MedPix® Patient Chart - Case No: 6492 :: - Review Images

68 year-old man with increased dyspnea on exertion and orthopnea.

Echocardiography and cardiac catheterization show evidence of constrictive physiology.

- Review Images for PT: 6492

PA and lateral chest x-rays demonstrate normal heart size with anterior and inferior pericardial calcifications and question of mild pulmonary venous engorgement. On non-contrast CT scan, the calcifications are described as eggshell-type calcifications which do not significantly involve the AV grooves. There is no pericardial effusion, evidence of right heart enlargement or failure, or vena cava and hepatic vein distention. Accessory splenules, old fractures of the spine and inferior sternum at the level of the pericardial calcifications are also seen. Echocardiography revealed mild dilatation of the inferior vena cava. Doppler of the mitral valve was suggestive of abnormal respiratory variation which can be seen in constrictive physiology.

- Review Images for PT: 6492

Calcific constrictive pericarditis vs. calcified pericardium from remote Post-traumatic hemopericardium. Underlying etiologies of constrictive pericardial disease include previous pericardiotomy or hemopericardium, radiation, virus, TB, chronic renal failure, rheumatoid arthritis, neoplastic involvement, and idiopathic.

- Review Images for PT: 6492

Dx: Calcified pericardium

Dx Confirmed by: Radiologic - confirmed by CT scan.

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Constrictive pericarditis work-up. Patients with constrictive pericarditis may benefit from pericardial stripping.

Elevated filling pressures in the presence of calcification of the pericardium is consistent with constrictive pericarditis. Fibrous or calcific thickening of the pericardium may lead to constrictive pericardial disease due to restriction of cardiac motion which chronically compromises ventricular filling. Onset of constrictive pericarditis is usually between the ages of 30-50 years and prevalence is three times greater in males than in females. An associated protein losing enteropathy may be present. The most common cause of constrictive pericardial disease is postpericardiotomy and hemopericardium for any reason. The second most common cause is radiation therapy, but Coxsackie B virus, TB, uremia, connective tissue disease, neoplasm, and idiopathic etiologies may be seen.

Patients with constrictive pericarditis commonly present with symptoms of heart failure to include dyspnea, orthopnea, and fatigability. They may occasionally present with liver enlargement, ascites and later on with cirrhosis ("cardiac cirrhosis")secondary to chronic hepatic congestion.

Normal pericardial thickness is less than 2mm. When greater than 4mm and accompanied by clinical findings of heart failure, constrictive pericarditis is highly likely. It is essential to realize, however, that neither pericardial thickening nor calcification is pathognomonic of constrictive pericarditis unless the patient also has concomitant symptoms of physiologic constriction. However, 50% of patients with pericardial calcifications have constrictive pericarditis. Pericardial thickening may be global or limited to the right side of the heart or to the right AV groove.

Calcifications are seen on plain film radiography in up to 50% of patients. Ascites and plural effusions are common. Normal to mild enlargement of the cardiac silhouette is commonly seen along with small atria, dilated superior and inferior vena cava and azygos vein, and flat or straitened right heart border.

Echocardiography may show thickened pericardium, abnormal septal motion, and increased left ventricular ejection fraction with a small end-diastolic volume.

CT and MR imaging are excellent in depicting the pericardium, and in aiding the diagnosis of constrictive pericarditis, especially in difficult cases. CT is particularly good for demonstrating pericardial thickening and calcification. Reflux of contrast into the coronary sinus, a bowed interventricular septum, flattening of the right ventricle, ascites, and pleural effusions, may all be seen. Both CT and MR show pericardial thickening, dilatation of the right atrium, inferior vena cava and hepatic veins along with a sigmoid septal shift (or prominent leftward septal convexity) and narrowing/reduced volume of the right ventricle. MR may demonstrate abnormal flow mechanics in the vena cava and atria.

From the clinical standpoint it is important to differentiate constrictive pericarditis from other restrictive myocardial diseases ( Myocarditis)since both entities have identical pathophysiologic findings on echocardiography or card cath. Myocarditis is difficult to treat and the only treatment is medical therapy. Constrictive pericarditis is treated surgically with pericardial stripping.