A 72-year-old man presented a 2-year history of dyspnea and atrial fibrillation. During the last three months, the patient exhibited occasional paroxysmal nocturnal dyspnea and two-pillow orthopnea. The patient denied any chest pain, history of myocardial infarction or thoracic trauma in the past. Physical examination revealed moderate elevation of jugular venous pressure and mild hepatomegaly without other gross features of heart failure, and no pericardial knock or rub could be heard. A contrast enhanced angio computerized tomography clearly demonstrated a large spherical mass about 11 x 9 x 4 cm in the anterior pericardium, presenting as a mediastinal tumor and compressing right ventricle inflow tract (Fig. 1A and B). At this time, the origin of the mass was unclear. However, the differential diagnosis included constrictive pericarditis and teratoma. A transthoracic echocardiogram identified the anterior cardiac mass and revealed again the presence of partial compression of the right ventricular free wall (Fig. 1C). The echocardiographic data are given in Table 1. Cardiac catheterization was performed to better elucidate the hemodynamic effect of suspected constrictive pericarditis on right ventricle filling, through observation of dynamic respiratory changes that occur in the heart during cardiac catheterization of the right cardiac side. During the same procedure the coronary angiography was performed and non coronary stenosis was identified.
With evidence of constriction confirmed, the patient underwent pericardiectomy and resection of the mass. Before sternotomy, the central venous pressure was 20 mmHg. Upon gross examination before removal, the mass was noted to extend from the diaphragm to the top of the right atrium, and from the right phrenic nerve to the anterior interventricular groove and right ventricular infundibulum (Fig. 2A). The pericardium was thick. The dissection was started from the anterior surface of the right ventricle toward the mass on the right atrioventricular groove (Fig. 2B). The outer calcified layer of the pericardial mass was a thick layer of calcification surrounded an inner amorphous low density material. This layer was easily opened and the contents of the mass appeared like old coagulated blood (Fig. 2C) which was evacuated with a sterile spoon (Figs. 2 D and 3 A). Then the inferior calcified layer of the pericardial mass which was extremely adherent with the epicardium, was carefully excised, without the use of cardiopulmonary bypass, from the origin of the great vessels to the diaphragm and all areas between the right and left phrenic nerves (Fig. 3B). The removed specimens were examined pathologically and were noted to have no evidence of granulomatous inflammation, acute inflammation, or tumor. The removed mass consisted solely of thickened and fibrotic pericardium with nodular calcifications (Fig. 3C) and coagulated blood. Polymerase chain reaction culture of the specimen of pericardium and pericardial fluid revealed no tuberculosis bacilli. The final diagnosis was idiopathic constrictive pericarditis. The patient was discharged 6 days later. Three months later, the clinical status of the patient was significantly improved with normal left ventricular ejection fraction.