Magnetic Resonance Imaging and Video-Assisted Thoracoscopy Facilitate the Comprehensive Management of a Large Pericardial Cyst

Abstract

Background

Pericardial cysts are rare benign mediastinal masses and are often incidental findings on chest imaging. However, patients may present with symptoms that warrant surgical resection.

Case Summary

A 47-year-old man presented with progressive dyspnea, cough, and chest tightness. Chest computed tomography revealed a 2.6 × 7.0 × 5.5-cm pericardial cyst anterior to the apical right ventricle. He underwent successful resection using video-assisted thoracoscopy. He recovered well, was discharged on postoperative day 2, and symptoms had fully resolved at his 3-week follow-up visit.

Discussion

This case highlights a safe and effective minimally invasive management option for pericardial cysts. Facilitated by thorough preoperative cardiological and radiological workup, video-assisted thoracoscopic surgery facilitates complete resection with rapid postoperative recovery.

Take-Home Messages

Pericardial cysts should be included in differential diagnoses for chronic cough and can easily be identified on computed tomography/magnetic resonance imaging. Video-assisted thoracoscopic surgery offers a safe, cost-effective, and reliable method of resection.

Visual Summary

History of Presentation

Our patient is a 47-year-old man who presented to pulmonology with dyspnea, cough, and chest tightness with exercise that had progressively worsened over the previous 6 months. He had no history of smoking. He had exposure to burn pits in Iraq and previously worked as a firefighter. Physical exam was unrevealing.

Take-Home Messages

• •Pericardial cysts should be included in differential diagnoses for chronic cough and can be easily identified on CT/magnetic resonance imaging.
• •Video-assisted thoracoscopic surgery offers a safe, cost-effective, and reliable method of resection.

Past Medical History

The patient had a past medical history of chronic cough since returning from the Iraq war in 2004.

Differential Diagnosis

The main differential diagnoses included both cardiac and pulmonary causes, such as ischemic heart disease and cardiomyopathy, as well as exercise-induced asthma and interstitial lung disease.

Investigations

An initial chest X-ray showed no abnormalities, and pulmonary function testing was within normal limits. Chest computed tomography (CT) revealed a 2.6 × 7.0 × 5.5-cm cystic structure anterior to the apical right ventricle that was consistent with a pericardial cyst. Cardiac magnetic resonance imaging (CMR) more precisely measured the pericardial cyst at 7.9 × 4.0 × 6.7 cm (Figure 1). A transthoracic echocardiogram revealed a pericardial cyst adjacent to the right ventricular apex with mild dilation of the right atrium and right ventricle. He was thus referred to cardiothoracic surgery for consideration of pericardial cyst resection. Coronary angiogram demonstrated no significant coronary artery disease, and pulmonary artery catheterization was significant for a reduced pulmonary artery pulsatility index of 2.7 but no pulmonary hypertension.

Figure 1.

Computed Tomography and Magnetic Resonance Images of the Pericardial Cyst, Arrows Denoting the Cyst

Management

The patient underwent video-assisted thoracoscopic resection of the pericardial cyst via left-sided approach. A 12-mm incision was made at the posterior axillary line at the eighth intercostal space for the introduction of a video scope. Two additional 5-mm incisions were made at the posterior axillary line at the fourth and eighth intercostal spaces for working ports. The cyst was situated just anterior to the pericardium and was attached to the diaphragm (Figure 2). The cyst was dissected from the pericardium and anterior chest wall using a ligature device (Medtronic). The phrenic nerve was identified and preserved. The cyst put tension on the phrenic nerve but did involve the nerve. Complete dissection was achieved without rupturing the cyst. The cyst was removed via an Endo Catch bag. Because of the size of the cyst, a needle was used to aspirate fluid and decompress the cyst before removal through the 12-mm port. Hemostasis was achieved and a 28-F chest tube was placed in the inferior mediastinum through the 12-mm port site and connected to Pleur-evac with suction. The 5-mm ports were closed and dressings placed. Intercostal nerve block was performed with 50 mL of 0.2% ropivacaine injection.

Figure 2.

Intraoperative Image of Large Pericardial Cyst as It Is Being Dissected Off the Pericardium

Outcome and Follow-Up

The patient did well postoperatively, and his chest tube was removed on postoperative day 1. His preoperative cough and chest tightness improved the day after surgery. Histopathological evaluation of the excised specimen showed a benign mesothelial-lined cyst (Figure 3). Pain was well controlled with oral pain medications. He was discharged on postoperative day 2 in good condition. Follow-up evaluation at 3 weeks and at 1 year postoperatively confirmed complete resolution of dyspnea, cough, and chest pain.

