Images in Cardiovascular Medicine Constrictive Pericarditis With Pseudocirrhosis Secondary to Compression of Right Cardiac Chambers by Huge Calcific Pericardial Cystic Mass Yoshihisa Morimoto, MD, PhD; Takaki Sugimoto, MD, PhD; Hideki Sakahira, MD, PhD; Hiroki Arase, MD; Kota Araki, MD
A
73-year-old male patient was admitted to our cardiology department with complaints of exertional dyspnea and abdominal distention of 6 months’ duration. He had complained of fatigue and shortness of breath, which corresponded to New York Heart Association class III symptoms, so his physician had put him on oral diuretics. On physical examination, his heart rate was 93 bpm. The liver was enlarged and palpable 10 cm below the right costal margin. Muffled heart sounds without murmur, venous dilatation of the extremities, neck vein distension, hepatojugular reflux, and abdominal ascites were detected. Chest x-ray showed bilateral pleural effusion but did not demonstrate a hyperdense calcific mass (Figure 1). Transthoracic echocardiography showed unclear but detected compression of right cardiac chambers, dilated inferior vena cava with reduced inspiratory collapse, mild tricuspid valve regurgitation, and an estimated right ventricular systolic pressure of 46 mm Hg, whereas the left heart system was normal. Computed tomography (Figure 2) and transesophageal echocardiography (Figure 3 and Movie I in the online-only Data Supplement) displayed a 48×46×38-mm high-density area, a cystic lesion located in the anterior mediastinum adjacent to the right cardiac chambers, and bilateral pleural effusion. We scheduled elective surgery. He underwent pericardial resection via median sternotomy without cardiopulmonary bypass (Movie II in the online-only Data Supplement). Despite careful removal of the cyst, the right ventricle could not unfold properly as a result of local constriction. Only after local epicardectomy could the right ventricle could unfold again. A cystic mass with thickened calcific fibrous tissue located anterior to the right cardiac chambers was removed, and brown fluid was aspirated. Central venous pressure and pulmonary arterial systolic pressure decreased from 33 and 66 mm Hg to 16 and 38 mm Hg.
Histopathological examination of the excised pericardial cysts revealed moderate nonspecific, noncellular inflammation, calcification, and thickened connective tissue. There was no pathogen agent. The pathological diagnosis was compatible with idiopathic constrictive pericarditis (CP). The follow-up after surgery was uneventful. At 6 months after surgery, the patient was considered to be in New York Heart Association class I. Considering that the patient had no previous episode of cardiac trauma or surgery, mediastinal irradiation, tuberculosis, or other infectious diseases or neoplasms, he may have chronic subclinical pericardial inflammation. CP, an uncommon entity, is characterized by an inflammatory process that leads to progressive pericardial fibrosis encasing the heart in a thickened, fibrotic pericardium. Localized CP is rare.1–3 Only 1 case with pseudocirrhosis secondary to compression of right cardiac chambers by localized CP has been reported.4 This patient had a similar picture. The diagnosis of CP is often difficult to make. In fact, CP shows various symptoms, and cirrhosis-like symptoms is rare.
Disclosures None.
References 1. Alsemgeest F, Spiegelenberg SR, Kamp O. Cholesterol pericarditis with massive pericardial cholesterol cyst. Eur Heart J. 2012;33:1554. 2. Blaha MJ, Panjrath G, Chacko M, Schulman SP. Localized calcific constrictive pericarditis masquerading as a basal aneurysm. J Am Coll Cardiol. 2011;57:e65. 3. Hamdulay ZA, Kumar P, Ali M, Bhojraj SS, Jain SB, Patwardhan AM. Localized pericardial constriction resulting in a “dumbbell” heart. Ann Thorac Surg. 2007;83:2222–2224. 4. Akpınar I, Tüfekçioğlu O, Yücel E, Okten RS. Pseudocirrhosis; constrictive pericarditis due to huge calcific pericardial cystic mass compressing right cardiac chambers. Anadolu Kardiyol Derg. 2012;12:E24–E25.
From the Division of Cardiovascular Surgery, Awaji Medical Center, Hyogo, Japan. The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA. 113.007534/-/DC1. Correspondence to Yoshihisa Morimoto, MD, PhD, Division of Cardiovascular Surgery, Awaji Medical Center, 1-1-137 Shioya, Sumoto, Hyogo 6560021, Japan. E-mail [email protected] (Circulation. 2014;129:2080-2082.) © 2014 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIRCULATIONAHA.113.007534
Downloaded from http://circ.ahajournals.org/ at University 2080 Of Central Florida--Orlando on March 27, 2015
Morimoto et al CP by Huge Calcific Pericardial Mass 2081
Figure 1. A, A chest radiograph taken at the patient’s first visit showed bilateral pleural effusion. B, A postoperative chest radiograph showed no pleural effusion.
