Constrictive Pericarditis Presenting as a Calcified Anterior Cardiac Mass

Surgical resection of enlarged calcification formed by idiopathic localized constrictive pericarditis during total aortic arch replacement for aortic dissection

A 75-year-old woman presented at a prior hospital with persistent cough and was treated conservatively for a thrombosed-type aortic dissection (Stanford A). One-year after discharge, follow-up computerized tomography revealed a DeBakey type II, chronic dissecting aortic aneurysm enlarged to 54 mm. She was referred to our hospital with slight edema in the face and extremities and chest radiography showed calcification around the heart. Computerized tomography performed at the prior hospital showed a large spherical mass in the anterior pericardium in addition to the aortic dissection. We therefore resected the mass immediately before a total aortic arch replacement. Surgery was successful and uneventful with patient discharge on postoperative day 21. The final differential diagnosis was idiopathic, localized, constrictive pericarditis.

Localized constrictive pericarditis compressing and obstructing the right ventricular inflow tract due to a giant anterior calcified cardiac mass. A case report

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Constrictive pericarditis is a rare disorder, characterized by thick pericardial fibrosis and calcification that causes progressively impaired diastolic filling of the heart with associated symptoms of heart failure.

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We report a case with localized anterior calcified constrictive pericarditis with a large hematoma formation obstructing the right ventricular inflow tract.

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A contrast enhanced angio computerized tomography clearly demonstrated a large spherical mass about 11 × 9 × 4 cm in the anterior pericardium, presenting as a mediastinal tumor and compressing right ventricle inflow tract.

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With evidence of constriction confirmed, the patient underwent pericardiectomy and resection of the mass. Before sternotomy, the central venous pressure was 20 mmHg.

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The dissection was started from the anterior surface of the right ventricle toward the mass on the right atrioventricular groove. The outer calcified layer of the pericardial mass was a thick layer of calcification surrounded an inner amorphous low density material. This layer was easily opened and the contents of the mass appeared like old coagulated blood which was evacuated with a sterile spoon.

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The inferior calcified layer of the pericardial mass was carefully excised from the great vessels' origins to the diaphragm and all areas between the right and left phrenic nerves, without employimg the cardiopulmonary bypass.

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Constrictive pericarditis should be taken itno consideration when generalized symptoms of right-sided heart failure and decreased cardiac output are present.

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The differential diagnosis with other calcified masses in the anterior mediastinum such as teratoma, hemopericardium after blunt trauma and idiopathic or tuberculous constrictive pericarditis should be considered. The most common etiologies of this disorder are viral infection, renal failure, tuberculosis, radiation therapy, collagen vascular disease, prior pericardiotomy, and idiopathic constrictive pericarditis.

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The mechanism by which such a large amount of coagulated blood was entrapped within the mass was unclear. The inflammatory changes of the pericardium might lead to neovascular process, which is often fragile, easily ruptured, and results in a large amount of blood in the cavity. Indeed, blood was confined in the cavity mass. Pericarditis is a common cause of obstruction of cardiac structures.

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Pericardectomy is the only established treatment for chronic constrictive pericarditis. Careful dissection is mandatory for a successful procedure.

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When clinical conditions support the presence of infection, the papillary fibroelastoma may be misdiagnosed as a vegetation due to endocarditis.

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The differential diagnosis of PFE includes other cardiac tumors, thrombus, vegetation, and Lambl’s excrescences.

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Careful echocardiographic analyses during evaluation of valvular masses are strongly recommended for differential diagnosis.

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Immediate surgical removal and valve repair or replacement are the procedure of choice.

Introduction

Localized pericardial constriction is a rare form of constrictive pericarditis CP. Depending on the CP location, clinical presentation may be variable, including compression and obstruction of right ventricular inflow tract(RVIT), coronary obstruction, or pulmonary stenosis.

Case presentation

A 72-year-old man presented a 2-year history of dyspnea and atrial fibrillation. A contrast enhanced angio computerized tomography clearly demonstrated a large spherical mass about 11 × 9 × 4 cm in the anterior pericardium, presenting as a mediastinal tumor causing compression and obstruction of the RVIT. The patient underwent surgical procedure. The outer calcified layer of the pericardial mass was a thick layer of calcification surrounding an inner amorphous low density material. The inferior calcified layer of the pericardial mass which was extremely adherent with the epicardium, was carefully excised, without employment of cardiopulmonary bypass, from the aorta and pulmonary artery origin to the diaphragm and all areas between the right and left phrenic nerves. The final diagnosis was idiopathic CP.

Discussion

The clinical presentation was due to right ventricular free wall compression and obstruction of the RVIT by a giant calcified anterior cardiac mass. The differential diagnosis with other calcified masses in the anterior mediastinum such as teratoma, hemopericardium after blunt trauma and idiopathic or tuberculous CP should be considered.

Conclusion

Herein we report a very rare case with localized CP causing compression and obstruction of RVIT due to a giant anterior calcified cardiac mass, treated successfully with pericardectomy. Careful dissection is mandatory for a successful procedure.