Herniation of Ventricles through Partial Pericardial Defect

A 62-year-old male was referred to our hospital for evaluation of chest discomfort. He had stent implantation 12 years ago for treating stable angina pectoris and treated multiple fractures from motor vehicle accident 8 years ago. His chest radiograph showed an increased heart size, suggesting aneurysmal dilatation of the left ventricle (LV, Figure 1A) compared with normal heart size taken 12 years ago (Figure 1B). Transthoracic echocardiography demonstrated indentation in the mid-portion of the LV and the apical portion of the right ventricle (RV, Figure 2A and B, arrow), which was not observed in the echocardiographic examination performed 12 years ago (Figure 2C and D, Supplementary Video 1). Contrastenhanced computed tomography showed herniated apical portion of the RV and a midportion of the LV through the partial pericardial defect (Figure 3A and B) without other obstructive coronary lesions. Although the physician recommended him to have a corrective operation, the patient refused the procedure and has been closely monitored without additional medications.