Although historically infective pericarditis was the most common cause, a wide variety of insults can lead to calcification of the pericardium.
- pericarditis: tuberculous, fungal, viral or pyogenic
- previous trauma (hemopericardium)
- cardiac surgery
- collagen vascular diseases: as systemic lupus erythematosus
- uremic pericarditis
- later sequelae of rheumatic heart disease
- malignant pericardial involvement (e.g. mediastinal teratoma)
- post-radiotherapy 5
- calcified pericardial masse or cyst
Pericardial calcification is more common over the right side, anterior and diaphragmatic aspects of the heart in the atrioventricular grooves 7. Calcifications over the left ventricle or cardiac apex are rare, unless pericardial calcification is extensive. It is important to assess for signs of associated constrictive pericarditis.
- a curvilinear density at the extreme margin of the cardiac silhouette (better on lateral view)
- extension of calcification over the pulmonary outflow tract (better on lateral view)
- dilated left atrium: due less pericardial investment, even with pericardial constriction, mimicking mitral stenosis
Tuberculous calcifications are the most dense, in the atrioventricular grooves and appear as thick, amorphous oblique circles or arcs of calcifications then spread over the atria and ventricles 7.
Treatment and prognosis
Medical management is ineffective, and surgical resection of the diseased pericardium is usually performed.
The differential diagnosis for pericardial calcifications include:
- constrictive pericarditis: in the setting of heart failure with concern for constrictive pericarditis or restrictive cardiomyopathy, calcifications are highly suggestive of the former
- chronic adhesive pericarditis in the absence of constriction: less dense with a more patchy distribution 1
- rheumatic pericarditis 2
- myocardial calcification: more left-sided and localized calcification (e.g. over the cardiac apex from prior infarction) 3,6
- 1. Fuster V. Hurst's the Heart. McGraw-Hill Professional Pub. (2010) ISBN:0071636463. Read it at Google Books - Find it at Amazon
- 2. Dan Longo, Anthony Fauci, Dennis Kasper et-al. Harrison’s Principles of Internal Medicine, 18E. McGraw-Hill Prof Med/Tech. (2012) ISBN:007174889X. Read it at Google Books - Find it at Amazon
- 3. Macgregor JH, Chen JT, Chiles C et-al. The radiographic distinction between pericardial and myocardial calcifications. AJR Am J Roentgenol. 1987;148 (4): 675-7. AJR Am J Roentgenol (abstract) - Pubmed citation
- 4. Wang ZJ, Reddy GP, Gotway MB et-al. CT and MR imaging of pericardial disease. Radiographics. 2003;23 Spec No : S167-80. doi:10.1148/rg.23si035504 - Pubmed citation
- 5. Paniagua González Miguel, Sánchez Alegre María Luisa. Extensive pericardial calcification secondary to radiotherapy, causing mixed constrictive-restrictive pathology. (2017) BJR|case reports. 3 (4): 20170036. doi:10.1259/bjrcr.20170036 - Pubmed
- 6. Stuart J. Hutchison. Principles of Cardiovascular Radiology. (2011) ISBN: 9781437704051
- 7. Ferguson EC, Berkowitz EA. Cardiac and pericardial calcifications on chest radiographs. (2010) Clinical radiology. 65 (9): 685-94. doi:10.1016/j.crad.2009.12.016 - Pubmed