European Heart Journal - Case Reports (2023) 7, 1–6 CASE REPORT

https://doi.org/10.1093/ehjcr/ytad497 Cardiovascular imaging

A haemorrhagic pericardial cyst compressing

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the right side of the heart: a case report
1
Abdelrahman Elhakim *, Andrea Boguschewski1, Piet Zamzow1,
2
and Mohammed Saad
1
Cardiology Department, Schoen Hospital Neustadt, Am Kiebitzberg 10, 23730 Neustadt in Holstein, Germany; and 2Cardiology Department, Schleswig-Holstein University Hospital-Kiel,
Arnold-Heller-Street 3, 24105 Kiel, Germany

Received 8 April 2023; revised 19 September 2023; accepted 5 October 2023; online publish-ahead-of-print 10 October 2023

Background Pericardial cysts are rare and represent the third most common cystic mass of the mediastinum. The majority are asymptomatic and
detected as incidental findings; however, they can be symptomatic and associated with life-threatening complications such as bron­
chial compression, congestive heart failure, cardiac tamponade, or even sudden death.
.............................................................................................................................................................................................
Case summary We present a rare case of a haemorrhagic pericardial cyst with subtotal compression of the right side of the heart. A symptomatic
male patient was referred due to progressive dyspnoea, signs of congestive heart failure for four months, and a transthoracic echo­
cardiogram showing subtotal compression of the right heart side; the diagnosis was confirmed with thoracic computer tomography
imaging and was removed surgically.
.............................................................................................................................................................................................
Discussion Pericardial cysts are asymptomatic and benign in the majority of cases; however, they can be associated with life-threatening com­
plications. Thus, regular follow-up is recommended, and in a minority of cases, minimal invasive intervention or surgery could be
imperative.

* Corresponding author. Tel: 00491638542698, Fax: 0456154337300, Email: ayelhakim1985@yahoo.com

Handling Editor: Edoardo Conte
Peer-reviewers: Jamol Uzokov; Rizwan Ahmed
Compliance Editor: Lavanya Athithan
© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits
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2 A. Elhakim et al.

Graphical Abstract

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Keywords Pericardial cyst • Congestive heart failure • Echocardiography • Computer tomography • Case report
-ESC
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2.2 Echocardiography • 6.6 Pericardial disease • 6.4 Acute heart failure • 9.7 Adult congenital heart disease • 2.4
Cardiac computed tomography

Learning points
• Pericardial cysts are asymptomatic and benign in the majority of cases, and close follow-up is usually sufficient. However, in a minority of
cases, they can be associated with life-threatening complications, which could necessitate intervention.
• This case highlights the importance of understanding the anatomical location, the size of the cyst, the haemodynamic state, and the rarity of
infection-induced haemorrhagic pericardial cysts in relation to the onset of symptoms.
• Of note, haemodynamic instability in case of congestive heart failure or cardiac tamponade includes clinical evidence of low cardiac output
and stroke volume in the setting of elevated cardiac filling pressures (e.g. hypotension or even shock, dizziness, and oliguria), with evidence of
increased sympathetic tone (e.g. tachycardia and peripheral vasoconstriction), and exclusion of other causes of shock.

develop chest pain, shortness of breath, and or paroxysmal

Introduction
Pericardial cysts are rare and represent the third most common
cystic mass of the mediastinum. Most of the cases are diagnosed as
an incidental finding in chest X-rays. They can be congenital or
acquired.
The estimated incidence of congenital pericardial cysts is 1:100,000,
and they account for up to 7% of the mediastinal masses reported in the
literature. They are formed by the incomplete coalescence of foetal la­
cunae during pericardial development.1
They are rarely found in children, are discovered more commonly in
the third or fourth decade of gender life. However, ∼30% of patients
tachypnoea.1
On the other hand, an acquired cyst can occur as a post-
inflammatory process, infection, or even post-trauma.
Most cysts are asymptomatic. Symptoms occur if the cyst com­
presses on a nearby structure, such as the right side of the heart, causing
congestive heart failure, or obstructs the right main stem bronchus; in­
gress of the cyst into the superior vena cava can occur, and recurrent
syncope, atrial fibrillation, and even sudden cardiac death have been re­
ported.2 In addition, inflammation of the cyst can occur with pericarditis
and pneumonia or can rupture into the pleural sac, mediastinal cavity,
or in the pericardial sac causing cardiac tamponade.
Huge haemorrhagic pericardial cyst 3

Summary figure transthoracic echocardiogram (TTE)) revealed subtotal compres­

sion of the right side of the heart from outside the heart border
(see Supplementary material online, Video S1). The cardiologist re­
ferred the patient urgently to our clinic for further assessment.
The routine blood test demonstrated markedly elevated creatinine
(3,5 mg/dL, glomerular filtration rate 18 mL/min, 48 mg/dL),
Date/time Case events NT-Pro BNP 2543 pg/mL, and D Dimer 1393 µg/L. For further clari­

