Pericardial disease--anatomy and function

Asymptomatic Chronic Large Pericardial Effusions: To Drain or to Observe?

Pericardial effusions, especially large ones, have traditionally been regarded with concern by clinicians due to the sometimes unpredictable development of life-threatening cardiac tamponade. In the European Society of Cardiology Guidelines on pericardial diseases, the simplified algorithm for pericardial effusion triage and management recommends pericardial drainage in cases of cardiac tamponade and/or suspicion of bacterial or neoplastic etiology. In the presence of acute pericarditis, empiric anti-inflammatory treatment should be given, while when a specific indication known to be associated with pericardial effusion is found, then treatment of the underlying cause is indicated. Notably, the most challenging subgroup of patients includes those with large, asymptomatic, C-reactive-protein-negative, idiopathic effusions. In the latter subjects, pericardial drainage is proposed in cases of chronic effusions (lasting more than three months). However, this recommendation is based on scant data stemming from small-sized non-randomized studies. Nevertheless, recent evidence in a larger cohort of patients pointed out that a watchful waiting strategy is a safe option in terms of complication-free survival. This review summarizes the contemporary evidence on this challenging topic and provides recommendations for tailoring individual patient treatments.

Chronic Pericardial Effusion: Causes and Management

Chronic pericardial effusion is a common pericardial syndrome whose approach has been well standardised in recent years. The main challenge associated with this condition is the progression (sometimes unheralded) to cardiac tamponade. Pericardial effusions may present either as an isolated finding or in the context of a specific etiology including autoimmune, neoplastic, or metabolic disease. Among investigations used during diagnostic work-up, echocardiography is of paramount importance for the diagnosis, sizing, and serial evaluation of the hemodynamic impact of effusions on heart diastolic function. In an individualised manner, advanced imaging including computed tomography and cardiac magnetic resonance imaging should be performed, especially if baseline tests are inconclusive. Triage of these patients according to the most recent 2015 European Society of Cardiology Guidelines for the diagnosis and management of pericardial diseases should take into account the presence of hemodynamic compromise as well as suspicion of malignant or purulent pericarditis as first step, C-reactive protein serum level measurement as second step, investigations for a specific condition known to be associated with pericardial effusion as third step, and finally the size and the duration of the effusion. Treatment depends on the evaluation of the above-mentioned parameters and should ideally be tailored to the individual patient. Prognosis of chronic pericardial effusions depends largely on the underlying etiology. According to novel data, the prognosis of individuals with idiopathic, chronic (> 3 months), large (> 2 cm), asymptomatic pericardial effusions is usually benign and a watchful waiting strategy seems more reasonable and cost-effective than routine drainage as previously recommended.

Expert review for clinical and translational imaging actionable imaging findings in the daily PET/CT scenario

Background and aim

The American College of Radiology (ACR) defines "actionable findings" the ones requiring a special communication between radiologists and referring clinicians, suggesting to organize their categorization in a three-degree scale on the basis of the risk for the patient to develop complications. These cases may fall in a grey-zone communication between different care figures with the risk of being underestimated or even not being considered at all. In this paper, our aim is to adapt the ACR categorization to the most frequent actionable findings encountered when reporting PET/CT images in a Nuclear Medicine Department, describing the most frequent and relevant imaging features and presenting the modalities of communication and the related clinical interventions that can be modulated by the prognostic severity of the clinical cases.

Materials and methods

We performed a descriptive, observational and critical analysis of the most relevant literature on the topic of "actionable findings", in particular, starting from the reports of the ACR Actionable Reporting Work Group, we categorised and described, in a narrative review, the most relevant "actionable findings" encountered in the Nuclear Medicine PET/CT daily practice.

Results

To the best of our knowledge, to date there are no clear indications on this selective PET/CT topic, considering that the current recommendations target mainly radiologists and assume a certain level of radiological expertise. We resumed and classified the main imaging conditions under the term of "actionable findings" according to the corresponding anatomical districts, and we described their most relevant imaging features (independently of PET avidity or not). Furthermore, a different communication timing and strategy was suggested on the basis of the findings' urgency.

Conclusion

A systematic categorization of the actionable imaging findings according to their prognostic severity may help the reporting physician to choose how and when to communicate with the referring clinician or to identify cases requiring a prompt clinical evaluation. Effective communication is a critical component of diagnostic imaging: timely receipt of the information is more important than the method of delivery.

