Giant calcific pericardial cyst: certainly unexpected during primary percutaneous coronary intervention

Pericardial cyst is a rare congenital anomaly that is usually diagnosed during evaluation for right‐sided heart failure. We report a 50‐year‐old man with a primary diagnosis of ST‐segment elevation myocardial infarction at admission, whose emergent angiography revealed a calcific mass close to right coronary artery. Further analysis of the mass with computed tomography and three‐dimensional echocardiography revealed a giant pericardial cyst causing partial obstruction of superior vena cava. Unlike previous cases reported, the patient had no symptoms compatible with right‐sided heart failure.     

Incremental benefit of three‐dimensional transesophageal echocardiography in the assessment of a primary pericardial hemangioma

Hemangiomas are rarely found in the heart and pericardial involvement is even more rare. We report a case of primary pericardial hemangioma, in which three‐dimensional transesophageal echocardiography (3DTEE) provided incremental benefit over standard two‐dimensional images. Our case also highlights the importance of systematic cropping of the 3D datasets in making a diagnosis of pericardial hemangioma with a greater degree of certainty. In addition, we also provide a literature review of the features of cardiac/pericardial hemangiomas in a tabular form.     

Isolated Ruptured Inter‐Atrial Septal Cystic Echinococcosis during Pregnancy

Herein, we present a case of asymptomatic isolated cardiac cystic echinococcosis localized entirely to the inter‐atrial septum in a pregnant woman. The patient underwent successful surgery. Cardiac cystic echinococcosis is rarely seen in pregnancy. A high index of suspicion is necessary for the diagnosis of a cardiac cyst hydatid. The treatment of cardiac cyst hydatid is surgical and should not be delayed during pregnancy. Early surgery might prevent septic embolization and cardiac life‐threatening complications and save the lives of both mother and baby as in the present case.     

Perforated giant mycotic aneurysm of mitral valve in a drug‐addicted young man: Rare complication of infective endocarditis

Infective endocarditis (IE) affects patients at high clinical risk and may present as an acute and rapidly progressive, subacute or chronic infection. Transthoracic and transesophageal echocardiography represent the key diagnostic method in IE diagnosis. In particular, three‐dimensional transesophageal echocardiography represents the imaging technique that allows to establish with adequate accuracy dimensions, shape, and localization of endocarditis vegetations. In our case, we show a huge vermiform mycotic aneurysm in an immunodeficient young drug‐addicted man with severe mitral valve regurgitation and the additive value of three‐dimensional transesophageal echocardiography in this specific clinical setting.     

Epidermoid cyst of the intrapancreatic accessory spleen producing CA19‐9

We report a rare case of an epidermoid cyst in an accessory spleen at the pancreatic tail with producing CA19‐9. A 55‐year‐old female was admitted to our hospital, Cancer Research Institute, Kanazawa University, for close examination of a cystic lesion at the pancreatic tail and a high serum CA19‐9‐value (176 U/mL). There were almost no abdominal symptoms related to the cystic lesion. A cystic tumor approximately 3 cm in diameter and composed of multilocular cysts without a protruding portion of the inner surface was found at the pancreatic tail by ultrasound sonography, computed tomography, and magnetic resonance imaging. Endoscopic retrograde pancreatography revealed that the main pancreatic duct shifted at the pancreatic tail and there was no communication between the main pancreatic duct and cystic lesion. Based on a preoperative diagnosis of mucinous cystic tumor, distal pancreatectomy with splenectomy was performed. Histological ?ndings suggested an epidermoid cyst (3.5 × 3.0 cm) originating from an intrapancreatic accessory spleen. Immunohistochemical analysis of CA19‐9 in the epidermoid cyst showed clear staining of the inner epithelium of the cyst and amorphous or hyalinous cystic contents. The serum CA19‐9 value was con?rmed to decline to normal 2 months after resection. Physicians should not forget this disease during differential diagnosis related to pancreatic cystic lesions with elevated levels of serum tumor markers, such as CA19‐9 or carcinoembryonic antigen, although this disease is extremely rare.     

Three‐Dimensional Transthoracic Echocardiography in Identification of Aorto‐Right Atrial Fistula and Aorto‐Right Ventricular Fistulas

We report the case of a 72‐year‐old woman who developed new onset right ventricular failure after redo aortic valve replacement. The diagnosis of left to right shunt was initially made using two‐dimensional transthoracic echocardiography (2DTTE) and 2D transesophageal echo with color Doppler (TEE). Definite diagnosis of aorto‐right atrial and aorto‐right ventricular fistula was made using thee‐dimensional transthoracic echocardiography (3DTTE) with color flow Doppler imaging. Early recognition and diagnosis of this rare surgical complication is imperative for prompt surgical repair of this lethal defect. 3DTTE should be utilized in cases of new onset heart failure with unclear etiology to diagnose unusual causes of this potentially fatal condition. (Echocardiography 2010;27:E105‐E108)     

Pseudogout associated with meniscal cysts - report of two patients

Two patients with pseudogout developed large meniscal cysts at the knee. In the first case the diagnosis of meniscal cyst was confirmed surically. In the second case, the cyst resolved following thorough aspiration. Polarized microscopy of repeated aspirated from cyst in this case as well as of fluids from the knees of both patients consistently showed positively birefringent rhomboid crystals. X-ray diffraction of fluids from the knee of the second patient identified the crystals as calcium pyrophosphate dihydrate.     