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..................................................................................... fication, we conducted a thoracic contrast computer tomography
September 2022 Dyspnoea NYHA III. (CT). It showed a large intrapericardial thick-walled mass with fluid
11 December 2022/ Echocardiography showed a large intrapericardial accumulation in the cystic cavity and homogeneous enhancement of
11:30 a.m. mass compressing the right side of the heart. the cyst wall without visible air trapping. It measured 89 × 58 mm,
11 December 2022/ Thoracic CT revealed that the intrapericardial
and the maximal pericardial thickness was 2 mm (Figures 1 and 2).
Consecutively, there was compression of the right side of the heart
1 p.m. cyst measured 89 × 58 mm.
(Figure 3). Mediastinally, there were multiple supracarinal pretra­
12 December 2022/ Pericardiolysis with resection of the pericardial cheal lymph nodes enlarged, measuring 19.7 × 12.3 mm.
9:20 a.m. cyst. The imaging diagnosis was a large pericardial cyst with signs of con­
18 December 2023 Discharge without symptoms. Follow-up in 90 comitant infection (presence of discrete fluid collections usually related
days without quality-of-life limitation. to increased vasodilation and vascular permeability, resulting in tissue
oedema and stranding of normally fatty signal. However, these signs
are non-specific).
We referred the patient to a tertiary heart centre. One day later, the
patient underwent pericardiolysis with resection of the pericardial cyst
(Figure 4) via an anterolateral right side mini thoracotomy incision and
Case presentation received symptomatic treatment, including inhalation, breathing exer­
A 73-year-old man with known diabetes mellitus type II presented cises, and antibiotic therapies. The subsequent post-operative histo­
with a four-month history of progressive dyspnoea as well as leg pathological and microscopic findings revealed a cyst containing
and facial oedema without symptoms of cough, sputum, fever, or haemorrhagic fluid with low cellular collagenous connective tissue
night sweats. Due to the non-improvement of symptoms on diuretic with chronic inflammation (lymphoplasmacytic infiltration, many plas­
medication, his family doctor referred him to a cardiologist. A phys­ ma cells, minor mixed eosinophils and granulocytes) without evidence
ical examination revealed markedly congestive neck veins. The of malignant cells.

Figure 1 Computer tomography coronal view revealed a large intrapericardial thick-walled mass with fluid accumulation in the cystic cavity and
homogeneous enhancement of the cyst wall without visible air trapping. It measured 89 × 58 mm, and the maximal pericardial thickness was 2 mm.
LA, left atrium; LV, left ventricle.
4 A. Elhakim et al.

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Figure 2 Computer tomography sagittal view revealed a large intrapericardial thick-walled mass with fluid accumulation in the cystic cavity and
homogeneous enhancement of the cyst wall without visible air trapping. It measured 89 × 58 mm, and the maximal pericardial thickness was 2 mm.
LV, left ventricle.

The patient recovered post-surgery with no deficits, the TTE
showed no compression of right heart side, and the patient was dis­
charged 7 days later. The discharge medications were painkillers as ne­
cessary. Three months after the procedure, the follow-up did not show
quality-of-life limitations.
Discussion
We present a rare case of a haemorrhagic pericardial cyst with com­
pression of the right side of the heart causing congestive heart failure,
which was removed surgically.
In general, pericardial cysts represent the most common benign tu­
mour of the pericardium. However, the presence of a pericardial cyst in
a typical location or, less frequently, in an unusual location, still poses a
diagnostic challenge in distinguishing it from other intracardiac or me­
diastinal benign or malignant lesions. Further image studies are required
to complete the study of these lesions.
TTE characteristics include a homogeneous echolucent mass with minor
attenuation of the ultrasound through a low-density fluid-filled structure.
It is easy to perform, especially in unstable patients, provides infor­
mation about the cardiac functional state, follow-up, and image-guided
percutaneous aspiration.
In a short acquisition time, thoracic CT provides clear and sharp
images with excellent delineation of the pericardial anatomy and can
aid in the precise localization and characterization of various pericardial
lesions, which is the key for optimal management.
The cyst’s characteristics are a single thin-walled, sharply defined round,
homogenous, and radiodense lesion without septation or solid component
seen at the cardiovascular fluid-filled sac and not enhanced with contrast.
Two-thirds occur on the right side, followed by the left costophrenic angle
(10–40%) or unusual localizations such as the posterior mediastinum.3
Magnetic resonance imaging provides an excellent soft-tissue architec­
ture demonstration. It shows a low signal intensity on T1-weighted se­
quences and high signal intensity on T2-weighted sequences. However,
an altered signal occurs when the cyst protein is high, and the calcification
is not as well visualized as in a CT.2
The differentiation of pericardial cysts from diverticula occurs with the
presence of a communicating tract between the pericardium and the cyst
cavity, which is not usually recognized in any of the imaging modalities.2
Huge haemorrhagic pericardial cyst 5

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Figure 3 Computer tomography horizontal view revealed a large intrapericardial thick-walled mass with fluid accumulation in the cystic cavity.
Consecutively, there was compression of the right ventricle as well as the right atrium. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right
ventricle.

