Pericardial calcification

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Pericardial calcification is usually seen in individual patients with a history of pericarditis and may be associated with constrictive pericarditis. 

Pathology

Although historically infective pericarditis was the most common cause, a wide variety of insults can lead to calcification of the pericardium. 

Radiographic features

Pericardial calcification is more common over the right side, anterior and diaphragmatic aspects of the heart in the atrioventricular grooves 72. 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.

Plain radiograph
  • 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 72.

Treatment and prognosis

Medical management is ineffectivePatients with pericardial calcification may be asymptomatic. If present, and surgical resectionsymptoms are usually those of heart failure caused by the pericardial calcification restricting the ability of the diseased pericardiumheart to distend with blood in diastole. In some patients this can be controlled medically, but if the calcification is usually performedestablished this is often ineffective. Pericardiectomy, although not without risk, is potentially curative 3.

Differential diagnosis

The differential diagnosis for pericardial calcifications include:

  • -<a href="/articles/pericarditis">pericarditis</a>: tuberculous, fungal, viral or pyogenic</li>
  • +<a href="/articles/pericarditis">pericarditis</a>: <a title="Tuberculous pericarditis" href="/articles/tuberculous-pericarditis">tuberculous</a>, fungal, viral or <a title="Purulent pericarditis" href="/articles/purulent-pericarditis-1">pyogenic</a>
  • +</li>
  • -<li>post-radiotherapy<sup> 5</sup>
  • +<li>post-radiotherapy<sup> 1</sup>
  • -<li>calcified pericardial masse or cyst</li>
  • -</ul><h4>Radiographic features</h4><p>Pericardial calcification is more common over the right side, anterior and diaphragmatic aspects of the heart in the atrioventricular grooves <sup>7</sup>. Calcifications over the left ventricle or cardiac apex are rare, unless pericardial calcification is extensive. It is important to assess for signs of associated <a href="/articles/constrictive-pericarditis">constrictive pericarditis</a>.</p><h5>Plain radiograph</h5><ul>
  • +<li>calcified pericardial mass or cyst</li>
  • +</ul><h4>Radiographic features</h4><p>Pericardial calcification is more common over the right side, anterior and diaphragmatic aspects of the heart in the atrioventricular grooves <sup>2</sup>. Calcifications over the left ventricle or cardiac apex are rare, unless pericardial calcification is extensive. It is important to assess for signs of associated <a href="/articles/constrictive-pericarditis">constrictive pericarditis</a>.</p><h5>Plain radiograph</h5><ul>
  • -</ul><p>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 <sup>7</sup>.</p><h4>Treatment and prognosis</h4><p>Medical management is ineffective, and surgical resection of the diseased pericardium is usually performed.</p><h4>Differential diagnosis</h4><p>The differential diagnosis for pericardial calcifications include:</p><ul>
  • +</ul><p>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 <sup>2</sup>.</p><h4>Treatment and prognosis</h4><p>Patients with pericardial calcification may be asymptomatic. If present, symptoms are usually those of <a title="Heart failure" href="/articles/congestive-cardiac-failure">heart failure</a> caused by the pericardial calcification <a title="Constrictive pericarditis" href="/articles/constrictive-pericarditis">restricting</a> the ability of the heart to distend with blood in diastole. In some patients this can be controlled medically, but if the calcification is established this is often ineffective. Pericardiectomy, although not without risk, is potentially curative <sup>3</sup>.</p><h4>Differential diagnosis</h4><p>The differential diagnosis for pericardial calcifications include:</p><ul>
  • -<a href="/articles/chronic-adhesive-pericarditis">chronic adhesive pericarditis</a> in the absence of constriction: less dense with a more patchy distribution <sup>1</sup>
  • +<a href="/articles/chronic-adhesive-pericarditis">chronic adhesive pericarditis</a> in the absence of constriction: less dense with a more patchy distribution <sup>4</sup>
  • -<a href="/articles/rheumatic-pericarditis">rheumatic pericarditis</a> <sup>2</sup>
  • +<a href="/articles/rheumatic-pericarditis">rheumatic pericarditis</a> <sup>5</sup>
  • -<a href="/articles/myocardial-calcification">myocardial calcification</a>: more left-sided and localized calcification (e.g. over the cardiac apex from prior <a href="/articles/myocardial-infarction">infarction</a>) <sup>3,6</sup>
  • +<a href="/articles/myocardial-calcification">myocardial calcification</a>: more left-sided and localized calcification (e.g. over the cardiac apex from prior <a href="/articles/myocardial-infarction">infarction</a>) <sup>6,7</sup>

