Congenital foramen of the left pericardium

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.

Congenital partial pericardial defect confirmed based on spontaneous pneumothorax: A case report and literature review

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Congenital partial pericardial defects are rare but can cause cardiac herniation.

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Pneumopericardium combined with pneumothorax suggests pericardial defect.

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Pneumothorax may worsen the heart protruding through the pericardial defect.

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VATS should be considered in the patients with a pericardial defect.

Introduction

Congenital pericardial defects are rare but can cause fatal complications. Most cases are asymptomatic and incidentally detected during a thoracic surgery or autopsy. We report a case of a partial pericardial defect confirmed based on spontaneous pneumothorax.

Presentation of case

A 16-year-old boy with left spontaneous pneumothorax showed pneumopericardium on chest X-ray. Chest computed tomography revealed a partial pericardial defect. Video-assisted thoracoscopic surgery was performed, and a small pericardial defect was confirmed at the level of the upper pulmonary hilum. We did not reconstruct the defect because of the improbability of cardiac herniation.

Discussion

Pneumopericardium combined with pneumothorax suggests the existence of a pericardial foramen. Partial pericardial defects could cause cardiac herniation or strangulation, and pneumothorax may worsen the protruding of the heart. Video-assisted thoracic surgery is an effective method to prevent the recurrence of pneumothorax and determine whether reconstruction of the defect is required.

Conclusion

Video-assisted thoracic surgery should be performed in the case of a pericardial defect combined with pneumothorax.

Iatrogenic pericardial defect

Pericardial defects are uncommon, usually congenital, and frequently involve a complete absence of the pericardium. Partial pericardial defects are more likely to result in complications. Iatrogenic pericardial defects are usually partial defects and may present with cardiac strangulation. We present the case of an iatrogenic pericardial defect in an asymptomatic 20-year-old female.

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 diaphragmatic hernia with concurrent aplasia of the pericardium in a foal

Background

In veterinary medicine congenital abnormalities of the diaphragm and pericardium are rare, idiopathic malformations, being reported mainly in dogs. This report documents an unusual case of developmental defects in a foal consisting of diaphragmatic hernia concurrent with pericardial aplasia.

Case presentation

Following a normal delivery, a full term, female Friesian stillborn foal with the placenta was presented for necropsy. External morphological examination indicated a normally developed foal. At necropsy, a large oval defect (approximately 20 × 15 cm in size) was observed in the left-dorsal side of the diaphragm (left lumbocostal triangle). This defect allowed the intestinal loops, spleen and partially the liver to translocate into the thorax. The loops of the left ascending colon, including the pelvic flexure and partially the small intestine covered the cranial and dorsal posterior parts of the heart due to the complete absence of the left pericardium. The remaining pericardium presented as a white, semi-transparent strip, partially covering the right side of the heart. The left lung and the main bronchus were severely hypoplastic to approximately one-fifth the size of their right homologue. The intermediate part of the liver, containing mainly the enlarged quadrate lobe was translocated in the thorax, severely enlarged and showed marked fibrosis. Histologically in the herniated lobes we diagnosed hepatic chronic passive congestion, telangiectasia and medial hypertrophy of blood vessels.

Conclusion

Concomitant malformation involving diaphragmatic hernia and pericardial aplasia in horses have not been previously reported. Moreover, this is the first case describing pericardial aplasia in horse.

Pericardial tear as a consequence of cardiopulmonary resuscitation (CPR) involving chest compression: a report of two postmortem cases of acute type A aortic dissection with hemopericardium

We present two cases of a pericardial tear as a consequence of cardiopulmonary resuscitation involving chest compressions in fatal acute type A aortic dissection (AoD) with hemopericardium. For each case, postmortem computed tomography revealed a hematoma in the false lumen of the ascending aorta with a slight hemopericardium and a large left hemothorax, as well as focal pericardial dimpling and discontinuity around the left ventricle. At autopsy, we confirmed a convex lens-shape gaping pericardial tear at the left posterolateral site of the pericardium and a massive volume of bloody fluid in the left thoracic cavity. It has been hypothesized that the pericardium ruptured due to chest compressions during resuscitation in these cases of acute type A AoD with hemopericardium and that intrapericardial blood leakage through the pericardial tear resulted in a hemothorax.

The role of post-mortem imaging in a case of sudden death due to ascending aorta aneurysm rupture

A 65-year-old man collapsed suddenly, while on an escalator. Despite intensive cardio-pulmonary resuscitation, the subject died 1h later. Post-mortem magnetic resonance imaging and post-mortem computed tomography angiography demonstrated rupture of an ascending aortic aneurysm, with haemorrhage into the pericardial cavity and the uncommon associated finding of haemorrhage into the left hemi-thorax through a small left-sided pericardial defect. The cause of death was thus attributed to the rupture of thoracic aortic aneurysm, and traditional autopsy was not performed. The circumstances of the case will be discussed, followed by a discussion of the imaging findings, mechanism of death, and explanation of the findings in this case. Finally, on the basis of this case report, we suggest that in selected cases, post-mortem imaging can be used as a screening tool for conducting hypotheses on the cause and mechanism of death before autopsy.

Left ventricular hernia in a pediatric transplant recipient: case report and review of the literature

Cardiac hernias are rare occurrences resulting from congenital pericardial defects, trauma, or postsurgical changes. Difficult to diagnose, they can lead to significant morbidity and mortality. The first reported case of left ventricular herniation in a pediatric cardiac transplant recipient is presented, and the literature concerning diagnosis and management is reviewed. Clinicians must have a high index of suspicion to diagnose this rare and potentially lethal defect.

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.

When, Why, and How to Examine the Heart During Thoracic CT: Part 2, Clinical Applications

OBJECTIVE

CT examination of the thorax is often requested for the investigation of disorders that may have an important underlying cardiac cause or association that is not clinically obvious. Conditions such as idiopathic and acquired cardiomyopathy, ischemic heart disease, and valvular dysfunction may underlie symptoms such as dyspnea, chest pain, and hemoptysis that prompt the request for CT of the thorax. Other conditions such as pulmonary thromboembolic disease, chronic obstructive airways disease, pectus excavatum, sleep apnea, and many intrathoracic malignancies may have an important effect on cardiac structure and function. Patients undergoing thoracic surgery may have unsuspected coronary artery disease that can be detected in the course of preoperative evaluation by CT; similarly, postoperative complications often have a cardiogenic basis.

CONCLUSION

Examination of the heart in the course of CT of the chest often can provide important and clinically relevant information that is not otherwise easily available.

Right-side congenital pericardial defect associated with ischemic heart disease

We report an unusual right-side congenital pericardial defect with herniation of the right atrium to the right thoracic cavity found intraoperatively in a 73- year-old man undergoing coronary artery bypass grafting for triple-vessel coronary artery disease. The right atrial wall showed fibrous changes due to contact with the defect edge. We suspected that the right coronary artery was obstructed by chronic strangulation of the right atrium. We repaired the defect with a polytetrafluoroethylene patch to prevent it from compressing the bypass graft and coronary arteries.