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A 68 year old man was admitted to the emergency room with recurrent syncopal attacks and clinical signs for a distinct right heart insufficiency. Clinical history was marked by a mild hepatopathy after hepatitis B and recurrent pleuritis treated by talc pleurodesis. No bacterial infection or systemic inflammation was detected. After the exclusion of neurological pathologies cardiac examination showed normocardiac atrial fibrillation and a left anterior hemi-block. Due to massive pericardial calcifications transthoracic echocardiography revealed only low quality images and was not conclusive. Left heart catheterisation confirmed a normal sized left ventricle showing the classical plateau phenomenon with equalisation of end diastolic pressure (panel A).
Chest x ray showed an increased heart size with impressive pericardial calcifications. We also found pleural densities in the right lower lung with mild effusions of the right pleural cavity, calcifications on the left basal area, and a pulmonary-venous congestion (panel B). Coronary angiography depicted three vessel disease with significant stenoses of the left anterior descending artery (LAD), circumflex artery (CX), and right coronary artery (RCA). Intraoperative exploration confirmed extensive pericardial calcifications. Because of the 2 cm thick calcified layer the pericardium could only be opened by an oscillating saw and surgical removal of the calcifications was extremely difficult. Concerning the increased cardiac stiffness, luxation for a postero-basal bypass to the CX proved to be too dangerous and only bypasses to the LAD and RCA were performed. Clinical follow up was uneventful with restored cardiac function and rapid improvement of right ventricular function. The origin of these impressive pericardial calcifications remains unclear.