Endocardial Blood Cyst: A Rare Site and Age of Presentation

Cardiac blood cysts are rare findings in clinical practice. They usually involve the valves and are very uncommon in adult age. Their clinical manifestation varies broadly, as they can interfere with intracardiac flow, or even be completely silent. We report a case of a newly developed cyst of the atrial septum, incidentally detected by transthoracic echocardiography in a 69‐year‐old asymptomatic patient. The diagnosis was confirmed by postsurgery histopathological examination. (Echocardiography 2011;28:E50‐E52)     

Recurrent acute pancreatitis revealing a hydatid cyst of the pancreas

The authors report a case of hydatid cyst of the pancreas in a 29-year-old man. Biology and computed tomography contributed to the preoperative diagnosis. The intervention consisted in a left pancreatectomy with spleen ablation. In the light of this case and the literature review, the authors discuss diagnostic issues raised by hydatid cyst of the pancreas.     

3D Echocardiographic Delineation of Mitral‐Aortic Intervalular Fibrosa Pseudoaneurysm Caused by Bicuspid Aortic Valve Endocarditis

Pseudoaneurysm of the mitral‐aortic intervalvular fibrosa is a rare complication of infective endocarditis of the aortic valve eventually resulting in coronary artery compression, stroke or rupture into the left atrium, aorta or pericardial space. A prompt diagnosis by either transthoracic or transesophageal echocardiography is mandatory to address the patient to cardiac surgery. We report the clinical case of a 25‐year‐old white man who was admitted to the emergency department for dyspnoea and fever. Echocardiographic examination showed a bicuspid aortic valve with a huge sessile vegetation and a pseudaneurysm of the mitral‐aortic intervalvular fibrosa. In addition to conventional two‐dimensional examination, three‐dimensional echocardiography provided additional information of this complication, precisely delineating the lesions and addressing the cardiac surgeon in choosing the most appropriate operating strategy. Patient underwent then aortic root replacement and the pseudoaneurysm was closed by means of a bovine pericardial patch. (Echocardiography 2011;28:E1‐E4)     

Double‐Chambered Right Ventricle with Ventricular Septal Defect and Subaortic Membrane— Three‐Dimensional Echocardiographic Evaluation

Double‐chambered right ventricle (DCRV) is a rare congenital anomaly in which the right ventricle is divided into two compartments with varying pressures due to an anomalous muscle bundle. Here, we describe a case of an adolescent male with DCRV with associated ventricular septal defect and subaortic membrane. Two‐dimensional and three‐dimensional transthoracic echocardiography with color flow clearly outlined all the three cardiac anomalies as well as their relationship with each other. The diagnosis was confirmed by cardiac catheterization. The patient underwent successful surgical resection of the anomalous muscle bundle along with repair of the associated anomalies.     

An unusual pericardial tumor: bronchogenic cyst]

The authors report the case of an intrapericardial bronchogenic cyst in a 42 year old woman with no cardiac symptoms. Despite extensive investigation, the final diagnosis was made only at anatomopathological examination. A pericardial localisation of this embryological tumour is very rare and a number of features of the condition are described. In this case, the carbohydrate antigen (CA 19-9) was a veritable marker of this tumour. This association, described for the first time, between a simple biological marker and an intrapericardial bronchogenic cyst, could be a valuable diagnostic aid in a pathology in which surgery could reasonably be deferred should the diagnosis of bronchogenic cyst be certain.     

Usefulness of three‐dimensional echocardiography in the assessment of valvular involvement in Loeffler endocarditis

Loeffler endocarditis is a complication of hypereosinophilic syndrome resulting from eosinophilic infiltration of heart tissue. We report a case of Loeffler endocarditis in which three‐dimensional transthoracic and transesophageal echocardiography provided additional information to what was found by two‐dimensional transthoracic echocardiography alone. Our case illustrates the usefulness of combined two‐ and three‐dimensional echocardiography in the assessment of Loeffler endocarditis. In addition, a summary of the features of hypereosinophilic syndrome and Loeffler endocarditis is provided in tabular form.     

Echinococcosis of the heart: clinical and echocardiographic features in 12 patients

We describe the clinical and echocardiographic features in 12 patients with hydatid cyst of the heart who were screened between 1985 and 2001. Presenting symptoms have a wide variability but the main symptom was precordial pain. The electrocardiogram was always abnormal and showed T wave inversion in 8 cases, ST depression in 5 cases, incomplete right bundle-branch block in one case and atrial fibrillation in one case.Transthoracic echocardiography and transoesophageal echocardiography constitute the imaging procedure of choice for the diagnosis of cardiac hydatid cyst with a high sensibility, specificity. Computed tomography (CT) was performed in all patients and confirmed the echocardiographic data. MRI was performed in one patient with right atrium hydatid cyst location and confirmed the echocardiographic data. CONCLUSION: In the presence of atypical symptomatology in a patient coming from an endemic area of hydatid cyst, the diagnosis of cardiac echinococcosis is possible.TTE and TEE are the imaging procedure of choice and sufficient for the diagnosis of cardiac hydatid cyst. CT and/or MRI provide more information about the extension of echinococcus disease in other intra- or extrathoracic locations.     

