Acute oppressive chest pain in a 66-year-old woman with a recent Amplatzer device closure of patent foramen ovale

Abstract

bpm); cardiac sounds were valid and rhythmic, without pathologic rumours. Peripheral pulses were symmetrically present and no carotid or femoral bruits were found. The electrocardiogram (ECG) revealed left axis deviation. A chest X-ray showed no pathologic findings. Considering the features of the chest pain, which was acute, oppressive, transmitted to the interscapular region and irradiated to the neck, the initial differential diagnosis was between acute coronary syndrome, pulmonary embolism and aortic dissection. Acute coronary syndrome was ruled out by ECG and myocardial damage markers, which were repeatedly negative. A pulmonary angioCT was performed and ruled out both pulmonary embolism and aortic dissection. Nevertheless the thoracic CT scan revealed a dense, circular, homogeneous mass with a maximum transverse diameter of 4 cm (Fig. 1a) located in a retrocardiac paracaval position, extended from the confluence of the inferior vena cava in the right atrium to the retrohepatic portion of the inferior vena cava, at the level of the confluence of the suprahepatic veins (Fig. 1b). A differential diagnosis among pleuro-pericardial cyst, iatrogenic paracaval haematoma (after device positioning) of the interatrial septum or pseudoaneurysm of the inferior vena cava wall was considered. Thoracic CT scan was performed with contrast medium and no enhancement of the pericaval lesion was observed after injection of contrast medium both in the arterial and venous phases. These findings were consistent with a lack of direct communication between right atrium or inferior vena cava and the pericaval lesion. The magnetic resonance imaging (MRI) confirmed the presence of the pericaval lesion with a density consistent with a liquid cyst (Fig. 1C). No additional information for the differential diagnosis could be obtained by MRI, thus the image was given a diagnosis of pleuro-pericardial cyst. Interestingly enough, standard and transoesophageal echocardiography performed at admission and repeated in the following days showed the Amplatzer on site without residual shunt, left ventricular of normal dimension and function, and in particular failed to detect the pericaval lesion, possibly because of the peculiar position of the cyst. The patient remained asymptomatic during the days following admission. Contrast CT scan was repeated twice (at day +3 and day +7) and no variation in the size and density of the lesion was observed. Given the absence of symptoms, the age, the dimension of the mass and co-morbidity, the patient is simply being followed on a regular basis. She has a clinical examination every two months and the latest thoracic CT scan, performed five months after discharge, was unchanged. Intern Emerg Med (2007) 2:229–230 DOI 10.1007/s11739-007-0064-4