References changed:

  • 1. Paniagua González M & Sánchez Alegre M. Extensive Pericardial Calcification Secondary to Radiotherapy, Causing Mixed Constrictive-Restrictive Pathology. BJR Case Rep. 2017;3(4):20170036. <a href="https://doi.org/10.1259/bjrcr.20170036">doi:10.1259/bjrcr.20170036</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/30363214">Pubmed</a>
  • 2. Ferguson E & Berkowitz E. Cardiac and Pericardial Calcifications on Chest Radiographs. Clin Radiol. 2010;65(9):685-94. <a href="https://doi.org/10.1016/j.crad.2009.12.016">doi:10.1016/j.crad.2009.12.016</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/20696295">Pubmed</a>
  • 3. Khalid N, Hussain K, Shlofmitz E. Pericardial Calcification. 2022. - <a href="https://www.ncbi.nlm.nih.gov/pubmed/30855926">Pubmed</a>
  • 4. Valentin Fuster, Richard Walsh, Robert Harrington. Hurst's the Heart, 13th Edition: Two Volume Set. (2010) ISBN: 9780071636469 - <a href="http://books.google.com/books?vid=ISBN9780071636469">Google Books</a>
  • 5. Dan Longo, Anthony Fauci, Dennis Kasper et al. Harrison's Principles of Internal Medicine, 18th Edition. (2011) ISBN: 9780071748896 - <a href="http://books.google.com/books?vid=ISBN9780071748896">Google Books</a>
  • 6. MacGregor J, Chen J, Chiles C, Kier R, Godwin J, Ravin C. The Radiographic Distinction Between Pericardial and Myocardial Calcifications. AJR Am J Roentgenol. 1987;148(4):675-7. <a href="https://doi.org/10.2214/ajr.148.4.675">doi:10.2214/ajr.148.4.675</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/3493647">Pubmed</a>
  • 7. Stuart J. Hutchison. Principles of Cardiovascular Radiology. (2011) ISBN: 9781437704051 - <a href="http://books.google.com/books?vid=ISBN9781437704051">Google Books</a>
  • 1. Fuster V. Hurst's the Heart. McGraw-Hill Professional Pub. (2010) ISBN:0071636463. <a href="http://books.google.com/books?vid=ISBN0071636463">Read it at Google Books</a> - <a href="http://www.amazon.com/gp/product/0071636463?ie=UTF8&tag=radiopaediaor-20&linkCode=as2&camp=1789&creative=9325&creativeASIN=0071636463">Find it at Amazon</a><div class="ref_v2"></div>
  • 2. Dan Longo, Anthony Fauci, Dennis Kasper et-al. Harrison’s Principles of Internal Medicine, 18E. McGraw-Hill Prof Med/Tech. (2012) ISBN:007174889X. <a href="http://books.google.com/books?vid=ISBN007174889X">Read it at Google Books</a> - <a href="http://www.amazon.com/gp/product/007174889X?ie=UTF8&tag=radiopaediaor-20&linkCode=as2&camp=1789&creative=9325&creativeASIN=007174889X">Find it at Amazon</a><div class="ref_v2"></div>
  • 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. <a href="http://www.ajronline.org/content/148/4/675.abstract">AJR Am J Roentgenol (abstract)</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/3493647">Pubmed citation</a><div class="ref_v2"></div>
  • 4. Wang ZJ, Reddy GP, Gotway MB et-al. CT and MR imaging of pericardial disease. Radiographics. 2003;23 Spec No : S167-80. <a href="http://dx.doi.org/10.1148/rg.23si035504">doi:10.1148/rg.23si035504</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/14557510">Pubmed citation</a><div class="ref_v2"></div>
  • 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. <a href="https://doi.org/10.1259/bjrcr.20170036">doi:10.1259/bjrcr.20170036</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/30363214">Pubmed</a> <span class="ref_v4"></span>
  • 6. Stuart J. Hutchison. Principles of Cardiovascular Radiology. (2011) <a href="https://books.google.co.uk/books?vid=ISBN9781437704051">ISBN: 9781437704051</a><span class="ref_v4"></span>
  • 7. Ferguson EC, Berkowitz EA. Cardiac and pericardial calcifications on chest radiographs. (2010) Clinical radiology. 65 (9): 685-94. <a href="https://doi.org/10.1016/j.crad.2009.12.016">doi:10.1016/j.crad.2009.12.016</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/20696295">Pubmed</a> <span class="ref_v4"></span>

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