Toward Defining Pulmonary Sequestration in Infancy Using Two‐dimensional Echocardiography and Novel High Temporal Resolution “Keyhole” Three‐dimensional Magnetic Resonance Angiography

This article describes a rare case of pulmonary sequestration presenting in infancy with mixed systemic and pulmonary venous drainage. This case illustrates the clinical application of the high temporal resolution three‐dimensional “keyhole” magnetic resonance angiography technique in the neonatal age group to achieve a diagnosis noninvasively. Further insight into the classification of pulmonary sequestration is also given.     

Nonparasitic solitary huge liver cysts causing intracystic hemorrhage or obstructive jaundice

We report two cases of a nonparasitic solitary huge liver cyst. The first case, that of a 42‐year‐old woman, was admitted with a chief complaint of upper abdominal pain. Computed tomography (CT) scans revealed a huge cyst, 10 cm in diameter, in segments 4 and 5 of the liver, and spontaneous rupture of the cyst with intracystic hemorrhage. Her general condition was improved by transcatheter arterial embolization (TAE). Percutaneous cystic needle aspiration cytological examination revealed no malignant cells, so she was discharged. After 3 weeks, however, the cyst had increased in size, and simple cystectomy was performed. Histological examination proved the cyst to be benign. The patient in the second case, a 70‐year‐old man, was admitted with epigastric discomfort and obstructive jaundice. CT scans revealed a huge liver cyst, 18 × 15 cm, in the right lobe of the liver, with dilation of the bile duct in the lateral segment. Magnetic resonance cholangiopancreatography showed compression of the left hepatic duct by the cyst and dilation of the bile duct in the lateral segment. Endoscopic retrograde cholangiopancreatography disclosed no communication between the bile duct and the cyst. Percutaneous transhepatic cyst drainage was performed, and minocycline hydrochloride was infused. The cyst was reduced in size, and the reduction has been maintained for 20 months since treatment.     

Role of endoscopic ultrasonography in pancreatic cystic neoplasms: Where do we stand and where will we go?

We increasingly encounter pancreatic cystic neoplasms (PCN) in clinical practice and the differential diagnoses vary widely from benign to malignant. There is no ‘one and only’ diagnostic procedure for PCN. Multiple modalities including computed tomography, magnetic resonance imaging, endoscopic retrograde cholangiopancreatography and endoscopic ultrasound (EUS) are widely used, but EUS has the advantage of anatomical proximity to the pancreas and upper gastrointestinal tract. In addition, EUS‐guided fine‐needle aspiration (EUS‐FNA) provides both cytological evaluation and cyst fluid analysis. Although the role of EUS‐FNA for PCN is established, the sensitivity of cytology is low and cyst fluid analysis is only useful for differentiation between mucinous and non‐mucinous cysts. Recently, novel through‐the‐needle imaging under EUS‐FNA, such as confocal laserendomicroscopy, is expected to attribute to a better diagnostic yield. Moreover, feasibility of cyst ablation has been reported and the role of EUS has expanded from diagnosis to treatment. However, clinical impact of cyst ablation in terms of safety, efficacy and cost‐effectiveness should be validated further. In summary, EUS and EUS‐guided intervention does and will play a central role in the management of PCN from surveillance to treatment, but many clinical questions remain unanswered, which warrants well‐designed prospective clinical trials.     

An exceptional and misleading case of choledochal cyst

The authors report a case of choledocal cyst extended to left and right hepatic ducts. An heterogeneous intracystic fluid, partial calcification of cystic wall, a slight positivity of echinoccosis serology in a patient from a highly endemic country erroneously led to diagnosis of hydatid cyst invading the left hepatic duct. The diagnosis of choledocal cyst was done on the resection specimen after left hepatectomy. A small patch of cyst wall with terminations of both right sectorial hepatic ducts was used for cysto-jejunal Roux-en-Y loop anastomosis. Peculiarities of this type of choledocal cyst are discussed.     

Ruptured cerebral hydatid cyst: a case report

In this report we describe a case of cerebral hydatid cyst which ruptured into the subarachnoid space and suggest points which help in the preoperative diagnosis.     

Epicardial cyst. Report of a case with successful resection

As a result of mass-screening, a 7-year-old girl was noted to have an abnormal shadow and was subsequently diagnosed as having a pericardial cyst. During surgery, we discovered that the cyst originated from the epicardium, and only its free wall was resected with the cyst left open to the pericardial cavity. The postoperative course was uneventful. This is presumed to be the first case of epicardial cyst ever reported in Japan. In diagnosing the epicardial cyst, the use of chest films, echocardiography and computed tomography assist angiography in making a differential diagnosis from intracardiac lesion. In treatment, surgical resection is advised. Even though the cyst may be asymptomatic, the possible compression on the surrounding organs and possible rupture into the pericardial cavity must be avoided.