Abstract:

Pericardial cysts are usually benign, mediastinal lesions, most commonly found incidentally on routine imaging, and typically cause no physiologic symptoms. There are however, case reports of pericardial cysts causing significant cardiorespiratory symptoms in some patients. This is a case of one such patient, a 51 year-old male with recurrent, worsening dyspnea during normal exercise who was found on work up to have a pericardial cyst compressing the right ventricle. It was suspected to be the likely cause of his symptoms. Intraoperative transesophageal echocardiogram (TEE) images are presented pre and post drainage of the cyst.

Case Report:

Our 51-year-old patient had extensive, previously known, cardiac history requiring several surgical interventions. He initially underwent Ross procedure for congenital aortic stenosis followed by successful aortic and pulmonic valve replacement for valve degeneration. He most recently presented, in October 2013, to his cardiac surgeon with complaints of progressive shortness of breath when climbing stairs and during low levels of exercise. His work up included chest CT and transthoracic echocardiogram (TTE), and was found to have a 6.5 x 3.7 x 1.9 cm anterior mediastinal cyst compressing the right ventricular outflow tract (RVOT) and pulmonary artery. His valves were competent and in good condition. The cyst appeared to be in an area where a CorMatrix® patch was previously used to close the pericardium anteriorly. The patient was scheduled to undergo cyst drainage by the cardiothoracic surgeon under TEE guidance provided by our anesthesiology team.

General Anesthesia was induced using a slow cardiac induction with etomidate and fentanyl to maintain hemodynamic stability. Dopamine infusion was started shortly after an uneventful intubation to assist ventricular contraction. A TEE probe was placed. TEE imaging revealed the cyst anterior to the right ventricle on four chamber view (Figure 1). On inflow/outflow RVOT view, the cyst was seen impinging on the RVOT (Figure 2). Surgical approach was through a mini thoracotomy. The cystic area was noted by surgery to contain necrotic tissue where a patch had been previously used. Successful drainage of approximately 10-20cc of cystic fluid was accomplished through needle decompression under the guidance of TEE. TEE imaging was also used to ensure obliteration of the cyst (Figure 3). There did not appear to be significant changes in ventricular compliance, however the RVOT obstruction was improved on final imaging. Dopamine infusion was successfully discontinued after cyst drainage. The patient’s cardiorespiratory status remained stable throughout the procedure and extubation in the OR was uneventful. After a two day stay in the ICU for close observation, the patient was discharged home in stable condition. The patient has been seen in follow up postoperatively and reports a significant improvement in exercise tolerance three weeks after drainage of the cyst.

Discussion:

An interesting question arose during this case concerning the use of CorMatrix® Extracellular Matrix (ECM) patches and cyst generation. CorMatrix® ECM patches are a relatively new technology having been available since 2006. They are frequently used for pericardial closure and have the advantage of supplying a scaffolding to allow for native tissue regeneration. After a thorough literature review, we were unable to find any evidence of other case reports that linked cyst development and the use of CorMatrix® patch. It is conceivable that this phenomenon may exist and may be of interest in further studies

References:

TEE images downloaded from Phillips Xcelera®

Figure 1

Figure 2

Figure 3

Intraoperative Transesophageal Echocardiogram for Confirming Diagnosis and Treatment of Pericardial CystUniversity of Arizona Anesthesia Program

Dr. Dallas Smith, D.O.; Dr. Samata Paidy, M.D.