The radiographic distinction between pericardial and myocardial calcifications

Myocardial calcification in a patient with B-lymphoblastic leukemia accompanied by tumor lysis syndrome

Myocardial calcification, a rare disease that leads to chronic or acute heart failure and with a poor prognosis, occurs in patients with abnormal calcium-phosphorus metabolism. The association between myocardial calcification and tumor lysis syndrome has not been reported to date. A 50-year-old man with hyperthermia and general malaise presented to our hospital and was clinically diagnosed with B-lymphoblastic leukemia (B-ALL) and febrile neutropenia accompanied by septic shock. Prednisolone was administered for tumor reduction. Two to three hours later, electrocardiography demonstrated ST elevation in V4-6, and blood tests showed elevated levels of cardiac enzymes. Transthoracic echocardiogram revealed diffuse severe hypokinesis with decreased left ventricular ejection fraction. Additionally, blood tests showed that serum phosphorus level increased to 8.0 mg/dl, which was likely due to tumor lysis syndrome. Circulatory and respiratory failure due to left heart failure progressed, and he died 3 days after administration of prednisolone. Pathological autopsy revealed diffuse proliferation of atypical B-lymphoblasts in the bone marrow, which led to the pathological diagnosis of B-ALL, accompanied by necrosis. On the cut surface of the heart, the left ventricle was dilated, and patchy yellowish-brown areas were present in the epicardial-side of the myocardium and spread through the circumferential wall of the left ventricle and interventricular septum. Microscopically, myocardial fibers were granularly basophilic in that area and were revealed as calcium deposits by Von Kossa staining. He was diagnosed with myocardial calcification. The drastic increase in the serum phosphorus level caused by tumor lysis syndrome seemed to be associated with myocardial calcification.

The imaging appearances of various pericardial disorders

The pericardium could be involved in a variety of clinical disorders. The imaging findings are not specific for an individual pathology in most of the cases; however, patient’s clinical history may guide radiologist to a definitive diagnosis. Congenital absence of the pericardium could be recognized with the imaging appearance of interposed lung tissue between the main pulmonary artery and aorta. Pericardial effusion is a non-specific condition that may occur due to inflammatory, infectious, and neoplastic disorders. Cardiac tamponade may occur in case of massive or rapid accumulation of fluid in the pericardial sac. Pericardial calcification is a common and easily identified entity on a computed tomography (CT) scan. Presence of calcification and/or fibrosis may result in pericardial constriction. Nevertheless, the pulsation of an adjacent coronary artery may prevent calcification formation in a focal area and consequently may result in pericardial diverticulum containing epicardial fat and coronary artery. The imaging findings encountered in patients with pericardial hydatid disease and Erdheim-Chester disease may mimic those of pericardial neoplasia. Pericardial adhesions and pedicled fat flaps may cause confusion on a CT scan in the post-surgical period following cardiac surgery. Pericardial fat necrosis can be diagnosed by CT in patients with chest pain. The radiologists should be familiar with the medical devices placed in pericardial space for certain individual indications. A pericardial patch and temporary epicardial pacemaker wires could be identified on a CT scan.

Myocardial Calcification with a Latent Risk of Congestive Heart Failure in a Patient with Apical Hypertrophic Cardiomyopathy

Myocardial calcification is rare. An 88-year-old man who had previously been diagnosed with apical hypertrophic cardiomyopathy exhibited left ventricular asynergy on echocardiography before undergoing cholecystectomy. Computed tomography revealed severe calcification in the apical region of the left ventricular myocardium, although the coronary arteries were intact and the hemodynamics on right heart catheterization were normal. The cause of the left ventricular asynergy appeared to be myocardial calcification, thought to be the result of rheumatic fever based on the patient's past history. Stress echocardiography showed a latent risk for the development of heart failure due to the distensibility of the calcified left ventricular myocardium.