Benign incidental cardiac findings in chest and cardiac CT imaging

With the continuous expansion of the disease scope of chest CT and cardiac CT, the number of these CT examinations has increased rapidly. In addition to their common indications, many incidental cardiac findings can be observed when carefully evaluating the coronary arteries, valves, pericardium, ventricles, and large vessels. These findings may have clinical significance or risk of complications, but they are sometimes overlooked or may not be described in the final reports. Although most of the incidental findings are benign, timely detection and treatment can improve the management of chronic diseases or reduce the possibility of severe complications. In this review, we summarized the imaging findings, incidence rate, and clinical relevance of some benign cardiac findings such as coronary artery calcification, aortic and mitral valve calcification, aortic calcification, cardiac thrombus, myocardial bridge, aortic dilation, cardiac myxoma, pericardial cyst, and coronary artery fistula. Reporting incidental cardiac findings will help reduce the risk of severe complications or disease deterioration and contribute to the recovery of patients.

Measurement of epicardial adipose tissue using non-contrast routine chest-CT: a consideration of threshold adjustment for fatty attenuation

Background

Epicardial adipose tissue (EAT) is known as an important imaging indicator for cardiovascular risk stratification. The present study aimed to determine whether the EAT volume (EV) and mean EAT attenuation (mEA) measured by non-contrast routine chest CT (RCCT) could be more consistent with those measured by coronary CT angiography (CCTA) by adjusting the threshold of fatty attenuation.

Methods

In total, 83 subjects who simultaneously underwent CCTA and RCCT were enrolled. EV and mEA were quantified by CCTA using a threshold of (N30) (− 190 HU, − 30 HU) as a reference and measured by RCCT using thresholds of N30, N40 (− 190 HU, − 40 HU), and N45 (− 190 HU, − 45 HU). The correlation and agreement of EAT metrics between the two imaging modalities and differences between patients with coronary plaques (plaque ( +)) and without plaques (plaque ( −)) were analyzed.

Results

EV obtained from RCCT showed very strong correlation with the reference (r = 0.974, 0.976, 0.972 (N30, N40, N45), P < 0.001), whereas mEA showed a moderate correlation (r = 0.516, 0.500, 0.477 (N30, N40, N45), P < 0.001). Threshold adjustment was able to reduce the bias of EV, while increase the bias of mEA. Data obtained by CCTA and RCCT both demonstrated a significantly larger EV in the plaque ( +) group than in the plaque ( −) group (P < 0.05). A significant difference in mEA was shown only by RCCT using a threshold of N30 (plaque ( +) vs ( −): − 80.0 ± 4.4 HU vs − 78.0 ± 4.0 HU, P = 0.030). The mEA measured on RCCT using threshold of N40 and N45 showed no significant statistical difference between the two groups (P = 0.092 and 0.075), which was consistent with the result obtained on CCTA (P = 0.204).

Conclusion

Applying more negative threshold, the consistency of EV measurements between the two techniques improves and a consistent result can be obtained when comparing EF measurements between groups, although the bias of mEA increases. Threshold adjustment is necessary when measuring EF with non-contrast RCCT.

Chronic pericardial effusion: current concepts and emerging trends

INTRODUCTION

Pericardial effusion (PEF) is a common and challenging pericardial syndrome with a variety of clinical manifestations ranging from asymptomatic, incidentally uncovered small PEFs, to life-threatening cardiac tamponade.

AREAS COVERED

: This review focuses on the pathophysiology, epidemiology, etiology, classification, clinical findings, diagnostic work-up, management and outcome of PEFs. Particular emphasis has been given on the most recent evidence concerning the contribution of imaging for the detection, differential diagnosis and evaluation of the hemodynamic impact of PEFs on the diastolic filling of the heart. Moreover, simplified algorithms for PEF triage and management have been included.

EXPERT OPINION

The management of patients with PEFs is mainly based on four parameters namely hemodynamic impact on diastolic function, elevation of inflammatory markers, presence of a specific underlying condition known to be associated with PEF and finally size and duration of the effusion. Novel data have contributed to change our view towards large, asymptomatic, "idiopathic" PEFs and dictated a rather conservative approach in most cases. It is also stressed that there is a compelling need for additional research, which is essential for tailored treatments aiming at the improvement of quality of life and containment of health care costs.

