Right mesothelial pericardial cyst determining intractable atrial arrhythmias

Abstract

Pericardial cysts are intrathoracic lesions usually considered to be congenital and less frequently to be acquired. They are normally found incidentally upon chest radiography, computed tomography (CT)-scan or echocardiography. They are usually asymptomatic and have a benign behavior although sometimes they can cause clinical symptoms and diagnosis can be uncertain. We present, herein, the case of a 51-year-old male with a history of atrial arrhythmia resistant to transcatheter ablation therapies with an accidental finding of a pericardial cyst adherent to the lateral wall of the right atrium at the emerging superior vena cava. The patient was studied with transesophageal echocardiography, CT-scan and cardiovascular magnetic resonance with the evidence of dimensional increasing of the cyst at seriate controls. Considering this, in the absence of a definitive diagnosis and suspecting a link between the mass and the arrhythmia, the cyst was surgically removed through median sternotomy, off-pump on a beating heart. Postoperative course was unremarkable. Histopathologic examination confirmed it was a mesothelial pericardial cyst. At 12 months of follow-up the patient is doing well and he is in sinus rhythm. In conclusion, we believe that, although the majority of pericardial cysts need only radiological and clinical follow-up, surgical resection should be performed when the patient is symptomatic and when diagnosis is uncertain.

An uncommon pericardial cyst in the central mediastinum: Incremental diagnosis with contrast-enhanced three-dimensional transesophageal echocardiography

“…[10] They are usually spherical or teardrop-shaped; cysts may be attached to the pericardium directly or by a pedicle, but they do not communicate with the pericardial space. [3] In the present case 3D TEE provided additional and more accurate details, both regarding the cyst itself (walls, content, signs of echinococcosis, and vascularization), both concerning its relations with the contiguous anatomical structures, without need of ionizing radiation or of hemodynamic stability of the patient. [1]…”

“…[1] However, pericardial cysts are very rare, with an estimated prevalence of 1:100,000 persons,[2] constituting 7% of all mediastinal masses. [3] They are encapsulated structures most commonly located in the right anterior cardiophrenic angle, although they can be found throughout the mediastinum[1](right cardiophrenic angle 51-70%, left cardiophrenic angle 28-38%, and other mediastinal locations not adjacent to the diaphragm 8-11%). Generally congenital in origin, pericardial cysts are also occasionally seen after previous cardiac surgery.…”

“…[2] The patient is frequently asymptomatic at the time of diagnosis; when symptoms occur, they are mainly due to the pressure of the cysts on adjacent organs. [3] Symptoms of atypical chest pain, dyspnea, paroxysmal tachypnea, and persistent cough are reported in about one-third of patients;[3] more rare are epigastric fullness, airway obstruction, asthma, venous obstruction, etc. [3] Possible complications are cyst rupture (leading to life-threatening pleural and pericardial effusion), erosion into adjacent structures, such as right ventricular wall or superior vena cava, cardiac tamponade or compression, mitral valve prolapse, obstruction of right main stem bronchus, and atrial fibrillation.…”

“…The imaging studies helpful in diagnosis are echocardiography, CT scan, and magnetic resonance imaging (MRI). [3] The main indications and limitation for each test are summarized in Table 1. Echocardiography remains the initial imaging method of choice for the majority of patients with pericardial disease, but in many clinical scenarios, a TTE alone is insufficient.…”

“…[1] TEE is considered a superior noninvasive modality to delineate the exact location of a pericardial cyst and to differentiate a cyst from other potential diagnoses such as fat pad, ventricular aneurysm, atrial appendage, aortic aneurysm, or a solid tumor. [310] Color Doppler is particularly helpful in differentiating a pericardial cyst from other vascular structures. [2] Pericardial cysts occur because of incomplete fusion of fetal mesenchymal lacunae forming the pericardium,[9] although it is important to recognize possible associated soft-tissue components that can be related to a malignant process; additional imaging by CT or cardiac MR is often helpful.…”