Refractory ascites as the only presenting symptom of chronic calcified constrictive pericarditis: a diagnostic challenge

Extracardiac manifestations of constrictive pericarditis, such as massive ascites and liver cirrhosis, often cover the true situation and lead to a delayed diagnosis. A young female patient was referred to this hospital due to a 4-year history of refractory ascites as the only presenting symptom. A diagnosis of chronic calcified constrictive pericarditis was eventually established based on echocardiography, ultrasonography, and computed tomography. Cardiac catheterization was not performed. Pericardiectomy led to relief of her ascites. Refractory ascites warrants thorough investigation for constrictive pericarditis.

Idiopathic massive myocardial calcification: a case report and review of the literature

We report a rare case of massive myocardial calcification in a 42-year-old male who presented with symptoms of congestive heart failure and arrhythmia. Myocardial calcification is most commonly associated with myocardial infarction or, less commonly, hypercalcemia. This case is particularly unusual due to the lack of any known predisposing risk factors, including normal coronary arteries, normal renal function, and normal serum calcium levels. Alternative etiologies are discussed accompanied by a review of the literature.

Cardiac and pericardial calcifications on chest radiographs

Many types of cardiac and pericardial calcifications identified on chest radiographs can be recognized and distinguished based on characteristic locations and appearances. The purpose of this review is to emphasize the importance of detecting cardiac and pericardial calcifications on chest radiographs, and to illustrate and describe the various types of calcifications that may be encountered and how they may be differentiated from one another. Each type of cardiac and pericardial calcification is discussed, its location and appearance described, and its significance explained. Recognizing and understanding these calcifications is important as they are often encountered in daily practice and play an important role in patient care.

Evaluation of Acute Chest Pain in the Emergency Department: Utility of Multidetector Computed Tomography

Distinguishing insignificant from life-threatening causes of acute chest pain in patients who present to the emergency department remains a major challenge. Initial evaluation with history, electrocardiography, and biochemical markers is often unrevealing leading to additional workup. Radionuclide perfusion and echocardiography may be diagnostic but provide only indirect assessment of coronary status. The development of multidetector computed tomography (MDCT) and its increasingly frequent placement near the emergency suite has facilitated its use for the evaluation of serious noncardiac diagnoses such as pulmonary embolism and aortic dissection. Recent innovations in MDCT technology have facilitated the depiction of coronary arteries. These advances have led to the possibility of using CT to evaluate cardiac etiologies of chest pain, using either a comprehensive or triple rule out protocol to assess both cardiac and noncardiac causes or a dedicated coronary protocol. This article will review both options and describes our preliminary experience with the first of these protocols. The article also reviews the potential value of an acute chest pain CT protocol and the considerable challenges that remain prior to its implementation for routine clinical use.

Chest Pain in the Emergency Department

The evaluation of patients presenting with chest pain to the emergency department remains a significant challenge. The primary goal is to distinguish clinically insignificant etiologies from life-threatening causes such as myocardial ischemia, aortic dissection, and pulmonary embolism. The conventional evaluation consisting of history, electrocardiography, and biochemical markers is often inconclusive and noninvasive imaging techniques may prove valuable. This article describes some of the available options and focuses on the potential role of CT angiography to assess indeterminate chest pain.

Emergency cardiac imaging: state of the art

Multiple strategies and testing modalities are available to evaluate patients presenting to the emergency department with cardiac complaints. Many provide anatomic and prognostic information about coronary stenosis and long-term out-comes. Although nuclear and stress echo imaging have the ability to predict outcomes in patients in the emergency department population, the newer modalities of cardiac imaging (EBCT, MDCT,and CMR) continue to show promising results and may soon be incorporated into emergency department chest pain centers. Protocols can be developed within an institution to meet the needs of the patient population while minimizing risk and improving outcomes for all patients.

Assessment of chest pain in the emergency room: What is the role of multidetector CT?

Chest pain is one of the most frequent complaints for patients seen in the emergency department. The current article describes the clinical stratification of patients who present to the emergency department with chest pain and discusses imaging options and analysis for these patients. It reviews conventional imaging approaches to assessing chest pain including chest radiography and stress testing. The main discussion focuses on the potential utility use of cross-sectional imaging, particularly multidetector CT, in the evaluation of chest pain in the emergency department.

