Asian Cardiovasc Thorac Ann 2008;16:432-433
© 2008 Asia Publishing EXchange Ltd
IMAGES IN CARDIOTHORACIC MEDICINE AND SURGERY |
Chronic Constrictive Calcific Pericarditis
Jaswinder Singh, MCh,
Naveen Swami, MS1,
Harkant Singh, MCh1,
Rajeshwar Sharma, MS,
Sudhir Mehta, MCh1,
Rajinder S Dhaliwal, MCh1
1 Department of Cardiovascular and Thoracic Surgery, Military Hospital, Pune
Department of Cardiovascular and Thoracic Surgery, Postgraduate Institute of Medical Education & Research, Chandigarh, India
For reprint information contact: Jaswinder Singh, MCh Tel: 91 202 426 5583 Fax: 91 202 630 6175 Email: drjaswindersingh{at}yahoo.co.in, Department of Cardiovascular and Thoracic Surgery, Military Hospital (CTC), Golibar Maidan, Pune 414 0040, India.
This 48-year-old male presented with dyspnea on exertion with NYHA class II of 8 years duration, palpitations on exertion of 4 years duration and puffiness of face and swelling of feet of 8 months duration. Thirty years back he had undergone treatment for pulmonary tuberculosis. His pulse and blood pressure were 90·beats–1 and 100/60 mm Hg, respectively; his jugular venous pressure was raised and had pitting bilateral pedal edema. On cardiovascular examination, apical impulse was neither visible nor palpable; heart sounds were muffled and pericardial click was heard. Abdominal examination showed hepatomegaly of 4 cm below the costal margin. Chest roentgenogram showed cardiomegaly along with ringed calcification in the cardiac silhouette (Figures 1
and 2). Contrast enhancing computed tomogram of the chest showed extensive chunky calcification of the pericardium in the atrioventricular and interventricular grooves ;cardiomegaly with dilatation of inferior vena cava along with right pleural thickening and calcification (Figures 3 and 4).
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Figure 1. Chest roentgenogram postero-anterior view showing cardiomegaly along with ringed calcification in the cardiac silhouette.
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Figure 3. Computed tomogram of the chest showing extensive chunky calcification of the pericardium in the atrioventricular groove.
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Figure 4. Computed tomogram of the chest showing extensive chunky calcification of the pericardium in the atrioventricular and interventricular grooves; dilatation of inferior vena cava and right pleural thickening and calcification.
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At sternotomy, pericardium was 3–4 mm thickened; loosely adherent to the visceral pericardium. There was dense adherent calcification along the atrioventricular and interventricular grooves. Pericardium was removed over the left ventricle, right ventricle and root of aorta and pulmonary artery. Adherent calcific pericardium in atrioventricular and interventricular grooves was left in situ with the fear of injuring the coronary arteries and myocardial rupture. Patient had an uneventful postoperative recovery.
More recently clinical spectrum of chronic constrictive percarditis has changed from the etiologic point of view; there has been an increase in the number of cases of constrictive pericarditis secondary to chest radiation and cardiac surgery. Cardiac surgery has emerged as an important cause of constrictive pericarditis, representing up to 18–29% of cases in some series.1–2
Although its prevalence is only 0.2–0.3% following coronary artery bypass grafting or valvar surgery. Constrictive calcific pericarditis, although still relatively uncommon has once again become a real clinical entity partly due to the emergence of drug-resistant strains of tuberculosis.3 In industrialized countries such as the United States, constrictive calcified pericarditis in association with treated pulmonary tuberculosis is rare, due to the decreased incidence of tuberculosis in modern cardiovascular practice.1 Yet tuberculosis remains a leading cause of pericarditis in some nonindustrialized countries.2–3 We submit this report not only for its striking appearance on the chest roentgenogram and computed tomogram of the chest but also the rare but once again emerging cause of constrictive pericarditis.
REFERENCES
- Ling LH, Oh JK, Schaff HV, et al. Constrictive pericarditis in the modern era. Evolving clinical spectrum and impact on outcome after pericardiectomy. Circulation 1999;100:1380–6.[Abstract/Free Full Text]
- Cameron J, Oesterle SN, Baldwin JC, et al. The etiologic spectrum of constrictive pericarditis. Am Heart J 1987;113:354–60.[Medline]
- Afzal A, Keohane M, Keeley E, Borzak S, Callender CW, Iannuzzi M. Myocarditis and pericarditis with tamponade associated with disseminated tuberculosis. Can J Cardiol 2000;16:519–21.[Medline]
