What is Pericardial Cyst?
A pericardial cyst is usually thought of as a birth defect, and it’s often discovered by accident during chest scans that are performed for other reasons. However, there are rare instances when the cyst can cause symptoms and needs to be treated.
What Causes Pericardial Cyst?
A pericardial cyst is typically seen as a birth defect. It happens when parts of the developing embryo (what a baby is called in the early stages of pregnancy) don’t completely join together like they should. This can lead to a weak spot or a small balloon-like outgrowth on the sac that contains the heart, known as the pericardial sac. This little pocket can stick around as an outgrowth or it can form a pericardial cyst if it gets sealed off from the rest of the pericardial sac. Usually, these cysts are filled with clear fluid.
Past studies suggest the average size of these cysts is about 5.4cm, a little larger than a golf ball. However, pericardial cysts can also appear in a few other situations. These include after chest surgery, after inflammation of the pericardial sac such as pericarditis or a parasitic infection called echinococcosis, from injuries, or reportedly, in patients who undergo long-term treatments to clean their blood when their kidneys can’t do it (this is called hemodialysis).
Risk Factors and Frequency for Pericardial Cyst
Pericardial cysts, which are quite rare, make up about 33% of all chest cavity cysts and 7% of masses found in the chest area. They are typically found by accident during routine medical imaging tests. These cysts can be detected at any age, even before birth, and have been found in people as old as 102 years old.
Signs and Symptoms of Pericardial Cyst
Pericardial cysts are a medical condition that often show no symptoms, with less than 25% of patients feeling any discomfort due to pressure or damage to surrounding structures. One unique case involved a large pericardial cyst, about 11 x 11 cm in size, that caused chest pain spreading to both shoulders after a long car journey. This cyst was found by accident during a medical imaging test to check for a lung clot, known as a pulmonary embolism.
When symptoms do occur, they can be ambiguous and may include a lingering cough, chest pain, difficulty breathing, and a feeling of pressure behind the breastbone. Though rare, more serious symptoms can involve irregular heartbeats, fainting, and pneumonia. There have even been extremely rare cases of life-threatening complications like pericardial tamponade, where excess fluid builds up in the sac surrounding the heart. This is associated with pericardial cysts. However, physical check-ups usually don’t provide any hints towards diagnosing pericardial cysts.
Testing for Pericardial Cyst
If your doctor believes you might have what’s known as a pericardial cyst, they may first spot signs of it on a chest x-ray. The majority of these cysts are found near the right side of the heart in about 51 to 70% of cases. They can sometimes occur on the left side of heart as well, though it’s less common at about 22 to 38% of cases. Less than 15% of the time, they can also appear in the area called the mediastinum that’s not directly next to the diaphragm.
Common laboratory tests and heart rate tests (electrocardiography) generally don’t provide enough information to confirm if a pericardial cyst is present.
A type of imaging test known as a computerized tomography (CT) scan, done without injecting a dye (contrast), is typically the best way to diagnose a pericardial cyst. It’s very helpful in pinpointing the exact location and characteristics of the cyst. The scan usually shows up a single mass that does not glow (or enhance) when the dye is used. However, if the cyst contains high amounts of a substance called protein, it may lead to mistakes in the scan results.
Some experts believe that a test called an echocardiogram, which uses sound waves to visualize the heart, can provide better images of the cyst and structures around it. However, due the limited view and operator-dependence of echocardiography, not all researchers prefer it as a method of diagnosis. This method can be difficult to use in certain situations like in the case of obesity, for example.
In some cases, your doctor may suggest a magnetic resonance imaging (MRI) test. This test can reveal more about the potential effects of the cyst on the heart. However, it’s a costly and time-consuming procedure and, if the protein content is high, it could also be prone to mistakes. Additionally, a pericardial cyst wouldn’t show up brighter or darker in CT or MRI scans in which a contrast dye has been used.
