Complete Pericardial Agenesis in a Pregnant Patient: A Clinical Dilemma

Abstract Pericardial agenesis is a rare congenital anomaly found predominantly in men, and its complete form is extremely rare and difficult to diagnose. This report describes the case of a pregnant patient with complete pericardial agenesis in which mode of delivery and sterilization raised debate among specialists.

Agenesia Pericárdica Completa. Presentación de una caso y revisión de la literatura / Complete pericardial agenesis. Presentation of a case and review of the literature

Resumen Paciente masculino de 18 años, quien es valorado en el Servicio de Cardiología del Hospital Víctor Manuel Sanabria Martínez referido del primer nivel de atención por cuadro crónico de dolor torácico atípico acompañado de pectus excavatum y desplazamiento izquierdo del latido de punta a la exploración física. La radiografía de tórax posteroanterior evidencia una cardiomegalia moderada con levocardia máxima. El ecocardiograma transtorácico con función sistólica biventricular conservada, dilatación moderada del ventrículo derecho, sin signos de hipertensión pulmonar e imagen cardiaca de "corazón en lágrima". Angiotomografía computarizada de tórax con contraste que documenta malformación de la caja torácica con hundimiento de la región esternal, en relación con pectus excavatum. Corazón aumentado de tamaño en relación con cardiomegalia grado I y desplazamiento hacia el hemitórax izquierdo. No se observa pericardio en ninguna región. Aurícula derecha levemente dilatada con un ventrículo derecho con diámetro aumentado en su porción media y deformidad de su tracto de salida debido a la forma de la caja torácica, de tal manera que se corrobora el diagnóstico de una agenesia pericárdica completa.

Abstract An 18-year-old male patient who is evaluated in the Cardiology Department of the Víctor Manuel Sanabria Martínez Hospital, referred to the first level of attention due to chronic symptoms of atypical chest pain accompanied by pectus excavatum and left displacement of the peak beat. Chest X-ray Posteroanterior with moderate cardiomegaly with maximum levocardia. Transthoracic echocardiogram with preserved biventricular systolic function, moderate dilatation of the right ventricle, without signs of pulmonary hypertension and cardiac image of "tear heart". Thoracic Computed Angiotomography with contrast documenting malformation of the rib cage with sinking of the external region, in relation to pectus excavatum. Heart enlarged in relation to grade I cardiomegaly and displacement towards the left hemithorax. No pericardium is observed in any region. Slightly dilated right atrium with a right ventricle with an increased diameter in its middle portion and deformity of its outflow tract due to the shape of the rib cage. Corroborating the diagnosis of complete pericardial agenesis.

Constrictive pericarditis with extensive calcification and caseous necrosis

Abstract Constrictive pericarditis is a disease where loss of pericardial elasticity and restriction of filling of the cardiac chambers occurs. It is most often seen as an associated symptom of heart failure. Pericardiectomy provides effective treatment for patients with symptomatic constrictive pericarditis, although high rates of morbidity and mortality are related to the procedure. We present a case with extensive calcification, massive caseous necrosis and an important impairment of right ventricular function successfully operated in our institution.

Caso clínico: agenesia pericárdica, diagnóstico imagenológico de una patología infrecuente / Clinical case: pericardial agenesis, radiological diagnosis of a rare disease

Resumen: La agenesia pericárdica congénita es una condición infrecuente, que generalmente cursa de forma asintomática y es diagnosticada como hallazgo radiológico. Sin embargo, se describe la asociación con malformaciones cardiacas y herniaciones del miocardio con el subsiguiente riesgo de muerte súbita. La radiografía de tórax es un pilar fundamental para la sospecha diagnóstica. Presentamos un caso clínico de una paciente de 11 años que consulta por dolor torácico y disnea, que frente a los hallazgos típicos en radiografía de tórax se sospecha agenesia pericárdica, posteriormente confirmada con TC y RM.

Abstract: Congenital pericardial agenesis is an infrequent but usually asymptomatic condition, and is diagnosed as an incidental radiological finding. However, the association with cardiac malformations and myocardial herniation with the subsequent risk of sudden death has been reported. Chest plain films are a fundamental tool to raise the diagnostic suspicion. We present a clinical case of an 11-year-old patient who consulted for chest pain and dyspnea, in which, with the typical findings on chest radiography, pericardial agenesis was suspected and later confirmed by CT and MRI.

