Ann Thorac Surg 2002;73:1633-1634
© 2002 The Society of Thoracic Surgeons
Case report
Successful resection of an epicardial cyst
Roberto Scrofani, MD*a,
Cristina Carro, MDa,
Luigi Beretta, MDa,
Carlo Antona, MDa
a Division of Cardiac Surgery, Hospital "L. Sacco," Milan, Italy
Accepted for publication August 8, 2001.
* Address reprint requests to Dr Scrofani, Divisione di Cardiochirurgia, Ospedale "L. Sacco," Via G.B. Grassi n. 74, 20157 Milan, Italy
e-mail: scrofani{at}robertomail.it
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Abstract
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Cases of pericardial cyst have been reported by many authors, but the incidence of epicardial cyst originating directly from the epicardium in the pericardial cavity is extremely rare. A case of successful resection of epicardial cyst fortuitously discovered and diagnosed during cardiac operation is presented.
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Introduction
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Cases of pericardial cyst have been reported by many authors [1–3], but the incidence of epicardial cyst originating directly from the epicardium in the pericardial cavity is extremely rare; only three cases are reported in the literature [4–6]. We present a case of successful resection of epicardial cyst fortuitously discovered and diagnosed during cardiac operation.
A 60-year-old man was admitted to our hospital for aortic valve replacement because of aortic valve insufficiency. For the previous year he had slight dyspnea on climbing stairs. A III/IV pansystolic murmur was detected at the cardiac base. As a result of this murmur, further examination by echocardiography was requested; the examination revealed a massive aortic insufficiency. The other cardiac structures were normal and no abnormal mass was revealed. Laboratory study, electrocardiogram, chest roentgenogram, and coronary angiographic examination were unremarkable.
The patient underwent operation for aortic valve replacement. A midline sternotomy was used and the pericardium was noted to be normal. After a conventional longitudinal pericardiectomy a normal quantity of clear fluid was found in addition to a voluminous mass. There were no adhesions between the mass and the pericardium; its attachment to the heart was in the upper portion of the right atrium overriding the area between the right atrium and right ventricle and surrounding the proximal portion of the ascending aorta (Fig 1A).
The mass was 7 x 5.5 cm, brown in appearance, elastic, soft, and well distended (Fig 1B). From these findings we thought the cyst originated from the epicardium. Part of the free wall tissue of the cyst was resected for immediate histologic examination, which confirmed its epicardial origin. Inside the cyst were many trabecular structures and a small quantity of yellow fluid. Cytologic studies of the fluid revealed no malignant cells. The diagnosis of epicardial cyst was confirmed by microscopic and macroscopic examination. Free wall tissue of the cyst was resected taking care not to injure the right artery and its branches. We then proceeded with aortic valve replacement.
The patient’s postoperative course was uneventful and he was discharged from the hospital on the eighth day. At follow-up, he was leading a normal life.
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Comment
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Cardiac cysts originating from the epicardium in the pericardial cavity are extremely rare: we found only three case reports. One was reported by Edwards and Ahamad [4] in 1972 in the United Kingdom, another was by Komeda and associates [5] in 1985 in Japan, and the last was by Ozasa and colleagues [6] in 1991. Leroux [7] reported the incidence of pericardial cyst as 1:100,000, but tere are no data in the literature concerning the incidence of epicardial cyst.
Two mayor hypotheses about the cause of epicardial cyst have been postulated: In 1940 Lambert [8] considered extrapericardial cyst a result of failure of coalescence of the mesodermal space. Ten years later Lillie and associates [9] suggested that this malformation could occur as an abnormality of development of the ventral recesses. The patient with this kind of lesion is generally asymptomatic, but symptoms may appear if the size of the cyst is large enough to compress surrounding organs. In our case the cyst was found incidentally at the time of operation, and, preoperatively, neither chest roentgenogram nor echocardiographic Doppler showed it. We believe that if diagnosis is possible before operation, computed tomographic scan and nuclear magnetic resonance are the best methods to identify the anatomic features of the cyst and its relation to the other cardiac structures and surrounding organs.
The difficulties in preoperative diagnosis of this tumor are evident; therefore, considering the possible compression of the cyst on the surrounding structures and the absence of a major contraindication to operation, we believe these tumors should be promptly managed surgically even if they are completely asymptomatic.Fig 2
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Fig 2. Microscopic view: immunohistochemical staining cyst wall layered by simple flat epithelium. (Emathosilin and eosin stain, x 250.)
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References
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Davis C.H., Dorsey J., Scanlon E. Cyst about the pericardium. Arch Surg 1953;67:110.
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De Roover P.H., Maisln J., Laquet A. Congenital pleuropericardial cysts. Thorax 1963;18:146.
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Loehr W.M. Pericardial cysts. Am J Roentgenol 1952;68:584.
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Edwards M.H., Ahamad A. Epicardial cyst. A case report. Thorax 1972;27:503.[Abstract/Free Full Text]
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Komeda M., Shigheito M., Kusuara K., et al. Epicardial cyst. Report of a case with successful resection. Jpn Circ J 1985;49:1201-1205.[Medline]
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Ozasa A., Nakazawa K., Kamegai M., et al. A case of epicardial cyst. Jpn Circ J 1991;55:53-57.[Medline]
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Leroux B.T. Pericardial coelomic cysts. Thorax 1959:14-27.
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Lambert A.V.S. Etiology of thin walled thoracic cysts. J Thorac Surg 1940;10:1.
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Lillie W.I., McDonald J.R., Clagett O.T. Pericardial diverticula. J Thorac Surg 1950;20:494.
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Abstract
Introduction
