Does echocardiography play a role in the clinical diagnosis of congenital absence of pericardium? A case presentation and a systematic review

Complete agenesis of pericardium in a young asymptomatic woman

Agenesis of pericardium is a rare finding resulting from alterations during embryologic formation. It is a congenital cardiac anomaly commonly asymptomatic. Cardiac magnetic resonance is actually considered the gold standard for diagnosis of pericardium agenesis. This report details the case of a 24-year-old woman who came to our clinic.

Pericardial agenesis: a case report of a rare congenital heart disease

Background

Pericardial agenesis is a rare congenital heart disease characterized by a variable clinical presentation.

Case summary

A 32-year-old man was sent by an occupational health physician to our health care centre because of pathological electrocardiogram (ECG). On transthoracic echocardiogram, we had some difficulty to obtain a good quality of four-chamber apical view that was shifted upper and laterally towards the left anterior axillary line. Nonetheless, an abnormal diastolic expansion of the apex of the left ventricle (LV) that had an otherwise normal systolic function was detected. A chest X-ray confirmed the leftward shift of the heart, with the elongation of the left border of cardiac silhouette and cardiac MRI, finally revealed the absence of left-sided pericardium associated with a leftward dislocation of the heart and a dysmorphism of the LV apex that appeared rounded and curved. The non-invasive work-up was completed with 48 h long Holter ECG that was unremarkable. The exercise test was also negative for both inducible myocardial ischaemia and arrhythmias. Patient was scheduled for loop-recorder implantation, and a 6-month clinical follow-up was advised.

Discussion

Pericardial agenesis is a rare congenital heart disease associated with an increased risk of cardiac arrhythmias and type A aortic dissection, however its clinical course could be also completely unremarkable. The diagnosis is challenging, and cardiac MRI remains the gold standard imaging modality. In complete left-sided and asymptomatic forms, no treatment is needed. Prognosis is not well established due to both the rarity of disease and extreme variability of clinical presentation.

Electrocardiogram Electrode Positioning on the Back During Echocardiography: An Exploratory Cross-Sectional Study

BACKGROUND

ECG interpretation is sometimes difficult due to baseline fluctuations and electrode detachments when placed on the subjects' front side, leading to misinterpretation of the rhythms and phases of the cardiac cycle. We aimed to compare the differences in the wave amplitudes and respiratory variations between conventional ECG electrode positioning on the front side of patients and an alternative position on the backs of patients.

METHODS

Echocardiography was performed in 85 patients lying in the left lateral position. We attached the red electrode to the right clavicle, the yellow to the left clavicle, and the green to the left lateral abdomen on the front side of the patients; on the back, we attached the electrode to the right clavicle, the right upper posterior iliac spine, and the left upper posterior iliac spine.

RESULTS

The ECG monitor amplitudes were greater on the front side compared to the back side, but the BF-breath values were smaller on the back side (6.0 pixels) compared to the front side (10.5 pixels, p<0.05). The P wave amplitude divided by the BF-breath on the back side was greater than that seen on the front side (2.8 vs. 1.8, p<0.05), whereas the QRS amplitude divided by the BF-breath was 15.0 and 16.3, respectively (p=ns).

CONCLUSION

As an alternative to front-side ECG monitoring, electrodes placed on the back can help avoid misinterpretation of the ECG rhythms and the phases of the cardiac cycle due to respiration during echocardiography.

Pericardial agenesis - the wandering heart

BACKGROUND

Congenital pericardial absence is an uncommon cardiac anomaly that is typically asymptomatic and commonly misdiagnosed due to a lack of symptoms or atypical symptoms. Pericardial agenesis (PA) should be considered one of the differential diagnoses when the patient presents with chest pain. This case shows how the diagnosis of pericardial agenesis is made exclusively using multi-modality imaging, starting from findings in a basic chest radiograph to cardiac MRI, while also demonstrating the classic signs seen in this condition. Magnetic resonance imaging of the heart is the gold standard for determining the absence of pericardium in the prognosis.

CASE PRESENTATION

A 32-year-old male who presented with chest discomfort and radiating pain to his back and left shoulder mimicking myocardial infarction with normal ECG and enzyme markers. A chest radiograph (taken 24 h apart) demonstrates the left lateral position of the heart and the bulging contour of the left heart border, a lucent area between the aorta and pulmonary artery. Subsequently, cardiac MRI reveals left pericardial agenesis.

CONCLUSIONS

This article provides insight into a rare differential to consider in a young patient presenting with chest discomfort. This case shows how the diagnosis of pericardial agenesis is made exclusively using multi-modality imaging, starting from findings in a basic chest radiograph to cardiac MRI, while also demonstrating the classic signs seen in this condition.