Porcelain heart: a case of massive myocardial calcification

Reports of massive myocardial calcification are limited mainly to case reports and this type intracardiac calcifications have been usually identified postmortem. We present a very interesting case of massive calcification of the left ventricular myocardium, interventricular and interatrial septae causing restrictive physiology and coronary artery obstruction in a 46-year-old Turkish woman. The diagnosis of myocardial calcification was suspected from chest X-ray and confirmed with computerized tomography and cardiac catheterization. The findings of the chest computed tomography were very similar to those previously reported cases of endomyocardial fibrosis (EMF) with massive calcification of the left ventricle.

Post-traumatic pericardial calcification

Trauma is a cause of calcific constrictive pericarditis, but less commonly may cause a localized mass. We report such a case in which the mass impinged on the right heart resulting in severe systemic venous stasis.

Left ventricular calcification following resuscitation

In this paper we report a case of 34-year-old man with a severe septic shock. Because of profound hypotension he was given massive amounts of catecholamines for 10 days. After a short recovery the function of his heart started to deteriorate again and clear calcification around the left ventricle was disclosed by computer tomography. Catecholamines are known to induce myocardial injury resulting in a special form of cardiomyopathy with eventual calcification, but there are no previous reports of myocardial calcification to this extent.

Calcific constrictive pericarditis: is it still with us?

BACKGROUND

The presence of pericardial calcification on a plain radiograph strongly suggests constrictive pericarditis in patients with heart failure. However, calcific constrictive pericarditis is considered rare in the United States since tuberculosis incidence has decreased, and doubt has therefore been raised about the importance of this radiologic finding in modern cardiovascular practice.

OBJECTIVE

To determine the clinical and prognostic significance of pericardial calcification on radiography in patients with constrictive pericarditis.

DESIGN

Retrospective cohort study.

SETTING

Tertiary referral center.

PATIENTS

A consecutive series of 135 patients (mean age +/- SD, 56 +/- 16 years) who from 1985 through 1995 had constrictive pericarditis confirmed surgically (n = 133) or by autopsy (n = 2). Patients were divided into two groups: those with pericardial calcification on chest radiography (group I) and those without (group II).

MEASUREMENTS

Clinical and diagnostic findings were compared in both groups, and outcome was compared in 132 patients who had pericardiectomy.

RESULTS

Pericardial calcification was seen in 36 patients (27%). The cause of constrictive pericardial disease was indeterminate in 67% of patients in group I and in 21% of patients in group II (P < 0.001). Patients in group I had had symptoms for a longer period and were more likely to have pericardial knock, larger atrial size, and atrial arrhythmia. Significantly more perioperative deaths were seen in group I, but incidence of late survival and incidence of noncalcific disease were similar in both groups.

CONCLUSIONS

Pericardial calcification is a common finding in patients with constrictive pericarditis. It is often associated with idiopathic disease and other markers of disease chronicity and is an independent predictor of increased perioperative mortality rates.

Constrictive pericarditis: clinical and pathophysiologic characteristics

Constrictive pericarditis is an uncommon disorder with various causes. Although most often idiopathic, it may also occur after cardiovascular surgery, radiation therapy, and tuberculosis, especially in developing countries. The encasement of the heart by a rigid, nonpliable pericardium results in characteristic pathophysiologic effects, including impaired diastolic filling of the ventricles, exaggerated ventricular interdependence, and dissociation of intracardiac and intrathoracic pressures during respiration. Constrictive pericarditis typically presents with chronic insidious signs and symptoms of predominantly systemic venous congestion. Notoriously difficult to diagnose and distinguish from restrictive cardiomyopathy (RCM), the use of cardiac catheterization, echocardiography (transthoracic and transesophageal), central venous (hepatic and pulmonary) and transvalvular Doppler measurements, and magnetic resonance imaging should secure the diagnosis in most cases, eliminating the need for diagnostic thoracotomy. Although medical treatment may temporarily alleviate symptoms of heart failure, patients do poorly without pericardiectomy.