Congenital defect of the left pericardium with sick sinus syndrome

Multimodality Imaging Approach Evaluation of the Congenital Pericardial Defect: a Contemporary Review

PURPOSE OF REVIEW

This review presents the etiology, clinical manifestations, diagnostic approach, and treatment of congenital pericardial defects. It also highlights the critical role of echocardiography, cardiac computed tomography (CCT), and cardiac magnetic resonance (CMR) in the diagnosis and management approach.

RECENT FINDINGS

Congenital pericardial defects are rare. Although most cases are found incidentally, some cases could potentially be associated with serious outcomes including sudden cardiac death. The diagnosis is often challenging due to non-specific clinical manifestations and electrocardiogram findings. Echocardiography is the first-line imaging investigation for the evaluation of this condition. Advanced cardiac imaging modalities, including CCT and CMR, play important adjuvant roles in establishing the diagnosis and assists with prognostication.

Right pneumothorax with congenital pericardial defect showed right atrium mimicking bulla in surgery

BACKGROUND

Congenital pericardial defect (CPD) is found incidentally in cases of pneumothorax. CPD is seen in left side rather than right side and it is not generally known among thoracic surgeons how the inside of the pericardial space can be seen from the thoracic cavity in cases of pericardial defect.

CASE PRESENTATION

A 52-year-old man with dyspnea was referred to our hospital because of the diagnosis of right pneumothorax. Chest radiography showed a right lung collapse and a pneumopericardium on the left side. Despite insertion of a chest tube, air leakage prolonged, bullectomy at the apex of the right lung was performed under thoracoscopy. During surgery, thoracoscope showed that the right atrium seemed as if it had been a non-pedunculated bulla or cardiac cyst. Heart beating, continuity with the heart, and the absence of respiratory motion could distinguish the right atrium from a bulla, and pericardial defect was confirmed. Preoperatively, the patient had no cardiac symptoms related to the CPD, and therefore, it was determined that a procedure to close the CPD was not necessary. Any complication and recurrence did not occur 6 months after surgery.

CONCLUSIONS

Right pneumothorax with CPD showed right atrium mimicking bulla in surgery. It is important to consider correction of CPD if there are cardiac symptoms at the onset of pneumothorax, and not to misinterpret the right atrium as a bulla.

Case series, contemporary review and imaging guided diagnostic and management approach of congenital pericardial defects

Objective

Congenital pericardial defect (CPD) is a rare entity with an estimated frequency of 0.01%–0.04%. The recognition of this anomaly is important since it can be associated with serious complications. The aim of this study and review was to describe clinical and imaging features that help in establishing the diagnosis of this condition.

Methods

We retrospectively reviewed all adult patients at the Cleveland Clinic Health System with the diagnosis of CPD between the years 2000 and 2015. Baseline clinical characteristics, clinical manifestations, ECG, transthoracic echocardiography (TTE), cardiac CT and cardiac magnetic resonance (CMR) images were reviewed.

Results

Eight patients were included in the study. Sixty-three percent of patients were males with mean age at diagnosis of 48 years, 63% had a partial pericardial defect on the left side and right ventricular (RV) dilation on TTE. Three patients had CMR. Levocardia was present in all CMRs. One patient had greater than 60° clockwise rotation and none of the CMRs showed ballooning of the left ventricular apex. One patient required surgical pericardioplasty. The remaining seven patients had a median follow-up of 17.3 months (5–144.9 months) and all remained asymptomatic.

Conclusion

CPDs are more likely to be partial on the left side and patients often have RV dilation on the TTE and levocardia on CMR. Most patients remain stable and do not require surgical intervention. TTE and CMR play an important role in making the diagnosis of this anomaly.

Pericardial approach for cardiac therapies: old practice with new ideas

Treatment of cardiac disease via the epicardium fell under the domain of cardiac surgery due to the need for an open thoracotomy. Since an open thoracotomy is invasive in nature and has the potential for complications, a minimally invasive and percutaneous approach would be more attractive for suitable patients. The recent success of epicardial ablation of refractory arrhythmia via the percutaneous pericardial approach has increased the potential for delivery of epicardial therapies. Epicardial ablation has increased the success and safety since anti-coagulation and transseptal catheterization for left atrial arrhythmias is not required. The pericardial space has also been used to deliver therapy for several cardiac diseases. There are reports on successful delivery of drugs and their efficacy. Even though there was a wide range of efficacies reported in those studies, the reported complication rates are strikingly low, which suggests that direct delivery of drugs to the epicardium via the pericardial space is safe. Furthermore, recent animal studies have supported the feasibility of epicardial delivery of biological agents, including genes, cells, and even genetically engineered tissue for therapeutic purposes. In conclusion, percutaneous pericardial cannulation of closed pericardial space can play a significant role in providing non-surgical therapy for cardiovascular diseases. However, it requires skills and operator experiences. Therefore, there is need to further develop new tools, safer techniques, and effective procedure environment before generalizing this procedure.

Paroxysmal atrial fibrillation due to left atrial appendage herniation and review of the literature

The incidence of the isolated form of partial absence of the pericardium is a rare finding. The authors present a case of an isolated left sided pericardial defect with intrathoracic protrusion of the left atrial appendage found during a left upper lobectomy for lung cancer, unrecognized after serial echocardiographs and computed tomography scan of the thorax. The patient suffered from episodes of atrial fibrillation which disappeared after pericardial defect repair without antiarrhythmic medication.