Circulation: Cardiovascular Imaging | 2021
U-Shaped Intrapericardial Chronic Expanding Hematoma Due to Blunt Chest Trauma.
Abstract
February 2021 190 Hiromasa Ito , MD Ryuji Okamoto , MD, PhD Masahiro Inagaki, MD Tetsuya Seko, MD, PhD Atsunobu Kasai, MD, PhD Toshiya Tokui, MD, PhD Masaaki Ito, MD, PhD Kaoru Dohi, MD, PhD A 59-year-old man was admitted to our hospital with an 8-month history of gradually developing shortness of breath and abdominal bloating. He had been receiving hemodialysis for 6 years because of end-stage renal failure due to antineutrophil cytoplasmic antibodies-associated glomerulonephritis. The patient had no history of cardiac surgery, but had crashed into a wall while driving a car about 2 years (20 months) earlier, resulting in chest injury from impact with the steering wheel. At that time, he attended hospital and had shown no bone fractures or organ damage other than bruising to the anterior chest. Echocardiography performed one and a half years before this presentation as regular screening showed no clear abnormalities (Figure [A]; Movie I in the Data Supplement). However, he reported hypotension sometimes occurred during hemodialysis. On admission, heart rate was 92 beats per minute with a blood pressure of 89/58 mm Hg and oxygen saturation at 95% on oxygen at 2 L/min via nasal cannula. Physical examination showed no cardiac murmur, but coarse crackles were audible in bilateral lower lung fields and mild calf edema was noted. Chest X-ray showed cardiomegaly and bilateral pleural effusion. However, transthoracic echocardiography revealed a large intrapericardial mass, compressing the right ventricle (Figure [B]; Movie II in the Data Supplement). Contrast-enhanced computed tomography of the chest demonstrated the mass (maximum cross-section; 12×7 cm) was Ushaped and sandwiching the heart, with poor contrast enhancement (Figure [C] and [D]; Movie III in the Data Supplement). This mass exhibited high and low signal intensity on T1-weighted (Figure [E]) and T2-weighted (Figure [F]) magnetic resonance imaging without contrast, respectively. From these finding, we diagnosed chronic expanding hematoma (CEH).1 Because the hemodynamics were becoming unstable, we performed puncture of the mass using an echo-guided technique. Although ≈800 mL of old blood was aspirated, no significant reduction in tumor size was achieved. Results for bacterial culture including tuberculosis were negative, and no malignant cells were found. We discussed this case with the heart team, and surgical removal of the tumor was planned to improve the unstable hemodynamics and yield the definitive diagnosis. Midline sternotomy exposed the thick pericardium. We opened the pericardium, but the CEH showed severe adhesion to the myocardium (Figure [G]) and surrounding tissues, making complete removal of CEH difficult. First, the mass located at the front of the right ventricle was carefully excised, demonstrating a cavity filled with chronic, dark-red hematoma. We subsequently tried to remove the mass around the inferior and posterolateral sides of the left ventricle, but not all of the mass could be removed. The main reason was that support from an artificial cardiopulmonary device was needed to remove all the tumor. We considered that the patient would not be able to tolerate the degree of surgical invasion. © 2021 American Heart Association, Inc. CARDIOVASCULAR IMAGES