External Compression of Epicardial Coronary Arteries with Partial Calcific Pericarditis

Abstract

Calcific pericarditis (CP) is a rare disease which results from long-standing pericardial inflammation. Pericardial calcification may completely or partially encase the ventricles, resulting in impaired diastolic filling. We present a case of a 53-year-old male who was incidentally found to have annular CP resulting in external compression of a large territory diagonal branch (D1) reaching the apex with likely chronically occluded left anterior descending artery with collateral circulation from the right coronary artery with hemodynamic compromise on coronary angiography. This was emergently treated with a drug-eluting stent with improved D1 flow and entailed the importance of percutaneous coronary intervention as a viable option in cases of CP resulting in acute hemodynamic compromise.

Keywords: Acute coronary syndrome; calcific pericarditis; percutaneous coronary intervention.

Figure 1

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

Figure 2

Presenting echocardiogram showing pericardial calcification. (a) Apical four chamber and parasternal short axis. (b) Views showing pericardial thickening (shown by arrows)

Figure 3

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 × 28 mm drug-eluting stent in D1 branch. (f) Postpercutaneous coronary intervention results with improvement in D1 flow [Supplemental Video 3]

Figure 4

Reconstructed computed tomography scan image showing the calcific ring (a) and the distal first diagonal artery stent (arrow) crossing underneath the calcific band (b)

Figure 5

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