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.

Constrictive Pericarditis. Frontal chest radiograph shows curvilinear calcification surrounding the heart consistent with calcific pericarditis.

Acknowledgement to Eduardo Benchimol Saad, MD