Congenital Pericardial Agenesis presenting as non-specific chest pain: A Case Report

Congenital absence of pericardium is an exceedingly rare condition with a prevalence of 0.002%-0.004%. Due to its rarity and absence of association with any specific clinical examination finding, the diagnosis may be challenging. Due to the absence of symptoms and clinical awareness, pericardial agenesis is commonly misdiagnosed. It is important to consider this as a differential diagnosis of exertional chest pains. We report the case of a 9-year-old boy who attended our institution for non-specific but frequent symptoms and was diagnosed with congenital complete absence of the pericardium. The rarity of the condition can hinder timely diagnosis, as a physician or radiologist may never encounter a single case in their lifetime.

Unexpected death in a newborn due to a congenital partial pericardial defect: a case report

Background

Pericardial defects are rare anatomical variations that can present as an isolated variation or be associated with other conditions. They are usually asymptomatic and misdiagnosed conditions, and given their rarity, partial pericardial defects can have devastating outcomes. The sudden death of an apparently healthy newborn certainly raises concerns, and a medico-legal investigation is crucial in establishing the cause of death. This case report highlights the importance of awareness on the part of obstetric professionals of the lethal outcomes of pericardial partial congenital defects. This case also demonstrates the difficulty of establishing a correct diagnosis.

Case presentation

The autopsy of a 15-h-old neonate revealed a partial pericardial defect ending in a biventricular strangulation by the defective pericardium. Other findings, such as the patency of the arterial ductus, a subarachnoid hemorrhage, and aspiration of amniotic fluid, were also reported.

Conclusions

Although imaging techniques have evolved, fetal detection of cardiac abnormalities can be tricky, especially when occurring as an isolated variation.

Absent pericardium and lung hypoplasia in a child with severe mitral regurgitation

An 8-year-old girl with severe mitral regurgitation presented with symptoms of heart failure. Clinical investigations did not raise suspicion of an absent left pericardium. Congenital defects of the pericardium are rare and frequently associated with other cardiac lesions. We describe a case of severe mitral regurgitation in a child in whom an absent left-sided pericardium with hypoplasia of left lung was found incidentally during surgery to repair the mitral valve. We believe such associations with other heart diseases is usually circumstantial but can influence the perioperative morbidity, length of hospital stay, and even alter the surgical management.

A Case Report of Congenitally Absent Pericardium Masquerading as Recurrent Pericarditis

A 24-year-old female with a history of Swyer-James-MacLeod syndrome presented with acute onset of pleuritic chest pain and was initially diagnosed with acute pericarditis. The 12-lead electrocardiogram demonstrated typical diffuse ST-segment elevation and PR-segment depression. Symptoms resolved rapidly with anti-inflammatory therapy consisting of ibuprofen and colchicine. After completing a 3-month course of the latter, her symptoms rapidly recurred. Workup, including labs and cardiac imaging consisting of a transthoracic echocardiogram and cardiac magnetic resonance imaging, was initially interpreted as normal. Re-review of her cardiac imaging revealed the patient had signs of a congenitally absent pericardium, including a "Snoopy Sign" on her posterior-anterior chest X-ray, which is characterized by levoposition of the cardiac silhouette, a lucent area between the pulmonary artery and aorta because of the presence of lung tissue, a lucent area between the base of the heart and the left hemidiaphragm, loss of the right heart border, a prominent pulmonary artery, and a flattened and elongated left ventricular contour. The patient had a cardiac computed tomography scan, which confirmed the diagnosis. In conclusion, a congenitally absent pericardium is a rare disorder, often undetected or misdiagnosed. There are characteristic findings on imaging such as a "Snoopy Sign" on a posterior-anterior chest X-ray, which can be easily missed because of its rarity. Our goal of this report is to educate health care providers about this rare disorder.

Congenital Partial Absence of Pericardium: A Mimic of Arrhythmogenic Right Ventricular Cardiomyopathy

Congenital absence of pericardium is a rare condition with electrocardiogram, chest X-ray, and echocardiographic findings which may mimic those of other cardiac conditions. We present a case of a 19-year-old asymptomatic female with incidental cardiomegaly on chest X-ray and electrocardiographic and echocardiographic changes, which meet the revised task force criteria for definite arrhythmogenic right ventricular cardiomyopathy but subsequently confirmed to have congenital partial absence of pericardium on cardiac magnetic resonance imaging.

Persistent Atrial Fibrillation Related to a Congenital Pericardial Defect and Left Atrial Appendage Herniation

Congenital pericardial defects (CPDs) are infrequent anomalies that are usually asymptomatic and are discovered incidentally during unrelated interventions. Here we report the case of a CPD with herniation of an enlarged left atrial appendage identified during total thoracoscopic ablation (TTA) for persistent atrial fibrillation (AF). The persistent AF was successfully treated with a hybrid procedure, in which TTA was followed by an electrophysiological study.