Review of pericardial disease on computed tomography

Echocardiography has long been the mainstay in the evaluation of cardiac and pericardial disease. As computed tomography (CT) has advanced, it has become a valuable partner in the imaging of the pericardium. The advantages of CT include a larger field of view, multiplanar reconstruction and increased discrimination between various soft tissues and fluids. CT is less operator dependent and can more easily, and reproducibly, image areas of the pericardium for which echocardiography has poor windows such as the right pericardium. The introduction of EKG gating has decreased cardiac motion artifact and can allow functional evaluation although echocardiography remains the primary source of real-time imaging of cardiac and valve motion. It is essential for the skilled cardiac imager to understand the strengths and weaknesses of CT and its role in the definition and assessment of pericardial disease.

Cardiac Outpouchings: Definitions, Differential Diagnosis, and Therapeutic Approach

Background and Aims

Cardiac outpouchings encounter a series of distinct congenital or acquired entities (i.e. aneurysms, pseudoaneurysms, diverticula, and herniations), whose knowledge is still poorly widespread in clinical practice. This review aims to provide a comprehensive overview focusing on definition, differential diagnosis, and prognostic outcomes of cardiac outpouchings, as well as further insights on therapeutic options, in order to assist physicians in the most appropriate decision-making.

Methods

The material reviewed was obtained by the following search engines: MEDLINE (PubMed), EMBASE, Google Scholar, and Clinical Trials databases, from January 1966 until March 2021. We searched for the following keywords (in title and/or abstract): (“cardiac” OR “heart”) AND (“outpouching” OR “outpouch” OR “aneurysm” OR “pseudoaneurysm” OR “false aneurysm” OR “diverticulum” OR “herniation”). Review articles, original articles, case series, and case reports with literature review were included in our search. Data from patients with congenital or acquired cardiac outpouchings, from prenatal to geriatric age range, were investigated.

Results

Out of the 378 papers initially retrieved, 165 duplicates and 84 records in languages other than English were removed. Among the 129 remaining articles, 76 were included in our research material, on the basis of the following inclusion criteria: (a) papers pertaining to the research topic; (b) peer-reviewed articles; (c) using standardized diagnostic criteria; and (d) reporting raw prevalence data. Location, morphologic features, wall motion abnormalities, and tissue characterization were found to have a significant impact in recognition and differential diagnosis of cardiac outpouchings as well as to play a significant role in defining their natural history and prognostic outcomes.

Conclusions

Careful recognition of cardiac outpouchings remains a diagnostic challenge in clinical practice. Due to a broad cluster of distinctive and heterogeneous entities, their knowledge and timely recognition play a pivotal role in order to provide the most appropriate clinical management and therapeutic approach.

Incidental finding of congenital pericardial defect during vats bullectomy. Tips and tricks to avoid blunder

The absence of a small portion of the pericardium is termed pericardial defect. This rare entity can be either acquired or congenital. The prevalence of congenital pericardial defect is exceedingly rare, which is approximately 0.002-0.004% of surgical and pathologic series. The most common type is the absence of the entire left side of pericardium, seen in 67% of all patients with a congenital pericardial defect. Other varieties are incredibly uncommon. Congenital pericardial defect has a male preponderance with a male to female ratio of 3:1, and familial occurrence is uncommon. We report a case of left partial congenital pericardial defect detected incidentally in a 22-year-old man who presented with recurrent left spontaneous pneumothorax. He underwent video-assisted thoracoscopic bullectomy and intraoperatively, we discovered a left partial pericardial defect which exposed the left atrial appendage. Although generally asymptomatic, patients may present with non-specific cardiac symptoms such as atypical chest pain. Partial pericardial defects have an increased risk of herniation of the whole left atrium, the left atrial appendage or the ventricles. If this occurs, cardiac strangulation may occur, leading to necrosis and sudden death. Cardiac MRI is a sensitive tool and will demonstrate the absence of preaortic pericardial recess. In conclusion, no surgical intervention is required in cases of congenital pericardial defect, unless the patient is symptomatic due to complications. If detected incidentally during cardiac or thoracic surgery, the best may be to leave it alone.

