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Acute Cardiac Tamponade Due to a Bleeding Pericardial Cyst in a 3-Year-Old Child

2007; Elsevier BV; Volume: 84; Issue: 1 Linguagem: Inglês

10.1016/j.athoracsur.2007.01.058

1552-6259

Yoshihisa Tanoue, Satoshi Fujita, Yoshiaki Kanaya, Ryuji Tominaga,

Cardiac tumors and thrombi

We report a case of a pericardial cyst complicated with acute cardiac tamponade in a 3-year-old child with no previous cardiac history who was transferred to our university hospital because of hemodynamic shock. A chest roentgenogram revealed marked cardiac enlargement, and transthoracic echocardiography showed massive pericardial effusion with a moving cystic structure. Percutaneous needle aspiration yielded bloody pericardial fluid. Emergency drainage of the pericardial effusion and resection of the cyst were performed through a median sternotomy. We found a blood-containing cyst that was attached to the right atrium near the sinus node and to the inferior wall of the pericardial cavity. We report a case of a pericardial cyst complicated with acute cardiac tamponade in a 3-year-old child with no previous cardiac history who was transferred to our university hospital because of hemodynamic shock. A chest roentgenogram revealed marked cardiac enlargement, and transthoracic echocardiography showed massive pericardial effusion with a moving cystic structure. Percutaneous needle aspiration yielded bloody pericardial fluid. Emergency drainage of the pericardial effusion and resection of the cyst were performed through a median sternotomy. We found a blood-containing cyst that was attached to the right atrium near the sinus node and to the inferior wall of the pericardial cavity. Pericardial cysts are rare (incidence 1 in 100,000) and are clinically silent in most cases [1Losanoff J.E. Richman B.W. Curtis J.J. Jones J.W. Cystic lesions of the pericardium: review of the literature and classification.J Cardiovasc Surg (Torino). 2003; 44: 569-576PubMed Google Scholar]. Some symptomatic cases with acute cardiac tamponade have been reported [2Shiraishi I. Yamagishi M. Kawakita A. Yamamoto Y. Hamaoka K. Acute cardiac tamponade caused by massive hemorrhage from pericardial cyst.Circulation. 2000; 101: E196-E197Crossref PubMed Google Scholar, 3Bava G.L. Magliani L. Bertoli D. et al.Complicated pericardial cyst: atypical anatomy and clinical course.Clin Cardiol. 1998; 21: 862-864Crossref PubMed Scopus (20) Google Scholar, 4Borges A.C. Gellert K. Dietel M. Baumann G. Witt C. Acute right-sided heart failure due to hemorrhage into a pericardial cyst.Ann Thorac Surg. 1997; 63: 845-847Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar], but there are few case reports of children. We report a case of a pericardial cyst complicated with acute cardiac tamponade and hemodynamic shock in 3-year-old child. Emergency drainage of the pericardial effusion and resection of the cyst were performed through a median sternotomy. A 3-year-old girl was transferred to our university hospital from another hospital because of hemodynamic shock. She had a history of bronchial asthma, but no previous cardiac history. Her body weight was 14.6 kg and her height was 96.2 cm. Physical examination revealed dilated neck veins, tachycardia, and paradoxical pulse. A chest roentgenogram showed marked cardiac enlargement. Transthoracic echocardiography demonstrated massive pericardial effusion with a moving cystic structure. A computed tomographic scan showed a large cystic structure in the pericardial cavity (Fig 1). Percutaneous needle aspiration yielded bloody fluid, and her hemodynamic state temporarily improved. Emergent surgery was carried out because of the progressively increasing pericardial effusion and her worsening hemodynamic state. A median sternotomy was performed. After opening the pericardium, approximately 210 mL of bloody fluid was aspirated from the pericardial cavity. Her blood pressure increased by approximately 20 mm Hg, and her central venous pressure decreased from more than 20 mm Hg to less than 10 mm Hg. There was a 60 × 40 mm blood-containing cyst attached to the right atrium near the sinus node and to the inferior wall of the pericardial cavity (Fig 2). There was bloody fluid oozing from the cyst wall, but no rupture was found. The tumor stalk attached to the right atrium was ligated and excised. The cyst was detached from the inferior wall of the pericardial sac, which included excision of some pericardial tissue. No cardiac anomalies were found. After