Dyspnea Unveiled: The Unexpected Legacy of Cardiac Surgery

Presenting Author(s)

• LR

  LUCIA RODRIGUEZ EYRAS, MD

  Cardiologist. Advanced cardiac imaging
  Hospital Universitari Vall d'Hebron
  Mar del Plata, Buenos Aires, Argentina

Primary Author(s)

• LR

  LUCIA RODRIGUEZ EYRAS, MD

  Cardiologist. Advanced cardiac imaging
  Hospital Universitari Vall d'Hebron
  Mar del Plata, Buenos Aires, Argentina

Co-Author(s)

• NV

  Nicolas Ezequiel. Villalva, MD

  cardiologist echocardiographer
  (1) Hospital Vall d'Hebron, Department of Cardiology. VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
  BARCELONA, Catalonia, Spain

Description of Clinical Presentation: A 68-year-old female from a small coastal town in Buenos Aires, with prior coronary artery bypass grafting 14 years earlier, presented with progressively worsening dyspnea. Cardiac functional testing showed no inducible ischemia. Transthoracic echocardiography and non-contrast CT revealed a large pericardial cystic lesion. Based on epidemiology, physicians initially suspected a hydatid cyst. Due to its unusual size and location, cardiac MRI was requested for detailed characterization and preoperative planning.

Diagnostic Techniques and Their Most Important Findings: Cardiac MRI with ECG-gated cine SSFP, T1/T2 mapping, first-pass perfusion, and late gadolinium enhancement was performed.

Left ventricle: Non-dilated, non-hypertrophic, mild systolic dysfunction (EDV 82 ml/m², EF 47%) with segmental wall motion abnormalities in basal and mid-inferior, inferoseptal, and apical regions.

Right ventricle: Normal size, preserved systolic function (EDV 57 ml/m², EF 70%).

Atria: Within normal limits; right atrium mildly compressed by the epicardial lesion.

Late gadolinium enhancement: Subendocardial fibrosis in basal and mid-inferior and inferoseptal segments; transmural involvement in apical anterior, inferior, and septal segments.

A large, well-defined epicardial cystic lesion (10 × 8 × 8 cm) was identified in the superior pericardial recess, anterior to the left mediastinum. It contained internal linear structures resembling cystic septations, atypical for true cysts. Native and post-contrast T1 mapping indicated heterogeneous tissue composition; T2 sequences showed internal hyperintensity compatible with fluid. First-pass perfusion revealed peripheral hyperintensity with absence of intra-lesional perfusion, consistent with a non-vascularized mass. Prior non-contrast CT showed no calcifications, and no hepatic or splenic lesions, making hydatid disease unlikely. Given the surgical history, these findings raised suspicion of a gossypiboma, later confirmed postoperatively.

Learning Points from this Case:

• 
  Rare Postoperative Complication: Gossypibomas (textilomas) are retained surgical materials, most commonly cotton gauze, that may remain asymptomatic for years. While more frequently reported in the abdomen, they can also occur in the pericardial or epicardial space, where we, as cardiac imaging specialists, may not routinely consider them.
  
  


• 
  Variable Imaging Appearance: Chronically, gossypibomas induce granulomatous reaction, fibrosis, and encapsulation, producing well-defined, heterogeneous MRI lesions. They may appear cystic with internal linear structures resembling septations or membranes, sometimes causing misinterpretation. Peripheral hyperenhancement and absent intra-lesional perfusion are key MRI clues.
  
  


• 
  Clinical Context is Essential: Patients may present with nonspecific manifestations, such as progressive dyspnea. Awareness of prior cardiac surgery is critical to raise suspicion. MRI can suggest the diagnosis and guide management, though definitive confirmation usually requires surgical exploration.
  
  

Imaging Features Differentiating Hydatid Cyst and Pericardial Gossypiboma: Case Correlation.

Feature	Hydatid cyst (typical)	Gossypiboma (typical)	This case
Epicardial / pericardial location	Rare but possible	Possible (post-surgical)	✓
Internal linear structures resembling membranes	✓ (true detached membranes)	✓ (folded gauze → pseudo-membranes)	✓ (images inside the mass)
Peripheral hyperenhancement (capsule)	± (pericyst reaction)	✓ (fibrous capsule)	✓
Absent intra-lesional perfusion	✓ (avascular cyst)	✓ (central non-perfused content)	✓
T2 signal	High (fluid)	Heterogeneous; fluid high with low-signal strands	✓
T1 signal	Low	Heterogeneous (variable)	✓
Wall calcification on non-contrast CT	✓ (common when chronic)	✗ (uncommon)	✗ (absent in this case)
Hepatic and/or splenic involvement	✓ (frequent)	✗	✗
Intra-lesional gas	✗	± (may be present)	✗
Surgical history prompting suspicion	✗	✓ (key clue)	✓

Image 1 – Axial and Coronal Views Top row (axial Cine SSFP) – Images 1 to 5, cranial to caudal: Shows the location of the epicardial cystic lesion relative to mediastinal structures: right atrium, aorta, pulmonary artery, and aortopulmonary recess. Internal strand-like structures are visible, as previously described in the report. Bottom row (coronal black-blood T2) – Images 4 to 8: Demonstrates lesion size and precise location. Small inferior satellite cystic lesions are visible (yellow arrow). Internal hyperintensity compatible with fluid content.
Image 2– Four-Chamber View Upper row (images 1 to 3): Cine SSFP four-chamber view, showing internal strand-like structures. Rest perfusion: peripheral hyperenhancement with absence of intra-lesional perfusion. Late gadolinium enhancement PSIR: peripheral capsular enhancement; internal lesion strands are also visible. Additionally, subendocardial septal ischemic-necrotic sequela is noted (orange arrow). Lower row (images 4 to 5): Native and post-contrast T1 in four-chamber view, demonstrating heterogeneous internal composition with peripheral enhancement.
Image 3 – Intraoperative Images Image 1: pericardial access before opening. Image 2: pericardial space opened, showing gauze and fluid. Image 3: gauze removed from the patient.