Diagnostic value of echocardiography in paracardiac cystic lesions: 43 cases from one single medical center

Paracardial cystic lesions (PCLs) are rare, benign lesions and may occur in any part surrounding the heart. It covers a variety of pathological types, including pericardial cysts, thymic cysts, bronchogenic cysts and so on. The aim of this study was to summarize the diagnostic value of echocardiography in different pathological types of the PCLs. Echocardiographic features of 43 consecutive PCL patients treated at the Union Hospital from January 2002 to December 2017 were compared and analyzed with their surgical and pathological findings retrospectively. The PCLs included 19 pericardial cysts, 12 thymic cysts, 7 bronchogenic cysts, 3 cystic teratomas, 1 enteric cyst and 1 lymphangioma. Among them, 29 cases (67.4%) were accurately diagnosed by echocardiography and 14 cases (32.6%) were missed the diagnosis. All diagnosed cysts were showed as thin-walled, monolocular, echo-free structures without blood flow signals in echocardiographic images. 4 patients had compression of the heart and great vessels caused by cysts. In addition, 4 intracardiac lesions were diagnosed by echocardiography and the results were further confirmed in surgery. Echocardiography is of great value in the diagnosis of paracardiac cystic lesions as well as combined intracardiac lesions. Differential diagnosis could be mainly made based on the location of the lesions.

Contemporary management of pericardial effusion

Pericardial effusion is a relatively common clinical condition with a variety of clinical manifestations ranging from incidentally discovered asymptomatic cases to life-threatening cardiac tamponade. The etiology encompasses idiopathic cases and forms secondary to different conditions, including autoimmune diseases, malignancies, metabolic disorders, etc. While medical therapy should be offered to patients with elevation of inflammatory markers, in specific forms treatment should be appropriate to the underlying disorder. In cases with hemodynamic compromise pericardial drainage either with pericardiocentesis or pericardial "window" is indicated for therapeutic and diagnostic purposes. In the remainder, factors like comorbidities, size and location of the pericardial effusion will influence the clinical decision making. In asymptomatic or minimally symptomatic chronic large idiopathic pericardial effusions, according to recent evidence, a conservative approach with watchful waiting seems the most reasonable option. The prognosis of pericardial effusions largely depends on the underlying etiologies. Metastatic spread to the pericardium has an ominous prognosis whereas large to moderate effusions have been often associated with known or newly discovered specific underlying causes. Chronic small idiopathic effusions have an excellent prognosis and do not require specific monitoring. Large chronic idiopathic effusions in clinically stable patients require a 3 to 6-month assessment ideally in a specialized unit.

COVID-19-Related Pericarditis with Pericardial Clotting as a Hallmark: Two Cases and a Review

The prevalence of pericardial effusion and its clinical significance is not well understood in COVID-19 patients. We report two cases of COVID-19-related pericardial effusion complicated by intrapericardial clot formation. The final outcome was favorable, but intrapericardial clot remained mostly unchanged at 6-month follow-up. The treatment approach and the long-term consequences are still unclear. We propose a review of this particular cardiovascular complication in COVID-19 patients.

A case report of malignant primary pericardial mesothelioma with atypical imaging appearance: multimodality imaging with histopathological correlation

BACKGROUND

Primary pericardial mesothelioma is a rare primary cardiac malignancy, with three main histopathological types, sarcomatoid histotype being the rarest. The imaging features were atypical due to concomitant extensive calcification, which resulted in aggravated differential diagnosis.

CASE SUMMARY

A 45-year-old man presented to our hospital with non-specific clinical symptoms. According to clinical history, a mediastinal tumour had been suspected with a previous unsuccessful attempt of transthoracic computed tomography-guided biopsy at an overseas hospital with limited data of performed imaging procedures. Multimodality imaging at our centre revealed extensively calcified solid masses in the pericardium, invading the left atrium. As the imaging features suggested an atypical primary pericardial malignancy, a diagnostic thoracoscopy was performed. Histopathological analysis of specimen revealed sarcomatoid type of pericardial mesothelioma with areas of necrosis and foci of osteogenic differentiation. Despite planned treatment, 2 weeks after histological diagnosis, the patient passed away due to perforated peptic ulcer-related sepsis.

DISCUSSION

The presence of extensive calcification in the lesion resulted in a challenging imaging workup and diagnosis. Initial differential diagnosis included primary or metastatic calcification-prone tumour, secondary calcification due to haemorrhage after previous interventional procedure and other pathologies, such as tuberculous pericarditis, calcified amorphous tumour, among others. Calcification may be part of the histological tumour characteristics; however, proper history taking is crucial as concomitant diseases, previous treatment, and interventional procedures may alter the imaging pattern.

