Localised calcific constrictive pericarditis causing pseudo-apical ballooning

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Acta Cardiol 2012; 67(5): 613-614

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doi: 10.2143/AC.67.5.2174141

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Localised calcific constrictive pericarditis causing pseudo-apical ballooning Johan R. BENNETT1, MD; Jan BOGAERT2, MD PhD; Bert FERDINANDE1, MD From the Departments of Cardiovascular Medicine1and Radiology2, University Hospitals Leuven, Leuven, Belgium.

Keywords

Constrictive pericarditis – pericardial calcification – pseudo-apical ballooning.

Address for correspondence: Johan R. Bennett, MD, Department of Cardiovascular Medicine, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium. E-mail: [email protected] Received 24 February 2012; second revision accepted for publication 25 June 2012.

A 61-year-old lady presented with a 4-month history of exertional dyspnoea, orthopnoea and peripheral oedema. Cardiac computerized tomography (CT, panel A, short-axis view at level of LVOT) showed extensive calcification (arrows), almost semi-ring like, around the base of the left and right ventricle. The calcification is mainly pericardial, although there is localized myocardial

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involvement of the infero-posterior LV wall (*). Threedimensional reconstruction of the cardiac CT in anteroposterior projection (panel B) showed pericardial calcification causing compression at the base of the LV (arrow). The LA was dilated. On angiography of the right coronary artery (panel C, RAO view) extensive pericardial calcification, predominantly in the AV groove, was visible (arrows). Left ventriculography (panel D) showed calcification (*), mainly involving the basal and basalinferior aspect of the left ventricle, giving rise to an appearance of pseudo-apical ballooning. On invasive haemodynamic studies, there were classical features of constriction with equalization of end-diastolic pressures (the “square root sign”) in the ventricles along with raised right atrial pressures, increasing on inspiration, with a prominent ‘y’ descent (panel E). Real-time magnetic resonance imaging in cardiac short-axis during in- and

expiration showed inspiratory septal inversion (arrow, panel F) a diagnostic feature of pericardial constriction. The patient was diagnosed with idiopathic localized calcific constrictive pericarditis. Due to progressive clinical deterioration surgical pericardiectomy was performed without complication with instantaneous improvement in cardiac haemodynamics. At 1-month follow-up, clinical status was much improved with NYHA class I symptoms and absence of orthopnoea and peripheral oedema. (LV: left ventricle, RV: right ventricle, LVOT: left ventricular outflow tract, RAO: right anterior oblique, AV: atrio-ventricular, PV: pulmonary valve, LA: left atrium, NYHA: New York Heart Association).

CONFLICT OF INTEREST: none.

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