1234 Enlarging Pericardial Cyst Compressing the Right Ventricle

Abstract

Abstract 52-year-old Indian builder initially presented to his General Practitioner with exertional breathlessness but no angina. His medical history included previous tuberculosis infection, Type 2 Diabetes Mellitus and hypothyroidism. He was referred to the cardiologist to exclude coronary artery disease. Stress testing found T-wave inversion in the inferior electrocardiogram leads and transthoracic echocardiogram showed reduced right ventricular (RV) function with basal wall hypokinesia. Cardiac Magnetic Resonance Imaging (MRI) revealed a 5cm x 2.5cm pericardial cyst (Figure 1a). As imaging suggested minimal RV compression and no venous obstruction, the patient was investigated for other causes of breathlessness. Repeat computed tomography (CT) two years later demonstrated enlargement of the cyst (6cm x 3.6cm) with contrast reflux into the inferior vena cava (IVC) (Figure 1b). Due to worsening breathlessness, surgical excision was offered. Surgery was attempted through a lower hemi-sternotomy. However, due to limited access to the cyst and thickened pericardium, median sternotomy was performed. The cyst measured 10cm x 7cm and was heavily adherent to the RV wall, right atrium and IVC preventing complete excision. The cyst was therefore unroofed, releasing cheese-like material suspicious of a tuberculous cyst (Figure 2). Adhesiolysis was undertaken to remove remaining cyst wall. Prior to closure, inflamed pericardial tissue was excised. Histopathology revealed a chronically inflamed pseudocyst with necrotising and non-necrotising granulomatous inflammation. Ziehl-Neelsen, Grocott, Gram and periodic acid-Schiff-diastase stains were negative. Intraoperative and histological findings and history of tuberculosis suggested a diagnosis of tuberculous pericardial cyst. The patient recovered uneventfully with significant symptomatic improvement at 2-month follow-up.