Encasement of the Heart by Calcific Constrictive Pericardium
A 49-year-old gentleman with no prior medical history presented with progressive dyspnea on exertion of 2 years’ duration and recent swelling of feet. He was in New York Heart Association class III. Physical examination revealed signs of systemic venous congestion and restrictive right heart filling. Chest skiagram revealed densely calcified cardiac silhouette margin suggestive of pericardial calcification. B- and M-mode echocardiograms (despite a suboptimal window) revealed dense calcification of the pericardium, restricted left ventricular posterior wall motion, and abnormal posterior motion of the interventricular septum during inspiration. There was premature opening of the pulmonary valve and more than 25% beat-to-beat variation in the height of the mitral E wave with respiration. Cardiac catheterization revealed elevation of right and left heart filling pressures with diastolic equalization of pressures in all 4 chambers (Figures 1, 2, and 3⇓⇓ and Movies I, II, and III) and a dip-and-plateau pattern of the ventricular pressure waveform in diastole. Dense eggshell pericardial calcification was evident on fluoroscopy.
The Data Supplement, which contains 3 movies, is available at http://circ.ahajournals.org/cgi/content/full/112/12/e148/DC1.