Definition & Overview

Pericardial cysts are rare congenital abnormalities that usually develop in the middle mediastinum or the central compartment in the chest cavity. It contains most of the organs of the thoracic cavity including the pericardium. The pericardium is a double-layered sac that envelops the heart. It protects the heart from shock and infection and lubricates it with pericardial fluid.

Pericardial cysts are usually benign and affect just 1 in 100,000 people. Most patients with this condition do not present any symptoms. Those who do, experience laboured breathing and persistent cough, among others. In the majority of cases, the cysts are accidentally discovered when patients undergo echocardiography or x-ray for unrelated medical conditions.

In some cases, pericardial cysts resolve without treatment specially when they rupture into the pleural space. However, if they rupture around the pericardial cavity, they can cause serious cardiac tamponade that requires surgery. To prevent serious complications, surgeons can recommend their removal through a surgical procedure.

Who Should Undergo and Expected Results?

The procedure is recommended for patients who were diagnosed with having a pericardial cyst or tumour. As mentioned above, most patients with this condition are asymptomatic. Some, on the other hand, exhibit various symptoms including breathlessness, chronic cough, chest pain, and low blood pressure. Also, while pericardial cysts are mostly benign, they can pose some serious complications in some cases. Aside from cardiac tamponade, they can also obstruct the lungs. They can also cause congestive heart failure or spontaneous bleeding or haemorrhage in the area.

How is the Procedure Performed?

The main focus in managing pericardial cysts or tumours is to assess their growth and movement. Resecting them is often recommended if they are growing rapidly as this can lead to intracystic haemorrhage that can obstruct the blood vessels of the heart and lungs.

Before surgery is even recommended, pericardial cysts are observed using computed tomography (CT). The goals here are to determine if they are benign and to assess their link to nearby organs. Based on the assessment, percutaneous drainage (draining out of the cyst through the skin) or resection can be recommended.

The resection of pericardial cysts requires the use of general anaesthesia and thoracoscopy, a medical procedure where an internal mass within the pleural or thoracic cavity is resected and examined through biopsy.

For the procedure, a thoracoscope is inserted into the right midaxillary line (the middlemost line on the side of the body) and the 7th intercostal space. An intercostal space is the space between the ribs. Incisions are also made in the 4th and 5th intercostal spaces.

Surgeons use surgical scissors to fully grasp and cut out the cyst or tumours as well as the bridge that connects them to the pericardial cavity.

Pericardial cysts can also be managed through aspiration. This is a non-invasive procedure and thus results in fewer complications. The injection of a sclerosing agent can also be considered as this decreases the likelihood of recurrence. This is because the agent immediately dissolves the cysts and destroys the “roots“ that anchors them to nearby organs.

More and more surgeons now prefer thoracoscopy in carrying out the procedure and reserves thoracotomy (invasive surgical incision in the chest wall) as the last resort. During surgery, a fibreoptic cable is used to guide the surgeon and illuminate the target area. Specialised tools are used to resect cysts and tumours in the pericardium.

Possible Risks and Complications

The majority of patients who had their pericardial cysts or tumour resected did not experience serious postoperative complications. However, there are some cases where there was a need to redo the operation after new cysts or tumours were found. Doctors advocate that all masses must be initially identified and carefully evaluated prior to resecting them.

Pericardial cysts and tumours themselves cause complications because they can obstruct the major vessels of the heart including the superior vena cava and the ventricular wall. They can also cause cardiac tamponade, atrial fibrillation, or irregular heartbeat that can lead to blood clots, stroke, or in extreme cases, complete heart failure.

In studies made around the globe, there were no complications observed during and after surgery. Even the one-year follow-up period showed no serious complications among patients who underwent the procedure.

However, surgeons still require patients to keep up with their follow-up schedule to check for signs of recurrence and possible complications.

References:

  • The Cardiothoracic Surgery Network; “Pericardial Cyst” http://www.ctsnet.org/article/pericardial-cyst

  • Oxford Journals; “Surgical resection of a giant pericardial cyst showing a rapidly growing feature” http://icvts.oxfordjournals.org/content/10/6/1056.full

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