Figure 3.

Histopathology Slides Showing a Benign Mesothelial-Lined Pericardial Cyst (Hematoxylin and Eosin ×50)

Discussion

Pericardial cysts are rare benign mediastinal masses that are typically considered to be congenital. They are most often found in the right costophrenic space (70% of cases) but can also appear in the left costophrenic space (22%) or elsewhere in the mediastinum (8%).¹ Although usually discovered incidentally on imaging, cases of patients presenting with symptoms such as flank pain and chest tightness have been reported.² Management for pericardial cysts involves surgical resection if the patient is symptomatic. If the patient is asymptomatic and the cyst is not growing on serial imaging, no intervention is required. Surgical resection is performed through median sternotomy, thoracotomy, robotic, or video-assisted thoracoscopic surgery (VATS) approaches.

Here, we present a case of a large left costophrenic pericardial cyst causing chronic cough, dyspnea, and chest pain in a 47-year-old man who underwent VATS pericardial cyst resection and had immediate improvement in his symptoms postoperatively. He recovered from his operation and was ready for discharge in just over 24 hours.

This case demonstrates that the use of multimodality imaging, and a minimally invasive treatment option for pericardial cysts is effective and safe. The size and location of the mass over the apex of the left ventricle did not seem to account for his significant symptoms but imaging with contrast-enhanced, gated, cardiac CT and CMR were helpful to confirm that the longstanding symptoms were likely attributed to the cyst. Pulmonary artery catheterization revealed a reduced pulmonary artery pulsatility index, which in this young, otherwise healthy patient and in the absence of any other possible attributable explanation may have resulted from the pericardial cyst's mechanical mass effect on the right ventricular apex.

CMR demonstrated a well-demarcated, homogeneous structure located in the cardiophrenic angle demonstrating low signal intensity on T1-weighted imaging and high signal intensity on T2-weighted imaging, consistent with the characteristic features of pericardial cysts.³ We assessed the mobility of the cyst relative to the heart using bright-blood balanced steady-state free precession cine imaging, and black-blood T1- and T2-weighted fast spin-echo sequences were used to assess for invasiveness into surrounding tissues and the pericardium.⁴ The heart was noted to move independently, and the mass was clearly noninvasive. There was no enhancement on early gadolinium enhancement and late gadolinium enhancement imaging.⁴ Although not performed in this case, the addition of parametric T1 and T2 mapping may further improve tissue characterization and enhance the diagnostic utility of CMR for preoperative evaluation of cardiac masses.^4,5

Based on imaging results, a left-sided approach was chosen for the VATS resection, which offered the most direct approach and ease of access. A right-sided approach was not possible, because it would have required reaching over the front of the heart, and a subxiphoid approach, although possible, would have been associated with more technical difficulties compared with the left-sided technique. Studies have shown that patients treated with VATS approaches have fewer postoperative complications and less postoperative pain compared with open thoracotomy.^6,7 Cost has been shown to be slightly higher with VATS compared with open thoracotomy; however, VATS is less expensive compared with robot-assisted thoracoscopic surgery, which is another modality commonly used to resect pericardial cysts.⁸ Finally, although the differential for chronic cough is quite extensive, pericardial cysts should be considered. In our patient with multiple occupational exposures, numerous other pathologies must first be excluded. Workup for these patients will almost certainly include chest radiography, which may or may not suggest a pericardial cyst if present. Multidetector CT and advanced CMR imaging together provide comprehensive anatomical assessment and tissue characterization of pericardial cysts, optimizing operative planning.

Conclusions

Pericardial cysts are rare benign masses seen in the costophrenic spaces. Approaches for resection should be minimally invasive given the benign pathology and the options of robotic and VATS technology. VATS is a cost-effective surgical approach in treating this pathology that is associated with shorter postoperative hospital stays and minimal morbidity.

Visual Summary.

Timeline of the Case

Timeline	Events
Presentation	47-year-old man presented with progressive dyspnea, cough, and chest tightness.
Investigations	Chest computed tomography: pericardial cyst anterior to the apical right ventricle.
Procedure	Video-assisted thoracoscopic surgery resection.
POD 1	Chest tube removed and symptoms improved.
POD 3	Discharged in good condition.
3-wk follow-up	Complete resolution of dyspnea, cough, and chest pain.
1-y follow-up	Doing well with no symptoms.

POD = postoperative day.

Funding Support and Author Disclosures

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.