Chocolate Heart: a Case of Pericardial Haematoma Presenting with Constrictive Haemodynamics
Cindy W. Tom, M.D., Thoralf M. Sundt, M.D., Kirk J. Rodysill, M.D., Jae K. Oh, M.D.
A 67-year-old male was referred for right heart failure and a right atrial mass. He first presented 5 years previously with congestive heart failure and significant fluid overload. At that time, the patient was medically managed and lost 18 kg of fluid. Worsening heart failure symptoms prompted a work-up at an outside institution that included an echocardiogram, which reported an apparent mass compressing the right atrium. This patient had not had any previous cardiac surgery, but he had ‘walked away’ from two separate plane crashes without significant injury approximately thirty years ago. Physical examination revealed a blood pressure of 120/80 mmHg, a pulse of 86 beats per minute, bi-basilar rales, a markedly elevated jugular venous pressure with a rapid ‘y’ descent, a II/VI systolic murmur at the left sternal border and apex, and a rub over the left upper sternal border area. A transthoracic echocardiogram (TTE) revealed a large cystic space compressing the right ventricle and atrial cavity (Panel A) and moderate-severe tricuspid regurgitation. This cystic entity was associated with significant constrictive haemodynamics. Further imaging to better characterize this entity included a TEE that showed the 9.2 x 6.0 cm mass compressing the right atrium extending up to the superior vena cava level (Panel B). Computed tomography (CT) indicated that the high-density mass compressed on both atria and extended posteriorly behind the left atrium, but spared the cardiac apex (Panel C). A complete pericardiectomy was performed and a loculated haematoma between the parietal and visceral pericardium was evacuated. The consistency of this was similar to that of ‘chocolate cysts’ seen in endometriosis, and was thought to be due to a chronic hematoma that had never been resorbed by the thick pericardium (Panel D). Pathology of the excised pericardium was significant for degenerating fibrin-rich blood clots (haemopericardium), haemosiderin-laden macrophages, and fibrotic pericardial thickening consistent with a mild focal inflammation. After an uneventful post-operative period, this patient was discharged in good clinical condition.
Acknowledgments: Thanks to Mark Zangs for photo preparation.
Figure legend
Panel A. TTE with the cystic space marked ‘*’. RV = right ventricle, LV = left ventricle, RA = right atrium, and LA = left atrium.
Panel B. TEE showed that this cystic space was adjacent to the right atrium.
Panel C. Non-contrast CT (contrast was held secondary to the patient’s mildly elevated creatinine) revealed the high-density collection (*) compressing both atria. This collection in aggregate was ‘U’ shaped, layered out at the base, and was consistent with a haematoma.
Panel D. Intra-operative image showing the ‘chocolate cyst’ consistency of this loculated haematoma.
[Table of Contents]