Figure 4 Intraoperative view of open-heart surgery via an anterolateral right side mini thoracotomy incision revealed a huge pericardial cyst.

Differential diagnoses can sometimes be confused with a coronary
artery aneurysm, dextrocardia, pneumonia, pleural effusion, granu­
lomatous lesions or abscess, benign or malignant lung, mediastinal, or
pericardial tumours, phrenic nerve palsy, bronchogenic cyst, diaphrag­
matic hernia, ventricular aneurysm, and valsalva sinus.4
In most patients, close follow-up is enough and is performed by serial
transthoracic echocardiography. Some pericardial cysts resolve spon­
taneously, most likely from rupture into the pleural space.
Decision-making in the management of a pericardial cyst should
be based on the presence or the absence of symptoms, the size of
the mass, the haemodynamic state, an unclear diagnosis or aggres­
sive behaviour, or the compression of important structures. In
such scenarios, treatment could be necessary to confirm the
diagnosis and to prevent life-threatening emergencies, such as car­
diac tamponade.1
Of note, haemodynamic instability in case of congestive heart failure
or cardiac tamponade includes clinical evidence of low cardiac output in
the setting of elevated cardiac filling pressures (e.g. hypotension, dizzi­
ness, and oliguria), with evidence of increased sympathetic tone (e.g.
tachycardia and peripheral vasoconstriction), and exclusion of other
causes of shock.
Treatment includes conservative management with follow-up, percu­
taneous aspiration of the cyst, and excision of the cyst. The task force on
the diagnosis and management of pericardial diseases of the European
Society of Cardiology recommended percutaneous aspiration and etha­
nol sclerosis as initial treatment for congenital and inflammatory cysts.4
6 A. Elhakim et al.
Video-assisted thoracotomy or surgical resection in the case of com­
plications, the potential for malignant transformation, haemodynamic
compromise, or even to prevent life-threatening emergencies could
be mandatory in a minority of cases.
This case highlights the importance of understanding the anatomical
location, the size of the cyst, the haemodynamic state, and the rarity of
infection-induced haemorrhagic pericardial cysts in relation to the on­
set of symptoms.
Conclusion
Pericardial cysts are asymptomatic and benign in the majority of cases,
and close follow-up is usually sufficient. However, in a minority of cases,
they can be associated with life-threatening complications, which could
necessitate intervention.
Lead author biography
Abdelrahman Elhakim is an interven­
tional cardiologist and head of catheter
laboratory at Schoen hospital Neustadt
in Holstein in Germany. He completed
his cardiovascular medicine residency
and interventional cardiology fellowship
in many hospitals in Germany. He is also
subspecialized in coronary artery inter­
vention, intensive care, and emergency
medicine in Germany. He is a lead of
pulmonary embolism workshops and
did a medical doctoral study on pulmon­
ary embolism at Schleswig-Holstein
University Hospital in Luebeck. He also holds master in cardiovascular
medicine at Al-Azhar University, Egypt and another master’s in busi­
ness and health administration at Nuernberg University in Germany.
Supplementary material
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Supplementary material is available at European Heart Journal – Case
Reports online.
Consent: Written informed consent was obtained from the patient in
line with COPE for publication of this case report and any accompany­
ing images. A copy of the written consent is available for review by the
Editor-in-Chief of this journal.
Conflict of interest: None declared.
Funding: This case report was not supported by any funding.
Data availability
All data related to the case are available on request. The paper is not
under consideration elsewhere. None of the paper’s contents have
been previously published. All authors have read and approved the
manuscript.
References
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2. Saldaña Dueñas C, Hernández A. Posttraumatic pericardial cyst. An Sist Sanit Navar 2015;
38:475–478.
3. Kei J. Image diagnosis: pericardial cyst. Perm J 2013;17:e149.
4. Maisch B, Seferović M, Ristić D, Erbel R, Rienmüller R, Adler Y, et al. Task force on the
diagnosis and management of pericardial diseases of the European Society of
Cardiology. Guidelines on the diagnosis and management of pericardial diseases execu­
tive summary. Eur Heart J 2004;25:587–610.