Figure 2. Preoperative computed tomography images. A, Horizontal view. A large calcific cystic mass is compressing right cardiac chambers. B, Axial view. C, Anterior view of the 3-dimensional reconstruction image. Top, A large calcific cystic mass and bones. Bottom, A large calcific cystic mass and a heart. D, Left lateral view of the 3-dimensional reconstruction image. Top, A large calcific cystic mass. Bottom, A large calcific cystic mass and the heart. E, Posterior view of the 3-dimensional reconstruction image.
Downloaded from http://circ.ahajournals.org/ at University Of Central Florida--Orlando on March 27, 2015
2082 Circulation May 20, 2014
Figure 3. Preoperative transesophageal echocardiography showed a large pericardial mass (arrow) with compression of the right ventricle (RV). LA indicates left atrium; LV, left ventricle; and RA, right atrium.
Downloaded from http://circ.ahajournals.org/ at University Of Central Florida--Orlando on March 27, 2015
Movie Legend:
Movie 1. Preoperative transesophageal echocardiographic showed a large pericardial mass with compression of the right ventricle. Best viewed with Windows Media Player.
Movie 2. A video recording of surgery for a constrictive pericarditis with huge calcific pericardial cystic mass. Best viewed with Windows Media Player.
Constrictive Pericarditis With Pseudocirrhosis Secondary to Compression of Right Cardiac Chambers by Huge Calcific Pericardial Cystic Mass Yoshihisa Morimoto, Takaki Sugimoto, Hideki Sakahira, Hiroki Arase and Kota Araki Circulation. 2014;129:2080-2082 doi: 10.1161/CIRCULATIONAHA.113.007534 Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2014 American Heart Association, Inc. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circ.ahajournals.org/content/129/20/2080
Data Supplement (unedited) at: http://circ.ahajournals.org/content/suppl/2014/05/19/129.20.2080.DC1.html
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Circulation can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Circulation is online at: http://circ.ahajournals.org//subscriptions/
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A
73-year-old male patient was admitted to our cardiology department with complaints of exertional dyspnea and abdominal distention of 6 months’ duration. He had complained of fatigue and shortness of breath, which corresponded to New York Heart Association class III symptoms, so his physician had put him on oral diuretics. On physical examination, his heart rate was 93 bpm. The liver was enlarged and palpable 10 cm below the right costal margin. Muffled heart sounds without murmur, venous dilatation of the extremities, neck vein distension, hepatojugular reflux, and abdominal ascites were detected. Chest x-ray showed bilateral pleural effusion but did not demonstrate a hyperdense calcific mass (Figure 1). Transthoracic echocardiography showed unclear but detected compression of right cardiac chambers, dilated inferior vena cava with reduced inspiratory collapse, mild tricuspid valve regurgitation, and an estimated right ventricular systolic pressure of 46 mm Hg, whereas the left heart system was normal. Computed tomography (Figure 2) and transesophageal echocardiography (Figure 3 and Movie I in the online-only Data Supplement) displayed a 48×46×38-mm high-density area, a cystic lesion located in the anterior mediastinum adjacent to the right cardiac chambers, and bilateral pleural effusion. We scheduled elective surgery. He underwent pericardial resection via median sternotomy without cardiopulmonary bypass (Movie II in the online-only Data Supplement). Despite careful removal of the cyst, the right ventricle could not unfold properly as a result of local constriction. Only after local epicardectomy could the right ventricle could unfold again. A cystic mass with thickened calcific fibrous tissue located anterior to the right cardiac chambers was removed, and brown fluid was aspirated. Central venous pressure and pulmonary arterial systolic pressure decreased from 33 and 66 mm Hg to 16 and 38 mm Hg.
