A pericardial cyst is a benign structur-al abnormality of the pericardium that is usually detected as an incidental mass le-sion on chest X-ray in asymptomatic per-sons. Pericardial cysts are not only con-genital, but can be also acquired pericardi-al anomalies (e.g. post-inflammatory, hy-datid cyst).
When it is symptomatic, pericardial cysts present with dyspnoea, chest pain or persistent cough. Most frequently, it is located at the right costophrenic angle, but it may also be found at the left costo-phrenic angle, hilum, or superior medias-tinum. The differential diagnosis of such a chest radiographic finding includes ma-lignant tumor, cardiac chamber enlarge-ment, diaphragmatic hernia and bron-chogenic cyst. Pericardial cysts appear as a cystic structure attached to the heart on cardiac imaging. Two-dimensional echo-cardiography, cardiac computed tomogra-phy (CT), or cardiac magnetic resonance imaging (CMR) may be used to differen-tiate pericardial cysts from other solid tu-mors. In asymptomatic patients, no treat-ment is necessary.
A 72-year-old woman presented to our outpatient clinic for dyspnoea and chest discomfort with minimal exertion. Her blood pressure was 100/80 mmHg. There was normal sinus rhythm in her ECG. The symptoms were present for 9 months. She had no history of any disease and she was non-smoker. A chest X-ray showed an en-
larged right heart border (.Fig.1). Api-cal four-chamber view of the transtho-racic echocardiogram showed an echolu-cent space next to the right atrium consis-tent with a pericardial cyst. The right and left ventricular chamber size and func-tion were normal, and there was sclero-sis in aortic valve compatible with her age (.Fig.2, 3, Video 1). The CT of the chest revealed a large mass adjacent to the right heart and outside the pericardium (.Fig.4). The patient refused admin-istration of intravenous contrast materi-al. Thus, on the CT scan (.Fig.4), the compression of adjacent organs and the characteristics of the mass could not be definitely established which precluded its complete evaluation. Blood chemistry was normal. There was no eosinophilia (3.3%), and an Echinococcus haemaglutination test was negative. Coronary angiography showed normal coronary arteries. The pa-tient did not accept video-assisted thora-coscopic surgery for either treatment or the establishment of a definite diagnosis.
Pericardial cysts are incidentally found in most cases. The diagnosis is frequent-ly suspected due to abnormal findings on chest X-ray, demonstrating an enlarged contour of the right heart border. Addi-tional diagnostic techniques for pericar-dial cysts are transthoracic echocardiog-raphy, computed tomography, and mag-netic resonance imaging of the chest .
Apical and subxiphoid images of the transthoracic echocardiogram can further delineate the margins and cystic charac-ter of the echolucent mass adjoining the cardiac border, initially diagnosed with a chest X-ray or other imaging study. The transthoracic echocardiogram also has the advantage of eliminating other possi-ble diagnoses, including aortic aneurysm, prominent fat pad, solid tumours, prom-inent left atrial appendage and left ven-tricular aneurysm . A loculated peri-cardial effusion also can mimic a pericar-dial cyst on transthoracic echocardiogra-
Additional material online
e-Herz: Case study
phy; thus differentiating one from the oth-er can be extremely difficult. However, in some cases, a pericardial cyst may be dif-ferentiated from a loculated pericardial ef-fusion by the presence of a thin wall sep-arating the cyst from the main pericardial
space. The transoesophageal echocardio-gram also plays an important role in es-tablishing a diagnosis of a pericardial cyst in atypical locations and in those instanc-es when transthoracic echocardiographic images are not adequate for the diagnosis.
Cardiac CT and CMR offer superb, de-tailed anatomical description of pericar-dial lesions and are valuable in the eval-uation of associated extracardiac diseas-es during the preoperative period [3, 4].
Pericardial cysts appear as oval, thin-walled, and well-defined homogeneous masses on CT. Usually, pericardial cysts fail to enhance in contrast imaging with both cardiac CT and CMR .
Seventy-five percent of pericardial cysts have no associated symptoms . Symptoms, when present, are usually due to compression of adjacent organs and in-clude atypical chest pain, dyspnoea and persistent cough . Sudden death, car-diac tamponade, rupture of the cyst, ob-struction of the right ventricular outflow, pulmonary stenosis, erosion of the cyst in-to the superior vena cava and right ven-tricular wall, congestive heart failure, atri-al fibrillation, pericarditis, and obstruc-tion of the bronchi can be encountered as complications of pericardial cysts [5, 6].
Management of a pericardial cyst de-pends on the characteristics of the cyst and the occurrence of symptoms. Serial transthoracic echocardiography is used to monitor asymptomatic patients and en-sure a benign course in which the pericar-dial cyst can resolve spontaneously [7, 8]. Among patients who have a symptomatic pericardial cyst, resection of cyst with ei-ther a thoracotomy or video-assisted tho-racoscopic surgery has been the most pre-ferred approach . Percutaneous punc-ture and aspiration of pericardial cysts, guided by echocardiography, ultrasonog-raphy or CT is also an option that has been reported with excellent results [9, 10].
Spontaneous resolution of a pericardial cyst has been previously reported. These cases underscore the role of conserva-tive management in this group of patients and suggest there is a small possibility of spontaneous resolution of these cysts [8, 11]. Previous reports discuss the possibili-ty of rupture of the cyst in a watchful wait-ing approach, but more thorough scientif-ic documentation is required to confirm this .
2 | Herz2013
e-Herz: Case study
Compliance with ethical guidelines.
Conflict of interest. T.Bezgin,A.Elveran,S.Varol,C.Doan,A.Karagz,andA.M.Esenstatethattherearenoconflictsofinterest.