Image of the month - October 2015 - A 46 year old lady with breathlessness

Submitted by Dr Alistair Moss
University of Edinburgh

A 46 year-old lady from South Africa was evaluated for breathlessness and heart failure. She had rheumatic fever aged two and aged nineteen she had severe calcific constrictive pericarditis and underwent 50% pericardiectomy. Transthoracic echocardiogram (TTE) revealed a calcified band with a calcific spur protruding through the anterolateral left ventricular (LV) wall, with tenting of the anterior mitral valve leaflet (Figure 1A Parasternal short axis and B modified apical 4 chamber TTE). CT coronary angiogram (CTCA) demonstrated a ring of dense calcification with LV impingement in two focal regions and systolic anterior motion of the anterior mitral valve leaflet. (Figure 1C Short axis CT and E 3D reconstruction of the calcification) The distal RCA was buried in the calcified pericardial band at the origin of the posterior descending artery (PDA) (Figure 1D, F & G).

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QUESTION

What is the most likely aetiology of the calcified pericardial band?

  1. Previous cardiac surgery
  2. Radiotherapy
  3. Viral pericarditis
  4. Tuberculous pericarditis

ANSWER

The most likely cause of calcified pericardium (concretio cordis) in this case is silent tuberculous pericarditis. Pericardial constriction occurs in 20-50%. Calcified constrictive pericarditis can occur following cardiac surgery, but does not explain the initial presentation.  Chevers reported the first post-mortem case of calcified pericardial constriction in an 18 year-old female in 1841 as ‘the cavity of the pericardium was entirely obliterated by a layer of firm and almost cartilaginous deposit’.1 While case reports have identified pericardial calcification invading the right ventricular myocardium2, it is rare to find infiltration of the LV myocardium and coronary arteries.3

REFERENCES
1      Chevers N. Observations on the Diseases of the Orifice and Valves of the Aorta. Guy’s Hosp. Rep. 1842;7:387-442
2      Ahlgren B, Reece B, Salcedo E, Seres T. Constrictive pericarditis with a calcific mass invading into the right ventricular myocardium. Echocardiography 2013;30:E4-6
3      Gouley BA, Bellet S, McMillan TM. Tuberculosis of the Myocardium: Report of Six Cases with observations on involvement of the coronary arteries. Arch Int. Med. 1933;51:224