irrigation with saline solution, the right pleural cavity was opened, and 50 mL of serous fluid was drained. The patient was intubated for 2 days after the operation due to complications caused by her bronchial asthma. The chest tubes were removed 3 days after the operation, and the rest of the postoperative course was uneventful. The patient continues to do well 6 months after the operation without recurrence of the pericardial effusion. Histologic examination showed that the cyst wall consisted of inflamed granulation tissue with fibrin deposition and fibrosis. A culture of the pericardial effusion was negative. No evidence of malignancy was found. The pathologic diagnosis confirmed a hemorrhagic pericardial cyst. We report the case of a pericardial cyst complicated with acute cardiac tamponade requiring surgery in a 3-year-old child. This is a very rare condition, especially during childhood. Pericardial cysts are usually asymptomatic and undetectable on physical examination [1Losanoff J.E. Richman B.W. Curtis J.J. Jones J.W. Cystic lesions of the pericardium: review of the literature and classification.J Cardiovasc Surg (Torino). 2003; 44: 569-576PubMed Google Scholar]. When symptomatic, chest pain, cough, and epigastric fullness are the most common presenting complaints. Although complications are uncommon, unexpected life-threatening events such as acute cardiac tamponade [2Shiraishi I. Yamagishi M. Kawakita A. Yamamoto Y. Hamaoka K. Acute cardiac tamponade caused by massive hemorrhage from pericardial cyst.Circulation. 2000; 101: E196-E197Crossref PubMed Google Scholar, 3Bava G.L. Magliani L. Bertoli D. et al.Complicated pericardial cyst: atypical anatomy and clinical course.Clin Cardiol. 1998; 21: 862-864Crossref PubMed Scopus (20) Google Scholar, 4Borges A.C. Gellert K. Dietel M. Baumann G. Witt C. Acute right-sided heart failure due to hemorrhage into a pericardial cyst.Ann Thorac Surg. 1997; 63: 845-847Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar], atrial fibrillation [5Vlay S.C. Hartman A.R. Mechanical treatment of atrial fibrillation: removal of pericardial cyst by thoracoscopy.Am Heart J. 1995; 129: 616-618Abstract Full Text PDF PubMed Scopus (25) Google Scholar] and sudden death [6Fredman C.S. Parsons S.R. Aquino T.I. Hamilton W.P. Sudden death after a stress test in a patient with a large pericardial cyst.Am Heart J. 1994; 127: 946-950Abstract Full Text PDF PubMed Scopus (36) Google Scholar] have been reported. Noninvasive investigation with echocardiography, computed tomography, and magnetic resonance imaging can aid in early diagnosis. As the risks associated with surgical resection are low, it is preferable to operate before serious complications arise. A critically large cyst should be considered for surgical resection. A differential diagnosis of malignancy is also an indication for surgical intervention. However, most patients can be treated conservatively without surgery. It is still controversial whether the preferred therapeutic approach to pericardial cysts should be surgical or conservative, especially in children [7Noyes B.E. Weber T. Vogler C. Pericardial cysts in children: surgical or conservative approach?.J Pediatr Surg. 2003; 38: 1263-1265Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar]. The differential diagnoses of cystic lesions of the pericardium include pericardial cysts, bronchogenic cysts, teratogenic cysts, mesothelial cysts, and cystic lymphangiomas [1Losanoff J.E. Richman B.W. Curtis J.J. Jones J.W. Cystic lesions of the pericardium: review of the literature and classification.J Cardiovasc Surg (Torino). 2003; 44: 569-576PubMed Google Scholar]. A preoperative diagnosis was difficult in the present case due to a lack of prior information about the patient. The exclusion of a diagnosis of infection or malignancy is of great importance for prognosis. We obtained rapid microscopic examination of fluid and tissue during the operation to exclude infection and malignancy. The possible mechanism of spontaneous bleeding from a pericardial cyst is very important. Our surgical findings suggested the frailty of the cyst wall to be the cause in this case. An ischemia-related lesion was excluded as the serum creatine kinase level did not increase. One of the most important problems with pericardial cysts is the potential risk of a patient with no previous cardiac history suddenly lapsing into a critical condition necessitating rapid diagnostic and therapeutic measures for survival, as demonstrated in the present case.