Pericardial Calcifications
Constrictive Pericarditis

• Calcification in the pericardium is most likely inflammatory in nature
  • Can be seen with a variety of infections, trauma, and neoplasms 
• Calcification most commonly occurs along the inferior diaphragmatic surface of the pericardium surrounding the ventricles
  • Thin, egg-shell like calcification is more often associated with viral infection or uremia
  • Calcification from old TB is often thick, confluent, and irregular in appearance, especially when compared with myocardial calcification

PA and lateral close-ups show thick pericardial calcification around
apex of heart from patient with history of tuberculous pericarditis

• Calcification is seen in 1/3-1/2 of patients with constrictive pericarditis
  • Its presence does not imply constriction
  • Pericardial calcification must be differentiated from coronary artery calcification, valvular calcification, calcified myocardial infarct or ventricular aneurysm, left atrial calcification, or calcification outside the heart 
  • This can usually be accomplished by the locations of these calcifications on multiple views, or the radiographic appearance of the calcium

• Constrictive Pericarditis
  
  
  • Present when a fibrotic, thickened, and adherent pericardium restricts diastolic filling of the heart.
  • Usually begins with an initial episode of acute pericarditis
    • May not be detected clinically
  • This slowly progresses to a chronic stage consisting of fibrous scarring and thickening of the pericardium with obliteration of the pericardial space
  • This produces uniform restriction of the filling of all heart chambers
    
    
• Signs and Symptoms
  
  
  • Reduced cardiac output ( fatigue, hypotension, reflex tachycardia )
  • Elevated systemic venous pressure ( jugular venous distension, hepatomegaly with marked ascites and peripheral edema )
  • Pulmonary venous congestion ( exertional dyspnea, cough and orthopnea )
  • Chest pain typical of angina may be related to underperfusion of the coronary arteries or compression of an epicardial coronary artery by the thickened pericardium.
  • Most impressive physical findings are often the insidious development of ascites of hepatomegaly and ascites, such patients are often mistakenly thought to suffer from hepatic cirrhosis or an intra-abdominal tumor.

·    Calcification of the pericardium is detected in up to 50 % of patients

·    This finding is not specific for constrictive pericarditis

o   A calcified pericardium is not necessarily a constricted one

o   Lateral chest film is useful for its detection in the atrioventricular groove or along the anterior and diaphragmatic surfaces of the right ventricle.

o   Pleural effusions are present in about 60 % of patients

§    Persistent unexplained pleural effusions can be the presenting manifestation

·    CT or MRI are superior in the assessment of pericardial anatomy and thickness

·    The diagnosis is confirmed by cardiac catheterization

·    Treatment for constrictive pericarditis is complete resection of the pericardium 

Constrictive Pericarditis. Coronal re-formatted CT of chest shows markedly thick pericardial calcification around the heart from patient with history of tuberculous pericarditis

Acknowledgement to Eduardo Benchimol Saad, MD