Localized constrictive pericarditis compressing and obstructing the right ventricular inflow tract due to a giant anterior calcified cardiac mass. A case report

Abstract

HighlightsConstrictive pericarditis is a rare disorder, characterized by thick pericardial fibrosis and calcification that causes progressively impaired diastolic filling of the heart with associated symptoms of heart failure.We report a case with localized anterior calcified constrictive pericarditis with a large hematoma formation obstructing the right ventricular inflow tract.A contrast enhanced angio computerized tomography clearly demonstrated a large spherical mass about 11 × 9 × 4 cm in the anterior pericardium, presenting as a mediastinal tumor and compressing right ventricle inflow tract.With evidence of constriction confirmed, the patient underwent pericardiectomy and resection of the mass. Before sternotomy, the central venous pressure was 20 mmHg.The dissection was started from the anterior surface of the right ventricle toward the mass on the right atrioventricular groove. The outer calcified layer of the pericardial mass was a thick layer of calcification surrounded an inner amorphous low density material. This layer was easily opened and the contents of the mass appeared like old coagulated blood which was evacuated with a sterile spoon.The inferior calcified layer of the pericardial mass was carefully excised from the great vessels' origins to the diaphragm and all areas between the right and left phrenic nerves, without employimg the cardiopulmonary bypass.Constrictive pericarditis should be taken itno consideration when generalized symptoms of right-sided heart failure and decreased cardiac output are present.The differential diagnosis with other calcified masses in the anterior mediastinum such as teratoma, hemopericardium after blunt trauma and idiopathic or tuberculous constrictive pericarditis should be considered. The most common etiologies of this disorder are viral infection, renal failure, tuberculosis, radiation therapy, collagen vascular disease, prior pericardiotomy, and idiopathic constrictive pericarditis.The mechanism by which such a large amount of coagulated blood was entrapped within the mass was unclear. The inflammatory changes of the pericardium might lead to neovascular process, which is often fragile, easily ruptured, and results in a large amount of blood in the cavity. Indeed, blood was confined in the cavity mass. Pericarditis is a common cause of obstruction of cardiac structures.Pericardectomy is the only established treatment for chronic constrictive pericarditis. Careful dissection is mandatory for a successful procedure.When clinical conditions support the presence of infection, the papillary fibroelastoma may be misdiagnosed as a vegetation due to endocarditis.The differential diagnosis of PFE includes other cardiac tumors, thrombus, vegetation, and Lambl’s excrescences.Careful echocardiographic analyses during evaluation of valvular masses are strongly recommended for differential diagnosis.Immediate surgical removal and valve repair or replacement are the procedure of choice.

Pericardial constriction with calcified cystic mass compressing the right ventricle and right coronary artery

“…Calcific constrictive pericarditis is an uncommon disorder, characterized by fibrosis and calcification of the pericardium that progressively impair the diastolic filling of the heart, causing symptoms of heart failure [1] . Pericardial constriction may be localized, leading to focal compression of the right or left ventricle and rarely coronary obstruction [2][3][4][5] . Fluid collections may develop between calcified visceral and parietal layers of the pericard, causing pericardial cysts or localized pericardial mass.…”