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Case of the Week
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Case-of-the-Week Information
The Case-of-the-Week is a presentation of 8 or more video loops to present an important topic in echocardiography. Please reveiw the image or video loops and then answer the questions below. After you have answered the questions you can view the explanation and obtain CME credit (if available).

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Preop Preop TEE or TTE
Intraop An Intraop TEE
IntraopPreOp Intraop TEE or TTE before Operation
IntraopPostOp Intraop TEE or TTE after Operation
IntraopEnd Intraop TEE or TTE at End of Anesthesia
Post Op Postop TEE or TTE
Case of the Month Information Table
IntraopEnd is usually a TEE after the Operation and after some event occured to show a change in the TEE
Abnormal Pericardium
Case#: 22
AMA CME Units: 0.25 Units
Estimated Time: 15 minutes. You need more cme units to do this COTW for CME (not required). Purchase CME Credits
54 y.o. female who had a 'rub' heard on auscultation. A CT scan was performed and she was referred to the operating room. What is the diagnosis? Please review the diagnosis and differential.

Case Discussion/CME Questions
The patient has a pericardial cyst near the right atrium. Pericardial cysts occur at a rate of 1:100,000. Pericardial cysts may occur from the failure of fusion of the mesenchymal lacunae that form from the pericardial sac. Pericardial cysts occur in the right and left cardiophrenic angle (70% and 22% respectively) and also anterior and posterior superior mediastinum. The cysts can be quite large and cause obstructive symptoms such as chest pain, cough, dyspnea, tamponade, sudden death, but, 75% cause no symptoms. Hemorrhage can occur inside the cyst. Cysts can rupture, and if the cyst ruptures into the pericardium, acute tamponade can occur. RVOT outflow obstruction, compression of cardiac chambers, erosion into adjacent structures, pulmonary artery stenosis, congestive heart failure, and atrial fibrillation are all possible complications.

The differential diagnosis is be:
  • Thymus
  • Lymphoma
  • Lung Cancer
  • Other
Pericardial cysts represent 6% of mediastinal masses and 33% of mediastinal cysts. Other cysts are:

  • Bronchogenic 34%
  • Enteric 12%
  • Thymic/Others 21%
  • Pericardial 6%
In the middle of the mediastinum, 61% of masses are cysts.  The size of the cyst can range from very small to a large, dumbell shaped cyst.

Pezzano reported on 4 patients with pericardial cysts. He found that M-Mode was not helpful but 2D mode was helpful in locating the cyst and, in one case, found a teratoma along with the cyst. Butz reported a case where echocardiography was used to drain a large cyst. The cyst, in this case, was compressing lung tissue along with compression of the left ventricle.  The cyst originated along the left cardiophrenic angle.

Treatment of pericardial cysts frequently involves observation with serial CT scans. Symptomatic or large cysts may be drained or resected. Anterior cysts can be drained by mediastinoscopy whereas, other cysts will require thoracotomy, thoracoscpy, or daVinciâ‚Äû¢ robotic assisted surgery.

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