Cardiovascular findings on cross-sectional imaging: spectrum of incidental and critical findings and clinical relevance for the abdominal radiologist

Although not the primary focus of the exams, cardiovascular structures are included to some extent on all abdominal or whole-body cross-sectional studies. Cardiovascular findings often present incidentally and may range from chronic to acute and emergent pathologies. Among the most common cardiovascular findings are the presence of cardiac calcifications, most commonly coronary, which correlate with the presence of coronary artery and valvular disease. Signs of myocardial ischemia, both acute and chronic, and its complications may also be visualized. Cardiac filling defects most commonly represent thrombus and are associated with systemic arterial embolic complications. Pericardial findings often manifest as effusion or thickening, which may lead to hemodynamic consequences visible at imaging. Incidental pulmonary emboli and systemic venous thrombi may be incidentally detected, particularly in hospitalized and oncologic patients, and warrant immediate attention. This review will highlight the appearance of common and important incidental cardiovascular findings and related pitfalls and discuss reporting and follow-up recommendations relevant to the abdominal radiologist.

Imaging of Pericardial Disease

Although the pericardium is simply a 2-layered membrane enveloping the heart and great vessels, there are numerous anatomic variations, congenital anomalies, and pathologic conditions that can occur. Although echocardiography is most often the first imaging modality used to assess the pericardium, computed tomography and MR imaging are frequently being used to aid in diagnosis and assess response to therapy. Therefore, detailed knowledge of the pericardium in both its normal and diseased states is important to best direct patient care and potentially improve patient outcomes.

Pericardial Agenesis as a Rather Unusual Cause of Palpitations: We Only See What we Know

Cardiac palpitations secondary to ventricular ectopic beats are a frequent clinical indication for a cardiac magnetic resonance (CMR) scan. CMR has already demonstrated its additive diagnostic value in patients with frequent arrhythmias even when echocardiogram appears normal. Hereby, we describe a case of a middle-aged male patient referred to our laboratory because of frequent ventricular ectopic beats and an inconclusive echocardiogram due to an extremely poor acoustic window. A diagnosis of pericardial agenesis (PA) was made explaining patient symptoms and arrhythmias previously detected. Furthermore, at the case report description, PA prevalence, associated cardiac pathologies, and novel CMR diagnostic criteria are being described.

Case of tuberculous pericarditis presenting as a giant pericardial adhesion and masquerading as a pericardial tumour

Chronic pericarditis characterised by adhesions between the parietal and visceral pericardium is called adhesive pericarditis. In South Africa, tuberculosis is the most common cause of chronic pericarditis. We report a case of adhesive pericarditis that mimicked a tumour.

Managing Incidental Findings on Thoracic CT: Mediastinal and Cardiovascular Findings. A White Paper of the ACR Incidental Findings Committee

The ACR Incidental Findings Committee presents recommendations for managing incidentally detected mediastinal and cardiovascular findings found on CT. The Chest Subcommittee was composed of thoracic radiologists who developed the provided guidance. These recommendations represent a combination of current published evidence and expert opinion and were finalized by informal iterative consensus. The recommendations address the most commonly encountered mediastinal and cardiovascular incidental findings and are not intended to be a comprehensive review of all incidental findings associated with these compartments. Our goal is to improve the quality of care by providing guidance on how to manage incidentally detected thoracic findings.

Cardiac Computed Tomography: Before and After Cardiac Surgery

Cardiac computed tomography angiography (CCTA) is a noninvasive imaging technique that has been rapidly adopted into clinical practice. Over the past decade, technological advances have improved CCTA accuracy, and there is an increasing amount of data supporting its prognostic value in the assessment of coronary artery disease. Recently, "appropriate use criteria" has been used as a tool to minimize inappropriate testing and reduce patient exposure to unnecessary risk and inconclusive studies. This review will summarize the appropriate uses of CCTA in patients before and after cardiac surgery. Although the most common indication for CCTA is assessment of patency of native coronary arteries, other potential perioperative uses (eg, assessment of congenital heart disease, valvular heart disease, pericardial disease, myocardial disease, cardiac anatomy, bypass grafts, aortic disease, and cardiac masses) will be reviewed.

Extensive pericardial calcification secondary to radiotherapy, causing mixed constrictive-restrictive pathology

This report presents the case of a patient who suffered from a mediastinal neuroblastoma in his childhood (in 1977), having been treated by surgery, chemotherapy and radiotherapy. As a result, he developed multiple calcifications in the atria walls, interatrial septum, right ventricular free wall, mitral and aortic valves and pericardium, triggering a mixed constrictive and restrictive pathology.