Treatment Options for Pericardial Cyst
For most people who have a fluid-filled sac, known as a cyst, in the sac that surrounds their heart (the pericardium), treatment is typically low-key because they don’t have any symptoms. Doctors will keep an eye on its size and stability over time using a type of ultrasound test known as transthoracic echocardiography. If the person remains symptom-free and the cyst doesn’t get any bigger, the usual approach is simply to continue watching it – what doctors call surveillance and conservative management.
If symptoms begin to occur or if the cyst starts to grow, then the person might need to have surgery. This is mainly to stop any serious emergencies from happening or to reduce any pressure symptoms caused by the cyst. While it’s quite rare for people to have symptoms, when they do happen, surgery may be an option. The type of surgery is usually minimally invasive, and it’s the surgeon who decides whether surgery is appropriate. It could include draining the fluid from the cyst using a needle – a procedure known as percutaneous aspiration that’s recommended by the European Society of Cardiology – or destroying the cyst using a treatment called ablation or ethanol sclerosis.
It’s worth noting that the cyst might come back (recur) after aspiration, with this happening in about 1 in 3 cases. There’s no information regarding whether adhesions (scar-like tissues that stick together) or recurrences occur after alcohol sclerosis. The other types of surgery to remove the cyst include surgical resection (cutting out the cyst) using various techniques that involve making incisions in the chest or at the base of the neck.
The recommendations for treating pericardial cysts are based on observational data, which means agreement on what approach is best might vary. As a result, the management of pericardial cysts is typically tailored to the individual person’s condition and needs.
What else can Pericardial Cyst be?
If a doctor is examining chest X-ray images, they might notice something that looks like a pericardial cyst. These are fluid-filled sacs near the heart. But, there could be a number of other conditions that might look similar on an X-ray. These conditions include:
- Excess fat around the heart or a bulge in the heart muscle, known as a ventricular aneurysm
- Tumors in the diaphragm like a teratoma, which usually has both solid and liquid parts
- Lymphangioma, a condition that would look like multiple small cysts
- Morgagni hernia or an eventration of the diaphragm, which are conditions that affect the diaphragm
- Bronchial cysts, which would show a layer of bronchial cells lining the cyst under a microscope
- A localized pericardial effusion, where there’s fluid between the layers of tissue around the heart
- Different types of birth defects that result in cysts, such as an esophageal duplication cyst or a neurenteric cyst. However, the typical location of these cysts can sometimes help doctors tell them apart from pericardial cysts.
So, it’s important for doctors to carefully consider a range of conditions and use extra tests if necessary to make a confident diagnosis.
What to expect with Pericardial Cyst
The overall outlook for people with pericardial cysts is typically very good, which isn’t surprising considering most patients don’t show any symptoms. In some cases, these cysts even improve on their own without treatment. However, it’s important to note that on very rare occasions, pericardial cysts can lead to serious, even life-threatening, conditions. In these situations, the outlook can vary and largely depends on how well the symptoms are managed with personalized care.
Possible Complications When Diagnosed with Pericardial Cyst
Pericardial cysts may sometimes cause complications due to pressure on the nearby structures like the lung, esophagus, and heart. Hence, the symptoms can be ambiguous and not very revealing. In exceptional cases, the complications may show up as infection in the cysts, compression of the superior vena cava, and heavy bleeding into the pericardial space, resulting in heart tamponade and even death.
Common Complications:
- Pressure on nearby structures like lungs, esophagus, and heart
- Ambiguous symptoms
- Infection of the cysts
- Compression of the superior vena cava
- Bleeding into the pericardial space
- Heart tamponade
- Potential death
Preventing Pericardial Cyst
It’s important to reassure patients that most pericardial cysts, which are small fluid-filled sacs in the lining of the heart, are usually found by accident and don’t usually lead to serious health concerns. This understanding can help reduce any worries or fears they may have about their diagnosis. Furthermore, patients should know that these cysts seldom lead to complications. Regular check-ups can be scheduled to monitor for any possible complications or growth of the cyst.
