Pericardial cyst

Small pericardial cyst circled on chest x-ray (left) and chest CT scan (right).

A pericardial cyst is an uncommon benign dilatation of the pericardial sac surrounding the heart. It can lead to symptoms by compressing nearby structures, but is usually asymptomatic.[1] Pericardial cysts can be congenital or acquired, and they are typically diagnosed with radiologic imaging.[1][2][3] Management of pericardial cysts can include follow-up imaging, percutaneous aspiration, or surgical resection.[1][2][3]

Presentation

Pericardial cysts most often are asymptomatic, with 50 to 75% of patients experiencing no symptoms.[1][2] The presentation of symptomatic cysts depends on the cyst location and effects on nearby structures, including the heart, lungs, and esophagus.[2][3] Symptoms can include chest pain, cough, shortness of breath, palpitations, syncope, recurrent pneumonia, congestive heart failure, difficulty swallowing, and weight loss.[1][2][3]

Causes

Pericardial cysts can be congenital or acquired, with the majority being congenital.[2][3] Congenital pericardial cysts happen due to an abnormality in the development of the pericardial sac that creates a bulge which is walled off to form a cyst.[1][3] Acquired pericardial cysts can be caused by inflammation from surgery, pericarditis, trauma, echinococcosis, tuberculosis, metastasis, or hemodialysis.[2][3] The inflammation can lead to a walled-off pocket of fluid that is a pericardial cyst.[3]

Diagnosis

Since pericardial cysts are often asymptomatic, the most common diagnosis is through incidental finding on a chest x-ray.[1][2] When patients have symptoms, transthoracic echocardiogram is one of the first tests used to look for a pericardial cyst.[3] CT or MRI may also be used to diagnose pericardial cysts.[4][5][6] On CT and MRI a pericardial cyst will commonly appear as a round, fluid-filled structure surrounded by thin walls.[4][5][6] Diagnosis of a pericardial cyst can also be made before birth using ultrasound.[2]

The differential diagnosis for a suspected pericardial cyst includes a bronchial cyst, pericardial effusion, teratoma, lymphangioma, pericardial fat, congenital diaphragmatic hernia, neuroenteric cyst, and congenital cyst from the primitive foregut.[1][2][3] A pericardial cyst also may look similar on imaging to a pericardial diverticula, which is connected to the pericardium and not fully walled off like a pericardial cyst.[4]

Management

Pericardial cysts that are small and cause no symptoms can be followed with repeat imaging through echocardiogram, CT, or MRI to assess for changes.[1][2] Pericardial cysts that are large or cause symptoms may be candidates for percutaneous aspiration, ethanol sclerosis, or surgery.[1][2][3] Percutaneous aspiration removes the fluid from inside the cyst, and ethanol sclerosis uses the injection of ethanol into the cyst after aspiration to decrease the likelihood of cyst recurrence.[2][3] Percutaneous aspiration with ethanol sclerosis is typically the first treatment for pericardial cyst that requires management.[2][3] Surgery can remove a pericardial cyst through a thoracotomy, sternotomy, mediastinoscopy, or video-assisted thoracic surgery.[1][2] The type of surgery is chosen based on the size and location of the pericardial cyst.[2]

Prognosis

With most pericardial cysts having no symptoms, the prognosis is very good.[1] The cysts can resolve without intervention.[1][3] If percutaneous aspiration is performed, the recurrence rate of pericardial cysts is about 30-33%.[1][3] Although pericardial cysts are benign, the location of cysts can rarely cause life-threatening emergencies by compressing the heart or lungs.[1][2]

Epidemiology

Pericardial cysts have an incidence of 1 in 100,000.[2][6] Pericardial cysts make up 6-7% of all mediastinal masses.[2][3] They can present at any age, but are most commonly diagnosed between the third and fifth decade of life.[2][3] Females and males have approximately equal incidences of pericardial cysts.[2]

History

Pericardial cysts were first reported on during autopsies in the 19th century by pathologists.[2][7] As the field of radiology progressed, pericardial cysts could be identified in living patients.[2][7] In 1931, the first surgical resection of a pericardial cyst was performed by Otto Pickhardt at Lenox Hill Hospital in New York using a thoracoscopy.[2][7] In 1943, Greenfield and his colleagues coined the term "spring water cysts" for pericardial cysts since the cysts contain clear fluid.[2][7]

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Meredith, Amanda; Zazai, Ibrahim K.; Kyriakopoulos, Chris (2021), "Pericardial Cyst", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 32965958, retrieved 2021-12-28
  2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Kar, Sandeep Kumar; Ganguly, Tanmoy (2017). "Current concepts of diagnosis and management of pericardial cysts". Indian Heart Journal. 69 (3): 364–370. doi:10.1016/j.ihj.2017.02.021. ISSN 0019-4832. PMC 5485391. PMID 28648435.
  3. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Khayata, Mohamed; Alkharabsheh, Saqer; Shah, Nishant P.; Klein, Allan L. (2019-05-30). "Pericardial Cysts: a Contemporary Comprehensive Review". Current Cardiology Reports. 21 (7): 64. doi:10.1007/s11886-019-1153-5. ISSN 1534-3170. PMID 31147788. S2CID 171094420.
  4. 1 2 3 Oyama, Noriko; Oyama, Naotsugu; Komuro, Kaoru; Nambu, Toshikazu; Manning, Warren J.; Miyasaka, Kazuo (2004). "Computed Tomography and Magnetic Resonance Imaging of the Pericardium: Anatomy and Pathology". Magnetic Resonance in Medical Sciences. 3 (3): 145–152. doi:10.2463/mrms.3.145. PMID 16093632.
  5. 1 2 Park, Jin Wang; Jeong, Won Gi; Lee, Jong Eun; Lee, Hyo-jae; Ki, So Yeon; Lee, Byung Chan; Kim, Hyoung Ook; Kim, Seul Kee; Heo, Suk Hee; Lim, Hyo Soon; Shin, Sang Soo (2021). "Pictorial Review of Mediastinal Masses with an Emphasis on Magnetic Resonance Imaging". Korean Journal of Radiology. 22 (1): 139–154. doi:10.3348/kjr.2019.0897. ISSN 1229-6929. PMC 7772375. PMID 32783412.
  6. 1 2 3 Peebles, C R; Shambrook, J S; Harden, S P (2011). "Pericardial disease—anatomy and function". The British Journal of Radiology. 84 (Spec Iss 3): S324–S337. doi:10.1259/bjr/16168253. ISSN 0007-1285. PMC 3473919. PMID 22723538.
  7. 1 2 3 4 Schweigert, Michael; Dubecz, Attila; Beron, Martin; Ofner, Dietmar; Stein, Hubert J. (2012). "The Tale of Spring Water Cysts". Texas Heart Institute Journal. 39 (3): 330–334. ISSN 0730-2347. PMC 3368475. PMID 22719140.
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