Complete Congenital Absence of Left Pericardium: A Case Report

Congenital absence of the pericardium (CAP) is a rare anomaly, often silent and easily mistaken for other cardiac conditions. In this case report, a 72-year-old man without cardiovascular risk factors presented with intermittent, non-exertional left-sided chest discomfort over two weeks. His ECG showed absent R-wave progression, raising suspicion of coronary artery disease. Transthoracic echocardiography revealed a poorly defined cardiac silhouette with a leftward shift. The stress echo was negative for inducible ischemia. A chest X-ray was done to look into the cause of the displaced apex and showed loss of the right heart border, an elongated left cardiac contour, and normal lungs with a central trachea. The CT confirmed the complete absence of the left pericardium. No high-risk features of cardiac herniation were observed. Given the benign nature of complete unilateral pericardial absence and absence of complications, the patient was managed conservatively and reassured for his complaints. This case report highlights that recognition of characteristic imaging signs, especially on chest X-ray and CT, is crucial for distinguishing pericardial agenesis from other cardiothoracic conditions. Awareness of this rare entity aids in preventing unnecessary interventions and ensuring optimal patient care.