ST segment elevation myocardial infarction of a rare aetiology: an unexpected diagnosis

A 43-year-old man presenting with acute coronary syndrome with ST segment elevation myocardial infarction underwent urgent coronary angiography. During the intervention, the patient was found to have several multiple filling defects with dynamic obstruction in the left coronary circulation. Thrombectomy was performed on distal left anterior descending artery and 2nd diagonal artery lesions with balloon angioplasty, which was unsuccessful. Considering the dynamic obstruction in the angiogram, immediate imaging was performed for structural evaluation of the heart. Cardiac CT revealed a circumferential groove on the heart, suggesting an external compression leading to dynamic obstruction of the coronary arteries on angiogram. Cardiac hernia, a very rare aetiology, was suspected to be the culprit for the ST segment elevation myocardial infarction. Thoracoscopy was performed, which revealed congenital cardiac hernia and a fibrous pericardial band encircling the apex. A left mini thoracotomy was performed to release the constriction imposed over the heart, with improvement in circulation.

Congenital defects of the pericardium: a review

Pericardial defects are a rare disorder that can be characterized as acquired or congenital. Congenital defects can be further characterized by location and size of the defect, e.g. left- or right-sided and partial or complete absence of the pericardium. While physical examination and electrocardiogram are not diagnostic, chest radiographs and echocardiography have findings that should alert the clinician to the absence of the pericardium as a possible diagnosis. Despite its limitations with visualizing the normal pericardium in areas of minimal adipose, cardiac magnetic resonance is currently the gold standard for diagnosing the congenital absence of the pericardium. Patients have a similar life expectancy to those without pericardial defects; however in certain cases, herniation and strangulation of cardiac chambers can be life threatening and lead to sudden cardiac death. Treatment is tailored to the patient's symptoms, presentation, and the size and location of the defect.

Congenital absence of the pericardium

Congenital absence of the pericardium is a rare cardiac malformation and is most often asymptomatic. It is usually discovered as an incidental finding. Physical examination, chest radiography, and electrocardiogram are often unremarkable. Echocardiography provides valuable information, and sometimes computed tomography or magnetic resonance imaging is needed for subsequent confirmation.

Fetal death resulting from an isolated congenital partial pericardial defect

BACKGROUND

Congenital pericardial defects occur from a defect in the formation of the pleuropericardial membrane during embryonic development. This defect may be asymptomatic but can be fatal if complicated by herniation of any portion of the heart.

CASES

We report two cases in which herniation of a portion of the heart occurred through a partial left pericardial defect and resulted in fetal death. In case one, there were no fetal symptoms, and in case two, an irregular heartbeat was detected prompting a fetal echocardiogram that was negative for heart abnormalities.

CONCLUSION

Although isolated congenital pericardial defects are rare, they can result in fetal death. Awareness may help to refine ultrasonography or other diagnostic modalities to evaluate possible congenital pericardial defects in utero.

Congenital complete and partial absence of the left pericardium

Congenital absence of pericardium is a rare malformation. We report 2 young patients with a diagnosis of congenital absence of the pericardium. The posteroanterior view of the chest X-ray showed displacement of the left cardiac border into the left hemithorax. Unusual acoustical windows and abnormal cardiac and septal motion during echocardiography suggested the diagnosis of congenital absence of pericardium. Magnetic resonance imaging definitive confirmed diagnosis of congenital absence of pericardium.

Complete absence of precordial R waves due to absence of left-sided pericardium

Poor R-wave progression (PRWP) in the precordial leads on random ECG is relatively frequent in the general population and includes a broad differential diagnosis. Here, we present for the first time a case of complete absence of precordial R waves associated with a prominent R wave in aVR due to the absence of the left-sided pericardium in a 44-year-old woman who experienced sudden cardiac death.

The day when the echocardiographist went mushrooming…

We report a case of partial congenital absence of the pericardium associated with severe aortic stenosis on a bicuspid valve in a 72-year-old man. Diagnosis was based on echocardiography and confirmed with magnetic resonance imaging, and the patient benefited from pericardioplasty and aortic valve replacement.

Sudden cardiac arrest due to subtotal absence of left-sided pericardium--case report and review of the literature

Congenital absence of the pericardium is a very rare cardiac malformation, usually diagnosed fortuitously on autopsy or surgery. Symptoms related to these abnormalities are usually benign, and fatalities reported in the literature are almost exclusively secondary to herniation of the heart through a partial defect. We present the unusual case of a 44-year-old woman admitted for sudden cardiac arrest. Initial evaluation suggested acute anterior myocardial infarction, but further investigation ruled out coronary heart disease. No arrhythmia could be initiated on electrophysiological study, and absence of most of the left pericardium was confirmed by cardiac magnetic resonance imaging. After the exclusion of common etiologies such as idiopathic ventricular fibrillation, transient great vessel torsion due to hypermobility of the heart with secondary malignant arrhythmia was considered to be the most likely mechanism for the sudden cardiac arrest. A review of the available literature on clinical presentation, diagnostic tools, and therapeutic options is also presented.