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Congenital absence of the left pericardium

Case contributed by Michael P Hartung
Diagnosis almost certain

Presentation

Myocardial apex palpated in the left axilla.

Patient Data

Age: 70 years
Gender: Male

Different positioning of the cardiac apex during the noncontrast and contrast sequences (obtained on separate days).

Extreme leftward rotation of the cardiac axis, with the left ventricular apex pointing posteriorly and leftward on the noncontrast sequence, and leftward on the contrast images. A fold of lung is seen between the aorta and pulmonary artery. Normal right pericardium along the rightward aspect of the descending aorta and about the right atrium.

The left pericardium is completely absent. Soft tissue projection about the apex of the right ventricle which extends inferiorly beyond the expected heart borders, likely a myocardial crease projecting through a pericardial defect. 

Case Discussion

Congenital absence of the left pericardium. 

Highlights:

  • Notice how the apex moved between the noncontrast and contrast sequences (done on separate days)
  • Fold of lung between aorta and pulmonary artery is a characteristic sign
  • Not complete absence of the pericardium as some of the right pericardium can be seen
  • Interesting soft tissue projection from the apex, presumably a small amount of myocardium herniating through a pericardial defect 

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