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      Partial Pericardial Defect Incidentally Discovered During Coronary Bypass Surgery

      case-report

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          Abstract

          A 71-yr-old male patient with three vessel coronary artery disease underwent a coronary artery bypass graft. The patient was found to have a large pericardial defect at the apex of the heart that measured approximately 18 cm in circumference. The edge of the pericardial defect impinged on the epicardial coronary arteries. The left phrenic nerve descended via the dorsal boundary of the pericardial defect. Following coronary artery bypass grafting, the pericardial defect was repaired with a polytetrafluorethylene patch. The patient had an uncomplicated postoperative course.

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          Isolated congenital absence of the pericardium: clinical presentation, diagnosis, and management.

          Congenital absence of the pericardium (CAP) is a rare clinical entity. We identified from the two hospital databases all patients with isolated CAP, reviewed their data, and invited them for prospective clinical evaluation with electrocardiography, chest x-ray findings (CXR), echocardiography, and magnetic resonance imaging (MRI). Ten patients (3 males, 7 females) presented at a median age of 21 years (range, 2-53 years) with paroxysmal stabbing chest pain, largely nonexertional (9), and heart murmur with an abnormal CXR (1). Three patients had partial and 7 had complete CAP (all 7 had marked lateral displacement of the cardiac apex). CXR combined with MRI were key to establishing the diagnosis; a "tongue" of lung tissue interposing between the main pulmonary artery and aorta was the most consistent diagnostic feature. Four patients underwent pericardioplasty, 3 for debilitating symptoms and 1 for left atrial appendage herniation, followed by improvement or resolution of symptoms. At a mean of 10.5 years from presentation all patients were alive. No complications were seen in the nonsurgical group. Isolated CAP has a common presentation pattern with periodic stabbing chest pain mimicking coronary artery disease. CXR and MRI are required for definitive diagnosis. Symptomatic patients with the complete form may benefit from pericardioplasty.
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            Diagnosis of congenital pericardial defects, including a pathognomic sign for dangerous apical ventricular herniation, on magnetic resonance imaging.

            To establish criteria for the accurate diagnosis of different forms of left sided pericardial defects on magnetic resonance imaging. Early detection of a partial apical defect is essential as it is potentially fatal. Examination of four children with congenital pericardial defects by magnetic resonance imaging, the results being compared with the features on conventional chest radiography and echocardiography and with published data. Magnetic resonance imaging improved the ability to diagnose and distinguish between complete and partial left sided pericardial defects. A deep myocardial crease was visualised in a patient with apical pericardial defect, indicating the risk of a life threatening ventricular strangulation. A prominent left atrial appendage was, in contrast to many reports, not a reliable sign for partial left sided pericardial defect. The various forms of congenital left sided pericardial defects cannot reliably be diagnosed in plain chest radiographs or on echocardiography. Their diagnosis and the distinction between partial and complete defects, however, is of clinical importance and can be accomplished more confidently by magnetic resonance imaging.
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              Strangulation of the left atrial appendage through a congenital partial pericardial defect.

              The first case of strangulation of a left atrial appendage through a partial congenital pericardial defect is presented. Surgery consisted of a left atrial appendectomy and closure of the defect.
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                Author and article information

                Journal
                J Korean Med Sci
                JKMS
                Journal of Korean Medical Science
                The Korean Academy of Medical Sciences
                1011-8934
                1598-6357
                January 2010
                26 December 2009
                : 25
                : 1
                : 145-147
                Affiliations
                [1 ]Department of Thoracic and Cardiovascular Surgery, Korea University Medical School, Seoul, Korea.
                [2 ]Department of Radiology, Korea University Medical School, Seoul, Korea.
                Author notes
                Address for correspondence: Kyung Sun, M.D. Department of Thoracic and Cardiovascular Surgery, Korea University Medical School, 126-1 Anam-dong 5-ga, Sungbuk-gu, Seoul 136-705, Korea. Tel: +82.2-920-5559, Fax: +82.2-927-3104, ksunmd@ 123456kumc.or.kr
                Article
                10.3346/jkms.2010.25.1.145
                2800011
                20052361
                26674b60-92c8-496f-928b-b65340e56501
                © 2010 The Korean Academy of Medical Sciences.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 05 November 2007
                : 28 July 2008
                Categories
                Case Report
                Cardiovascular Disorders

                Medicine
                coronary artery bypass,pericardium,phrenic nerve,congenital abnormalities
                Medicine
                coronary artery bypass, pericardium, phrenic nerve, congenital abnormalities

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