericardiocentesis was planned as a bridging therapy while awaiting transfer to a specialized cardiothoracic unit. But, the systolic blood pressure (SBP) rose to 170 mmHg when the chest tube was first inserted, worsening the hemopericardium. The patient's condition rapidly deteriorated, causing another cardiac arrest and death.
Discussion
The recommended treatment for Type A and B PUA-associated Intra Mural Hematoma is urgent surgical aortic graft placement. For hemodynamically unstable patients who cannot be taken for urgent surgery, The 2015 European Society of Cardiology guidelines recommend controlled pericardiocentesis to maintain a target SBP of 90 mmHg as a temporary measure.
Conclusion
In addition to aortic dissection, PAU should be considered in the differentials of patients with dilated ascending aorta and hemopericardium. An acute rise in blood pressure above 90 mmHg during pericardiocentesis is associated with worsening tamponade.
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