Prepared by Ravi K. Mallavarapu, MD, Resident, and Erskine A. James, MD, FACC, Assistant Professor of Medicine, Departments of Medicine and Cardiology, Mercer University School of Medicine, Macon, Ga
A 78-year-old woman presented to the emergency department with chronic chest discomfort, shortness of breath, and fatigue. Her history included myocardial infarction (MI) 30 years earlier, heart failure, atrial fibrillation, and hypertension. A retired schoolteacher, she grew up in England and had immigrated to the United States more than 20 years ago. She denied any foreign travel since then or exposure to any construction trades, including mining.
Physical examination revealed a diffuse apical impulse, holosystolic murmur radiating to the axilla, and an S3 gallop. Computed tomography (CT; Figure 1) of the chest without contrast and chest radiographs (Figure 2) are shown.
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| Figure 1 |
What’s Your Diagnosis?
- Pericardial calcification
- Calcified left ventricular (LV) aneurysm
- Asbestosis
- Cardiac echinococcosis
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| Figure 2 |
Quiz Answer
Calcified LV aneurysm—Figures 1 and 2 show marked calcification on the LV silhouette diagnostic of a calcified LV aneurysm, which occurs in a small percentage of patients with a large anteroseptal MI. LV aneurysm is a well-defined, thin, scarred or fibrotic wall (devoid of or containing necrotic muscle), resulting from a transmural MI that has healed over time. The calcified scar appears as a fine, curvilinear density, usually appearing on the anterolateral aspect of the heart or in the lower portion of the interventricular septum.
Pericardial calcification is associated with a history of pericarditis, most often related to tuberculosis but can also be linked to other etiologies, such as a viral process. Pericardial calcification can be ruled out in this case, because the calcification pattern seen on the imaging studies does not follow the contour of the pericardium. Unlike the calcification curving posteriorly, below the level of the pulmonary valve seen in Figure 2A, pericardial calcification extends along the pulmonary outflow tract.
Pericardial calcification occurs mostly over the rightsided cardiac chambers, and involvement of the pericardium over the cardiac apex is usually associated with extensive calcification in other parts. Myocardial calcification can be distinguished from pericardial calcification by a thicker, more focal appearance, and by being less in conformance with the outer contour of the heart.
Asbestosis is associated with pleural calcification after chronic asbestos exposure, which was not the case in our patient. Also, the calcification is not pleural.
Cardiac echinococcosis may be an isolated, solitary finding on a chest radiograph and appears as an abnormal cardiac silhouette or a calcified lobular mass adjacent to the LV. Our patient did not travel to areas endemic for echinococcosis—South and Central America, China, the former Soviet Union, and the Middle East.
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| Figure 1—Chest CT showing marked calcification of the LV silhouette (arrow marks the heart border). |
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| Figure 2—Lateral and posterior-anterior chest radiographs showing marked calcification of the LV silhouette. The superior rim of calcification curves posteriorly and medially toward the base of the LV, below the pulmonary valve (Panel A, arrow). The arrows in Panel B mark the heart border. |
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