Abstract
BACKGROUND Congenital pericardial agenesis is a rare condition that is frequently associated with abnormal intrathoracic anatomy, especially malpositioning of the heart within the thoracic cavity. In the setting of coronary artery bypass, these anatomic derangements can present surgical challenges that can necessitate incorporating complementary, non-surgical solutions for complete revascularization. CASE REPORT A 48-year-old male patient presented with acute anginal symptoms, with workup revealing severe, multivessel coronary artery disease, as well as partial absence of the pericardium. Preoperative imaging revealed a severely displaced heart deep into the left chest. He was subsequently scheduled for coronary artery bypass grafting. However, altered anatomy from the absent pericardium required the procedure to be unexpectedly modified intraoperatively to address displaced coronary vessel targets that were surgically inaccessible. The patient's anterior vessels were grafted without complication, but the lateral and posterior vessels were unable to be grafted, due to excessive manipulation of the heart required for visualization. An intra-aortic balloon pump was utilized to maximize perfusion until a percutaneous coronary intervention could be completed by a cardiologist in these remaining vessels. CONCLUSIONS While congenital pericardial agenesis is a rare condition, the anatomic abnormalities encountered in this case are not uncommon within this patient population. These variances can interfere with standard coronary artery bypass grafting techniques. Understanding the unique challenges present in patients with this condition can aid in preoperative planning and coordination of a multispecialty approach for complicated revascularization.