Partial congenital absence of the pericardium: a case report

Abstract The complete or the partial absence of pericardium is a rare congenital malformation for which the patients are commonly asymptomatic and the diagnosis is incidental. The absence of the left side of the pericardium is the most common anomaly that is reported in the literature while the complete absence of pericardium or the absence of the right side of the pericardium are uncommon and their criteria are still unrecognized given their rare occurrence in clinical practice. This paper aims to report a case of 19-year-old male with the congenital partial absence of both sides of the pericardium and to highlight the symptoms and the different cardiac imaging modalities used to confirm the diagnosis of this defect.

The relation between echocardiographic epicardial fat thickness and cha2ds2-vasc score in patients with sinus rhythm

Abstract Objective: To evaluate the predictive value of epicardial fat thickness (EFT) in CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, previous stroke or transient ischemic attack, vascular disease, age 65-74 years, sex category) score risk groups. Methods: A total of 158 consecutive patients (75 females, 83 males, mean age 70.8±6.3 years) admitted routinely for cardiologic control were divided into two groups according to their CHA2DS2-VASc scores (scores 0 and 1 were regarded as low risk, and score ≥2 as high risk). One hundred twenty-five of 158 patients had a high-risk score. Results: Mean EFT was significantly higher in the high-risk group than in the low-risk group (4.34±0.62 vs. 5.37±1.0; P<0.001). EFT was positively correlated with CHA2DS2-VASc score (r=0.577, P<0.001). According to receiver operating characteristics (ROC) analysis, EFT value of 4.4 mm was found to be predictive of high risk in CHA2DS2-VASc score with 80% of sensitivity and 79% of specificity (C-statistic = 0.875, P<0.001, 95% confidence interval [CI] = 0.76-0.90). And according to multivariate logistic regression analysis, EFT was an independent predictor of high thromboembolic risk in terms of CHA2DS2-VASc score. Conclusion: Our findings suggest that echocardiographic EFT measurement could provide additional information on assessing cardiovascular risks, such as thromboembolic events, and individuals with increased EFT should receive more attention to reduce unfavorable cardiovascular risk factors and the development of future cardiovascular events.

Relationship Between Neck Circumference and Epicardial Fat Thickness in a Healthy Male Population / Relação Entre Circunferência do Pescoço e Espessura da Gordura Epicárdica em Uma População de Homens Saudáveis

Abstract Background: Epicardial fat is an upper body visceral fat depot that may play a significant role in the development of adverse metabolic and cardiovascular risk profiles. There is a significant direct relationship between the amount of epicardial fat and general body adiposity (body mass index, BMI), but data regarding subcutaneous adiposity is limited. Objective: We conducted a study to determine the association between neck circumference and epicardial fat thickness in healthy young male individuals, and assess their individual correlations with general body adiposity and cardiometabolic risk factors. Methods: One hundred consecutive male patients aged 18 years or older with no known major medical conditions were included in the study. All participants underwent detailed physical examination including measurement of blood pressure, weight, height, waist/hip ratio, and neck circumference. Blood was collected to determine fasting glucose and lipid parameters. A standard echocardiographic examination was performed with additional epicardial fat thickness determination. Results: Among 100 study participants, neck circumference correlated significantly with weight, waist circumference, BMI, blood glucose, serum total cholesterol, low-density (LDL)-cholesterol, and triglycerides levels. No significant correlation was found between neck circumference and high-density lipoprotein (HDL)-cholesterol levels. Neck circumference correlated moderately and positively with echocardiographic epicardial fat thickness. Conclusion: Among patients with low cardiometabolic risk, increased neck circumference was associated with increased epicardial fat thickness.

