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

IntroductionLocalized 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 presentationA 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.DiscussionThe 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.ConclusionHerein 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.     

A case of tuberculous granulomatous mediastinitis and constrictive pericarditis simulating malignant mediastinal tumor

A case is 40-year-old man. He presented anterior chest pain. Pericardial effusion was pointed out and a tuberculin skin test was positive. Tuberculous pericarditis was highly suspected, so INH and RFP were medicated. After 6-month medication pericardial effusion decreased, but right pleural effusion appeared on chest X-ray. Chest CT revealed a thickening of pericardium extend to anterior mediastinal mass. Echocardiogram revealed a pressure gradient in right ventricle, which was compressed by the thickened pericardium. We underwent median sternotomy in order to rule out neoplastic diseases. Intraoperative pathologic diagnosis was granulomatous mediastinitis and pericarditis, so we resected granuloma as much as possible to decompress the heart. Although Mycobacterium tuberculosis was not found in the resected granuloma, it was most probable pathogen. He received additional antituberculous chemotherapy for 6 months.     

Right ventricular metastatic choriocarcinoma obstructing inflow and outflow tract

We operated on a 34-year-old man with a metastatic tumor that extended from the tricuspid valve to the pulmonary valve and obstructed the right ventricle inflow and outflow tracts. The tumor was removed with preservation of the tricuspid valve. Additional chemotherapy was carried out according to the BEPO (etoposid, eisplatin, bleomycin, vincritin) scheme. Histology revealed metastasis of a choriocarcinoma originating from the right testis. Computed tomography performed after 6 months detected no metastases in the lungs. Magnetic resonance imaging showed a thickened right ventricle free wall and apex. The patient is doing well 18 months postoperatively.     

Metastatic hepatocellular carcinoma obstructing the right ventricular outflow tract.

A 49-year-old female with a past history of liver resection due to hepatocellular carcinoma was referred to our Department for treatment of a metastatic cardiac tumor obstructing the right ventricular outflow tract. She underwent operation twice with cardiopulmonary bypass, and symptoms were relieved. Metastasis from hepatocellular carcinoma to the heart is very rare, but should be taken into consideration during follow-up after treatment for a primary liver tumor.     

Emergency management of severe right ventricular inflow obstruction secondary to a metastatic cardiac tumor

We report the case of a 21-year-old female with previous history of primitive neuroectodermal tumor of the anterior abdominal wall who developed severe manifestations of right heart failure due to a mass obliterating the right ventricular cavity. She underwent emergent resection of the mass with histopathologic confirmation of metastatic neuroectodermal tumor. To the best of our knowledge, this is the first case of emergent surgical excision of a metastatic cardiac tumor of primitive neuroectodermal origin.     

Maximal rate of fall of left ventricular pressure in cardiomyopathy and constrictive pericarditis.

The maximal rate of fall of left ventricular pressure (peak negative dp/dt) was measured in 4 patients with congestive cardiomyopathy (primary myocardial disease), in 5 patients with constrictive pericarditis and in 3 controls. Measurements were made at rest, with leg raising, after a bolus of 6 mug intravenous isoprenaline, and in patients with constrictive pericarditis during pulsus paradoxus. Peak negative dp/dt was 1810 +/- 234 mmHg/sec in controls; it was reduced in patients with constrictive pericarditis (1337 +/- 514 mmHg/sec) and greatly decreased in patients with congestive cardiomyopathy (812 +/- 190 mmHg/sec). There was close linear correlation between resting peak positive and peak negative dp/dt and there was little change with leg raising. Isoprenaline caused an increase in peak positive dp/dt, but there was only a small change in peak negative dp/dt. In patients with constrictive pericarditis, peak negative dp/dt varied during pulsus paradoxus: the linear relationship to peak positive dp/dt was maintained throughout the respiratory cycle. Peak negative dp/dt may be a useful index of myocardial function.     

Noninfectious constrictive pericarditis in a heart transplant recipient.

Acute rejection, infection, and allograft coronary artery disease have been recognized as the major causes of postoperative morbidity and mortality in cardiac transplant patients. More recently, pericardial and mediastinal complications have been recognized as a more common complication than previously believed. We describe a case of a heart transplant recipient admitted for apparent congestive heart failure exacerbation who was unresponsive to standard medical management of congestive heart failure and rejection. After further invasive evaluation, it was discovered the patient's condition was attributable to posttransplantation constrictive pericarditis. It is appropriate to consider this diagnosis in any postcardiac surgery (especially heart transplant recipients) in patients presenting with congestive heart failure exacerbations refractory to usual medical management.     

Collagen diseases as a cause of constrictive pericarditis.

Seven patients with constrictive pericarditis associated with collagen disease underwent pericardiectomy with good results in all but one. The collagen disease was confirmed as rheumatoid arthritis in five patients, but in two its nature remained obscure. In one case the illness was marked by a persistent eosinophilia and eosinophilic infiltration of the pericardium. The association of constrictive pericarditis with rheumatoid arthritis and other collagenoses is briefly discussed.     

Asbestos induced pericardial effusion and constrictive pericarditis.

The number of disorders attributable to asbestos exposure has increased gradually over the years. The latest to be recorded is pericardial effusion and constrictive pericarditis, and three cases are reported here. A man with bilateral pleural thickening and plaques developed acute pericarditis and an effusion and was treated by pericardiectomy. Two men died from constrictive pericarditis associated with bilateral pleural effusions and diffusion pleural thickening. The pericardium showed nonspecific fibrous thickening. All had been occupationally exposed to asbestos. In the fatal cases the lungs contained amphibole fibres, in keeping with a modest degree of occupational exposure. Asbestos produces progressive fibrosis of the pericardium that is similar to diffuse pleural thickening and may be fatal. Both conditions may develop after relatively short or light exposure.     

Dilatation of the azygos vein simulating a mediastinal tumour.

A mediastinal tumour was simulated by gross dilatation of the azygos vein resulting from compression by enlarged hilar lymph nodes at the point where it crossed the right main bronchus to enter the superior vena cava. This cause of dilatation of the azygos vein has not previously been reported. Published reports are reviewed and attention drawn to the large proportion of patients (11/19) with this condition who had needless thoracotomies. The possibility of making a diagnosis by means of clinical observation and simple radiological techniques and thus avoiding surgical intervention is discussed.