Histopathological examination of the excised pericardial cysts revealed moderate nonspecific, noncellular inflammation, calcification, and thickened connective tissue. There was no pathogen agent. The pathological diagnosis was compatible with idiopathic constrictive pericarditis (CP). The follow-up after surgery was uneventful. At 6 months after surgery, the patient was considered to be in New York Heart Association class I. Considering that the patient had no previous episode of cardiac trauma or surgery, mediastinal irradiation, tuberculosis, or other infectious diseases or neoplasms, he may have chronic subclinical pericardial inflammation. CP, an uncommon entity, is characterized by an inflammatory process that leads to progressive pericardial fibrosis encasing the heart in a thickened, fibrotic pericardium. Localized CP is rare.1–3 Only 1 case with pseudocirrhosis secondary to compression of right cardiac chambers by localized CP has been reported.4 This patient had a similar picture. The diagnosis of CP is often difficult to make. In fact, CP shows various symptoms, and cirrhosis-like symptoms is rare.
Disclosures None.
References 1. Alsemgeest F, Spiegelenberg SR, Kamp O. Cholesterol pericarditis with massive pericardial cholesterol cyst. Eur Heart J. 2012;33:1554. 2. Blaha MJ, Panjrath G, Chacko M, Schulman SP. Localized calcific constrictive pericarditis masquerading as a basal aneurysm. J Am Coll Cardiol. 2011;57:e65. 3. Hamdulay ZA, Kumar P, Ali M, Bhojraj SS, Jain SB, Patwardhan AM. Localized pericardial constriction resulting in a “dumbbell” heart. Ann Thorac Surg. 2007;83:2222–2224. 4. Akpınar I, Tüfekçioğlu O, Yücel E, Okten RS. Pseudocirrhosis; constrictive pericarditis due to huge calcific pericardial cystic mass compressing right cardiac chambers. Anadolu Kardiyol Derg. 2012;12:E24–E25.
From the Division of Cardiovascular Surgery, Awaji Medical Center, Hyogo, Japan. The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA. 113.007534/-/DC1. Correspondence to Yoshihisa Morimoto, MD, PhD, Division of Cardiovascular Surgery, Awaji Medical Center, 1-1-137 Shioya, Sumoto, Hyogo 6560021, Japan. E-mail [email protected] (Circulation. 2014;129:2080-2082.) © 2014 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIRCULATIONAHA.113.007534
Downloaded from http://circ.ahajournals.org/ at University 2080 Of Central Florida--Orlando on March 27, 2015
Morimoto et al CP by Huge Calcific Pericardial Mass 2081
Figure 1. A, A chest radiograph taken at the patient’s first visit showed bilateral pleural effusion. B, A postoperative chest radiograph showed no pleural effusion.
Figure 2. Preoperative computed tomography images. A, Horizontal view. A large calcific cystic mass is compressing right cardiac chambers. B, Axial view. C, Anterior view of the 3-dimensional reconstruction image. Top, A large calcific cystic mass and bones. Bottom, A large calcific cystic mass and a heart. D, Left lateral view of the 3-dimensional reconstruction image. Top, A large calcific cystic mass. Bottom, A large calcific cystic mass and the heart. E, Posterior view of the 3-dimensional reconstruction image.
Downloaded from http://circ.ahajournals.org/ at University Of Central Florida--Orlando on March 27, 2015
2082 Circulation May 20, 2014
Figure 3. Preoperative transesophageal echocardiography showed a large pericardial mass (arrow) with compression of the right ventricle (RV). LA indicates left atrium; LV, left ventricle; and RA, right atrium.
Downloaded from http://circ.ahajournals.org/ at University Of Central Florida--Orlando on March 27, 2015
Movie Legend:
Movie 1. Preoperative transesophageal echocardiographic showed a large pericardial mass with compression of the right ventricle. Best viewed with Windows Media Player.
Movie 2. A video recording of surgery for a constrictive pericarditis with huge calcific pericardial cystic mass. Best viewed with Windows Media Player.
Constrictive Pericarditis With Pseudocirrhosis Secondary to Compression of Right Cardiac Chambers by Huge Calcific Pericardial Cystic Mass Yoshihisa Morimoto, Takaki Sugimoto, Hideki Sakahira, Hiroki Arase and Kota Araki Circulation. 2014;129:2080-2082 doi: 10.1161/CIRCULATIONAHA.113.007534 Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2014 American Heart Association, Inc. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circ.ahajournals.org/content/129/20/2080
Data Supplement (unedited) at: http://circ.ahajournals.org/content/suppl/2014/05/19/129.20.2080.DC1.html
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Circulation can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Circulation is online at: http://circ.ahajournals.org//subscriptions/
Downloaded from http://circ.ahajournals.org/ at University Of Central Florida--Orlando on March 27, 2015
