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J Thorac Cardiovasc Surg 1998;115:724-725
© 1998 Mosby, Inc.

BRIEF COMMUNICATIONS

Massive pericardial hematoma simulating constrictive pericarditis: acomplication of radiofrequency catheter ablation

Anastasios K. Konstantakos, MDa, Robert C. Gilkeson, MDb, Frank V. Brozovich, MD, PhDc, Jai H. Lee, MDa

Cleveland, Ohio

From the Division of Cardiothoracic Surgery,aDepartment of Radiology,b Division of Cardiology,c CaseWestern Reserve University, University Hospitals of Cleveland, Cleveland, Ohio.

Received for publication Oct. 3, 1997. Accepted for publication Oct. 10, 1997. Address for reprints: Jain H. Lee, MD, Division of CardiothoracicSurgery, Case Western Reserve University, University Hospitals of Cleveland,11100 Euclid Ave., Cleveland, OH 44106.

Radiofrequency catheter ablation (RFCA) has become an increasinglypopular technique for nonpharmacologic treatment of various cardiac arrhythmiasbecause of its efficacy and low complication rate.Go 1 This appears to be the firstreported case of an occult myocardial perforation induced by RFCA that led to aclinical presentation of constrictive pericarditis and right ventricular (RV)obstruction.

Clinical Summary

A 54-year-old man with a long-standing history of atrial flutter (AF) wasseen for elective evaluation of recurrent bouts of exertional dyspnea, worseningexercise tolerance, and occasional palpitations that had developed over a 3-yearperiod. During this time he was diagnosed with constrictive pericarditis. He hada mild stroke 15 years ago and had been placed on a warfarin sodium (Coumadin)anticoagulation regimen since then. Approximately 3 years before thispresentation he had an RFCA for attempted treatment of the AF. However, duringelectrophysiologic testing, AF could not be induced, and several radiofrequencyenergy lesions were placed in the lower right atrial area near the presumedorigin of the AF circuit.

Because he continued to have episodes of symptomatic AF, he was admittedelectively for evaluation and possible RFCA of his AF. During this secondattempt at RFCA, AF was not inducible. However, it was noted on fluoroscopy andsubsequently confirmed by chest x-ray films that the patient had diffuse nodularepicardial and curvilinear pericardial calcifications anterior to the RV (Fig.1). A subsequent echocardiogram showed athickening around the RV that greatly reduced the RV chamber size. Cardiaccatheterization revealed decreased RV and pulmonary artery pressures with awell-defined "dip and plateau" pattern of restrictive filling.Magnetic resonance imaging scans demonstrated a homogenous mass anterior to andcompressing the RV (Fig. 2).



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  		Fig. 1. Preoperative chestradiograph demonstrating thick curvilinear calcifications overlying the cardiacsilhouette (arrowheads). Extensive, abnormalsoft tissue opacity extends beyond these calcifications.

 


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  		Fig. 2. Preoperative axial cinemagnetic resonance image at the ventricular level demonstrating apericardial/epicardial mass causing marked compromise of the right ventricularchamber (arrowheads).

 
The patient was taken to the operating room for exploration through amedian sternotomy. Operative dissection revealed a thickened pericardium withdense adhesions to the epicardium of the RV and left ventricle. A 12 cmcalcified mass, which appeared to be an old hematoma, was noted adjacent to thediaphragmatic surface of the RV and extended laterally to the left ventricle.Dissection around this mass was accomplished, but because of patchy ingrowthinto the epicardium, a small part of the RV myocardium was entered and wasrepaired. After resection of the mass, RV compression was relieved, and RVcontractility had markedly improved.

Gross pathologic examination confirmed the presence of an old calcifiedhematoma. Histologic examination revealed an organizing thrombus with focaldystrophic calcifications. The patient's recovery was uneventful. He has apostoperative echocardiogram that showed complete resolution of the compressionand markedly improved RV function. At follow-up 6 months postoperatively, thepatient was well and reported no complaints.

Comment

The most likely cause of this hematoma is an occult myocardialperforation at the time of the first RFCA, which led to the slow accumulation ofpericardial blood and subsequent organization and calcification over 3 years'duration. The patient's warfarin therapy also could have predisposed him to thislow-grade, occult bleeding. Furthermore, it has been suggested that injuredmyocardium from RFCA therapy may be less resistant to rises in ventricularpressure.Go 2 Thus it is quitepossible that a delayed rupture of the myocardium occurred sometime after RFCAtherapy and led to a slow accumulation of hemopericardium.

Although we were not able to determine the exact site of the chamberperforated, rupture of the right atrium would have been unlikely. The immediateaccumulation of blood within the pericardium owing to the inability of atrialtissue to locally contract and contain extravasation would have acutelymanifested itself as pericardial tamponade.

The etiologic spectrum of constrictive pericarditis consists ofpostradiotherapy, postoperative, and postinfectious sequelae, as well asneoplasia, connective tissue disorders, and autoimmune disease.Go 3 A persistent intrapericardialhematoma induces pericardial inflammation, leading to granulation tissue,adhesions, and finally constriction.Go 4Thus the possibility of an organized pericardial hematoma should not beoverlooked in the differential diagnosis of constrictive pericarditis after RFCAtherapy.

Definitive diagnosis and therapy of constricting pericardial massesdepends on operative removal as illustrated in this report.

References

  1. Hindricks G. The multicenter Europeanradiofrequency survey (MERFS): complications of radiofrequency catheter ablationof arrhythmias. Eur Heart J 1993;14:1644-53.
  2. Kongsgaard E, Foestrster A, Aass H, Madsen S,Amie JP. Effects of combined radiofrequency and direct current energy catheterablation on ventricular myocardium in pigs. Eur Heart J 1995;16:514-20.[Medline]
  3. Cameron J, Oesterle SN, Baldwin JC, HancockEW. The etiologic spectrum of constrictive pericarditis. Am Heart J 1987;113:354-60.[Abstract]
  4. Brown DL, Ivey TD. Giant organizedpericardial hematoma producing constrictive pericarditis: a case report andreview of the literature. J Trauma 1996;41:558-60.[Abstract/Free Full Text]




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