Congenital absence of the pericardium and its relationship to the ligamentum arteriosum

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.

Congenital partial defect of the left pericardium presenting as chest pain

Congenital pericardial defect is a rare cardiac defect with variable clinical presentations. It is usually an unexpected finding during cardiac surgery or autopsy. The clinical detection of congenital absence of pericardium is important because of its life-threatening complications such as fatal myocardial strangulation, myocardial ischaemia and sudden death. We present a patient with the incidental finding of left-sided partial defect of the pericardium during evaluation of chest pain.

Complete congenital absence of the pericardium: An incidental finding

A 62-year-old male presented with generalized aches and pains accompanied by night sweats and weight loss. Clinical examination was unremarkable and the chest X-ray was reported as normal. Subsequent computed-tomography thorax and bone marrow aspirate diagnosed a diffuse large B-cell lymphoma. Prior to commencing chemotherapy, a routine echocardiography proved technically difficult and reported abnormal ventricular function. Following a cardiology review, a cardiovascular magnetic resonance scan was requested which demonstrated congenital absence of the pericardium and a normal ventricular function. The patient was asymptomatic and therefore continued on to chemotherapy treatment for the large B-cell lymphoma. <Learning objective: Congenital complete absence of the pericardium (CCAP) is a rare condition that often presents atypically and is detected incidentally. Multi-parametric, non-invasive cardiac imaging such as cardiovascular magnetic resonance imaging is the gold-standard diagnostic tool. CCAP is usually asymptomatic and does not require any surgical intervention. However, symptomatic patients who may be at risk of serious complications require surgical treatment such as pericardiotomy or pericardioplasty. Routine investigations such as the electrocardiogram, the chest X-ray, and the echocardiography may raise clinical suspicions of CCAP as demonstrated in this case report.>.

Partial absence of pleuropericardial membranes in Tbx18- and Wt1-deficient mice

The pleuropericardial membranes are fibro-serous walls that separate the pericardial and pleural cavities and anchor the heart inside the mediastinum. Partial or complete absence of pleuropericardial membranes is a rare human disease, the etiology of which is poorly understood. As an attempt to better understand these defects, we wished to analyze the cellular and molecular mechanisms directing the separation of pericardial and pleural cavities by pleuropericardial membranes in the mouse. We found by histological analyses that both in Tbx18- and Wt1-deficient mice the pleural and pericardial cavities communicate due to a partial absence of the pleuropericardial membranes in the hilus region. We trace these defects to a persisting embryonic connection between these cavities, the pericardioperitoneal canals. Furthermore, we identify mesenchymal ridges in the sinus venosus region that tether the growing pleuropericardial membranes to the hilus of the lung, and thus, close the pericardioperitoneal canals. In Tbx18-deficient embryos these mesenchymal ridges are not established, whereas in Wt1-deficient embryos the final fusion process between these tissues and the body wall does not occur. We suggest that this fusion is an active rather than a passive process, and discuss the interrelation between closure of the pericardioperitoneal canals, lateral release of the pleuropericardial membranes from the lateral body wall, and sinus horn development.

Congenital pericardial defect: report of two cases and literature review

The authors report two cases of congenital pericardial defect and emphasize the role of MRI as a diagnostic tool. A review of the development of the pericardium and of the various possible explanations dealing with these abnormalities is then presented. Finally, clinical data and diagnosis and therapeutic options are discussed.

Congenital absence of pericardium revisited

Although much have been published regarding congenital absence of pericardium, it is essential that this anomaly, like an old friend, be revisited from time to time. Review of this anomaly with emphasis on its embryological process is discussed. Furthermore, with the advances in magnetic resonance imaging, absence of pericardium can now be diagnosed with ease and the radiological findings of this condition are reviewed as well.

An unusually long ligamentum arteriosum

During routine laboratory dissections an unusually long ligamentum arteriosum, measuring 40 mm, was observed. Apparently, such a length for an otherwise normal ligamentum has not been reported previously. Forty-three other ligamenta in adults and three in newborn or stillborn infants were also measured having a range of 8 mm to 24 mm (mean 15.47 mm) and 7.5 mm to 11 mm (mean 9.5 mm) respectively. Since short and long ligaments have been reported previously, both in the newborn as well as in the adult, the variability in length of this structure appears normal and without any functional significance.

Congenital partial and complete absence of the pericardium

Between 1952 and 1991, 15 Mayo patients were found to have partial or complete absence of the pericardium at the time of a cardiovascular surgical procedure. One patient with complete absence of the left pericardium had symptoms possibly related to the pericardial abnormality. This 42-year-old man had severe insufficiency of the tricuspid valve attributable to chordal rupture of the anterior leaflet, possibly precipitated by complete displacement of the heart into the left pleural space. Excision of the ruptured chordae and plication of the anterior flail leaflet rendered a competent tricuspid valve. In two patients, a small defect in the pericardium was repaired. Three patients who underwent operation for complex congenital heart disease died: two early postoperatively and one late after a reoperation. In the other 12 patients, no early or late postoperative complications were encountered. Although rare and usually asymptomatic, complete and partial deficiency of the pericardium may lead to serious complications such as cardiac valvular insufficiency or incarceration of cardiac tissue.