To the Editor:
We read with great interest the case presented by Peruzzi and colleagues1 and would like to make a few comments. The authors successfully managed a case that involved a large pericardial effusion accompanied by pneumopericardium, with initial signs of diastolic compression of the heart. This was subsequent to an angioplasty procedure and the successful implantation of 2 bare-metal stents.
Pneumopericardium is a rare, life-threatening condition that can compromise cardiac function. It can be observed as an iatrogenic sequela of numerous surgical interventions, or it can arise from natural intrathoracic causes. Other than cardiac surgery, the causes of pneumopericardium are as various as acute asthma,2 thoracic trauma, mechanical ventilation (in neonates), fistula formation from esophageal or gastric ulcers, and rupture of bronchogenic cysts.
In the report by Peruzzi and colleagues, we believe that, in the absence of coronary artery perforation, an intrapericardial bronchogenic cyst is the most probable explanation for pericardial fluid in the presence of pneumopericardium. Rupture of the cyst and the ensuing inflammatory response possibly led to the large pericardial effusion and to imminent cardiac tamponade.
Bronchogenic cysts arise from an abnormal budding of the ventral diverticulum of the foregut or the tracheobronchial tree during embryogenesis. They may arise from many locations, depending upon the time of their formation during embryogenesis, including the pericarinal, paratracheal, and intrapulmonary regions, along the esophagus, and below the diaphragm. The heart is one of the atypical sites of such cysts.3–5 The incidence of bronchogenic cysts is approximately 6% to 15% of primary mediastinal masses.4 Although they most often are detected incidentally upon routine chest radiography, they can become symptomatic: an intrapericardial bronchogenic cyst can present with symptoms of chest pain, shortness of breath, and compression of the heart and vessels, depending upon the location of the cyst and its size.5 That bronchogenic cysts can cause cerebral air embolism, pneumomediastinum, and pneumopericardium has been documented.6 Perhaps, in the documentation of this patient's case, there exists a pre-procedural computed tomogram or magnetic resonance image that could confirm or disprove our hypothesis. In any event, we think it important to consider intrapericardial bronchogenic cyst in the patient's differential diagnosis.
Dimos Karangelis, MD, PhD
Georgios I. Tagarakis, MD, PhD
Georgia Kalafati, MD, PhD
Nikolaos B. Tsilimingas, MD, PhD
Department of Cardiovascular & Thoracic Surgery, University Hospital of Larissa, Thessaly, Greece
Footnotes
Letters to the Editor should be no longer than 2 double-spaced typewritten pages and should contain no more than 6 references. They should be signed, with the expectation that the letters will be published if appropriate. The right to edit all correspondence in accordance with Journal style is reserved by the editors.
References
- 1.Peruzzi M, Frati G, Rose D, Chirichilli I, Santo C, Ricci M. Spontaneous pneumopericardium after coronary angioplasty. Tex Heart Inst J 2010;37(6):728–9. [PMC free article] [PubMed]
- 2.Agarwal MP, Giri S, Jain R, Sharma V. Spontaneous pneumopericardium in acute asthma. Int J Emerg Med 2010;3(2):141. [DOI] [PMC free article] [PubMed]
- 3.Gomes MN, Hufnagel CA. Intrapericardial bronchogenic cysts. Am J Cardiol 1975;36(6):817–22. [DOI] [PubMed]
- 4.Kobza R, Oechslin E, Jenni R. An intrapericardial bronchogenic cyst. Interact Cardiovasc Thorac Surg 2003;2(3):279–80. [DOI] [PubMed]
- 5.Prates PR, Lovato L, Homsi-Neto A, Barra M, Sant'Anna JR, Kalil RA, Nesralla IA. Right ventricular bronchogenic cyst. Tex Heart Inst J 2003;30(1):71–3. [PMC free article] [PubMed]
- 6.Jung S, Wiest R, Figerio S, Mattle HP, Hess CW. Cerebral air embolism caused by a bronchogenic cyst. Pract Neurol 2010; 10(3):164–6. [DOI] [PubMed]