PMC5448248_01
Presenting chest radiograph showing cardiomediastinal silhouette enlargement with mild congestion and pleural opacity on the right chest wall. Annular calcific pericardial ring later seen on echocardiogram, coronary angiography, and computed tomography scan is not well visualized
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F1
Chest radiograph showed cardiomediastinal silhouette enlargement with mild congestion and pleural opacity on the right chest wall [Figure 1]. Coronary angiography revealed subtotal occlusion of mid-left anterior descending (LAD), first diagonal, and obtuse marginal arteries secondary to external compression by a calcific band, which was also confirmed on intravascular ultrasound [Figure 3a-c and Supplemental Video 1].
Presenting echocardiogram showing pericardial calcification. (a) Apical four chamber and parasternal short axis. (b) Views showing pericardial thickening (shown by arrows)
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F2
Echocardiogram revealed moderately depressed left ventricular ejection fraction with anterior wall hypokinesis and pericardial thickening [Figure 2]. The right coronary artery had mild luminal irregularities giving of collaterals to distal LAD [Figure 3d and Supplemental Video 2].
Coronary angiography and intravascular ultrasound imaging at baseline and postangioplasty. (a) Initial angiography showing subtotal occlusion of mid-left anterior descending artery, distal first diagonal (D1), and obtuse marginal branches secondary to external compression by calcific band (shown by arrows) [Supplemental Video 1]. (b) Calcific band seen on fluoroscopy across anterior atrioventricular groove. (c) Intravascular ultrasound showing the intravascular ultrasound catheter hugging the D1 lumen with external compression by calcific ring seen as layers of extravascular calcium and resulting shadowing artifact (*). (d) Collaterals seen from the right coronary artery to distal left anterior descending with late filling of distal left anterior descending (shown by arrows) [Supplemental Video 2]. (e) Successful deployment of a 2.5 mm x 28 mm drug-eluting stent in D1 branch. (f) Postpercutaneous coronary intervention results with improvement in D1 flow [Supplemental Video 3]
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F3
Coronary angiography revealed subtotal occlusion of mid-left anterior descending (LAD), first diagonal, and obtuse marginal arteries secondary to external compression by a calcific band, which was also confirmed on intravascular ultrasound [Figure 3a-c and Supplemental Video 1]. The right coronary artery had mild luminal irregularities giving of collaterals to distal LAD [Figure 3d and Supplemental Video 2]. Intra-aortic balloon pump (IABP) was placed for hemodynamic support with successful placement of a drug-eluting stent to improve flow in the first diagonal branch which was thought to be the culprit vessel considering the presence of collaterals to distal LAD from the right coronary artery [Figure 3e-f and Supplemental Video 3].
Reconstructed computed tomography scan image showing the calcific ring (a) and the distal first diagonal artery stent (arrow) crossing underneath the calcific band (b)
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F4
Findings of localized CP were later confirmed by computed tomography sca [Figure 4a and b] with hemodynamic improvement.
Autopsy gross specimens of lungs and heart. (a) Lung gross specimen showing pulmonary thromboemboli with massive right pulmonary hemorrhagic infarct and pleural hemorrhage which was thought to be the cause of death. (b) Dissected specimen of left anterior groove with patent and intact recently placed first diagonal artery stent (arrow). (c) Gross specimen of heart with hypertrophied left ventricle and fibrocalcific constrictive annular band in atrioventricular groove (arrow) with dense fibrosis and calcification
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F5
Autopsy was performed which revealed cause of death to be massive right pulmonary hemorrhagic infarct [Figure 5a]. Severe calcific, complex atherosclerosis of proximal to mid-left anterior and proximal to mid-left circumflex arteries was seen with a patent and intact recently placed mid-LAD artery stent [Figure 5b]. Fibrocalcific constrictive pericarditis with a constrictive annular band in atrioventricular groove was noted with dense fibrosis and calcification [Figure 5c], but no ongoing inflammation and no explanation for the healed pericarditis on microscopy.