Resumo Fundamentos: A gordura epicárdica é um depósito de gordura visceral na parte superior do organismo que pode desempenhar um papel importante no desenvolvimento de perfis cardiovasculares e metabólicos adversos. Há uma relação direta significativa entre a quantidade de gordura epicárdica e a adiposidade corporal geral (índice de massa corporal, IMC), mas dados sobre a adiposidade subcutânea são limitados. Objetivos: Realizamos um estudo para determinar a associação entre a circunferência do pescoço e a espessura da gordura epicárdica em jovens saudáveis do sexo masculino, além de avaliar as suas correlações individuais com a adiposidade corporal geral e fatores de risco cardiometabólicos. Métodos: Cem pacientes consecutivos do sexo masculino com idade igual ou superior a 18 anos e sem nenhuma condição médica importante e conhecida foram incluídos no estudo. Todos os participantes foram submetidos a um exame físico detalhado que incluiu medida da pressão arterial, peso, altura, razão cintura/quadril e circunferência do pescoço. Sangue foi coletado para determinação da glicemia de jejum e parâmetros lipídicos. Um exame ecocardiográfico padrão foi realizado com determinação adicional da espessura da gordura epicárdica. Resultados: Entre os 100 participantes do estudo, a circunferência do pescoço mostrou correlação significativa com o peso, circunferência de cintura, IMC, glicemia e níveis séricos de colesterol total, lipoproteína de baixa densidade (LDL-colesterol) e triglicerídeos. Não foi observada correlação significativa entre a circunferência do pescoço e níveis de colesterol de alta densidade (HDL-colesterol). A circunferência do pescoço correlacionou moderadamente e positivamente com a espessura da gordura epicárdica à ecocardiografia. Conclusão: Entre pacientes com baixo risco cardiometabólico, o aumento da circunferência do pescoço foi associado a um aumento da espessura da gordura epicárdica.

Intraoperative anastomotic site detection and assessment of LIMA-to-LAD anastomosis by epicardial ultrasound in off-pump coronary artery bypass grafting - A prospective single-blinded study.

The study was done to detect the optimal site of left anterior descending (LAD) artery for grafting and for the assessment of geometrical and anatomical characteristics of left internal mammary artery (LIMA)-to-LAD artery anastomosis in elective off-pump coronary artery bypass grafting surgery. Fifteen consecutive patients who underwent coronary artery bypass graft (CABG) were included in the study. All the operations were performed by a single surgeon. Epicardial ultrasound probe was placed at the site of grafting for scanning and the site of anastomosis selected. The anticipated target site selected by the surgeon was scanned for patency, size, septal perforator branches, and presence of plaque and calcification. The surgeon identified the LAD artery in 12 patients. In three patients, the LAD artery was not visible. However, with epicardial ultrasound, the LAD artery was identified in all patients. In 6 of 15 patients, the anticipated target anastomotic site was changed to a clear segment either due to the presence of perforators or plaques or calcifications. In all 15 patients, the surgeon scored the anastomosis as good, based on his or her experience independent of the ultrasound image. The anastomotic score by the cardiac anesthesiologist showed 5 anastomoses with satisfactory results and 10 anastomoses with good results. The study demonstrates that epicardial ultrasound scanning with a 10-MHz transducer provides reliable information in choosing the proper anastomotic site and allows proper visualization of LIMA-to-LAD anastomosis. All these measurements are easily obtained without risk of any complications and the method is not time consuming.

How do I get an optimal image.

Trans-esophageal echocardiography (TEE) is fast becoming an indispensable monitoring and diagnostic modality in cardiac operation rooms. Its convenience and dependability in making important and crucial decisions intra-operatively, during cardiac operative procedures, makes it one of the most useful weapons in a cardiac anesthesiologist's armory. But to make reliable inferences based on intra-operative TEE, creation and development of a proper image is one of the fundamental requirements. The image quality can be affected by factors like patient anatomy, quality of the ultrasound system, and skill of the echocardiographer. Since the first two cannot be changed, in most of cases, we will have to work on the third factor to optimize image quality. A working knowledge of the physics of ultrasound imaging and a sufficient familiarity with the various knobs and controls on the machine will go a long way in helping one acquire an optimum image.

A case of prominent epicardial fat mimicking a tumor on echocardiography

Epicardial fat may anteriorly produce an echo-free space that can be mistaken for pericardial fluid. We recently experienced a 67-year-old woman with prominent epicardial fat which was presented as an echogenic tumor-like mass. She underwent open pericardiostomy to relieve large amount of pericardial effusion. Operative findings revealed only prominent epicardial fat. Biopsy of the pericardial and fat tissues revealed an inflammation and normal fat cells without any malignant cell infiltration.

Malignant pericardial tumor in childhood: a case report diagnosed by cross-sectional echocardiogram and magnetic resonance imaging.

Since primary malignant pericardial tumors are seldomly found in children, we reported a case with massive pericardial effusion. Pericardial tumor was diagnosed by cross-sectional echocardiogram. The extent of the tumor was well demonstrated by magnetic resonance imaging. The tumor was removed successfully and proved to be low grade fibrosarcoma. Modern technics can be very helpful in the diagnosis of pericardial tumor.