Current concepts of diagnosis and management of pericardial cysts

Pericardial cysts are rare with an incidence of about 1 in every 100,000 persons and one in 10 pericardial cysts may actually be a pericardial diverticulum. Pericardial cysts and diverticula share similar developmental origin and may appear as an incidental finding in chest roentgenogram in an asymptomatic patient. CT scan is considered as best modality for diagnosis and delineation of the surrounding anatomy. Cardiac MRI is recommended in the evaluation of the compressive effects caused by the pericardial cysts. The authors recommend echocardiography for serial follow up and image guided aspiration of the pericardial cyst in presence of compressive effects leading to cardiovascular and airway symptoms. A systematic approach is desirable for management of pericardial cysts depending on size, shape and compression effects, symptoms and easy access to serial Echocardiographic follow up. However, pericardial diverticulum may not be differentiated from cysts by the above testing, and only identified at surgery.

Computed tomography and magnetic resonance imaging evaluation of pericardial disease

Pericardial diseases are commonly encountered in clinical practice and may present as an isolated process or in association with various systemic conditions. Traditionally transthoracic echocardiography (TTE) has been the method of choice for the evaluation of suspected pericardial disease but increasingly computed tomography (CT) and magnetic resonance imaging (MRI) are also being used as part of a rational multi-modality imaging approach tailored to the specific clinical scenario. This paper reviews the role of CT and MRI across the spectrum of pericardial diseases.

Isolated Partial Congenital Absence of the Pericardium: A Familial Presentation

Congenital defects of the pericardium are uncommon heart abnormalities. Most of the patients are asymptomatic and are usually diagnosed incidentally. Complications are more common in partial absence than in complete absence of the pericardium; thus, this congenital defect should be identified because of the associated risk of sudden death. We report the first mention in the literature, to our knowledge, of a 3-generation familial presentation of isolated congenital partial absence of the pericardium with similar physical examination and radiological findings.

The role of MDCT in the diagnosis of primary pericardial tumours: a case report and review of literature

Primary pericardial tumours are very rare and are hence not usually part of our differential diagnosis, especially since they have non-specific signs and symptoms. While chest radiography remains the most common initial imaging investigation in the assessment of suspected cardiothoracic pathology, the diagnostic yield for assessing pericardial lesions is limited, often necessitating the need for further assessment with echocardiography, CT scan or MRI. We present a case of an adult male patient with an incidental primary pericardial tumour diagnosed during the routine imaging assessment of suspected pulmonary infections. After proper formulation of diagnosis, the patient was managed accordingly for pulmonary pathology and discharged on recovery. Over the years, with advancement and widespread increase in use of multidetector CT and MRI, diagnosing primary pericardial tumours has become easier. MRI has now become the modality of choice for imaging of pericardial tumours because of its better soft-tissue contrast resolution.

Aneurysm-like outpouching of ventricular wall through a gap caused by constrictive pericarditis with focal sparing

Constrictive pericarditis is usually generalized though it can be focal, affecting only a patch of pericardium, or very rarely, generalized with focal sparing. We describe a case of constrictive pericarditis with focal sparing along the right ventricle. This focal sparing behaved like a defect in the otherwise thickened pericardium, resulting in protrusion of normal right ventricular myocardium between the margins of the thickened pericardium simulating an aneurysm.

[Chronic epicarditis, a soft pericardial constriction: about one case]

Chronic constrictive epicarditis is a special form of chronic pericarditis. It is characterized by a thickening of the visceral pericardium that becomes adherent to cardiovascular structures, thus impeding the diastolic filling of the ventricles. The parietal pericardium remains soft, without symphysis with the visceral pericardium. We illustrate the diagnostic and therapeutic approaches to this pathology by a clinical case.

[Congenital esophageal duplication cysts: progressive dysphagia in adulthood]

Esophageal duplications are congenital abnormalities of the foregut. We present the case of a 33-year-old woman suffering from progressive dysphagia who had surgery for esophageal duplication. The following three criteria define the cystic lesion: an intimate attachment to the esophageal wall, the presence of a smooth muscle coat and a mucosal lining consisting of squamous and/or ciliated respiratory epithelium. Diverticula, bronchogenic cysts and cystic neoplasms have to be considered in the differential diagnosis. Congenital cystic esophageal duplication is a rare cause of dysphagia in adulthood.