This is a 16-years old boy who presented with a restrictive physiology for the last eight years. Imaging earlier had been inconclusive. The cardiac MRI (Fig. 1) shows an indentation just distal to the AV groove, adjacent to the lateral wall of the LV. The real-time MRI (cine file) shows leftward deviation of the septum in early inspiration, suggesting pericardial pathology. Note the accompanying article by Francone et al in the "Literature" blog and an accompanying case from 3 days ago. However, the pericardial thickening was not well seen.
A plain CT scan was then performed. Thin MIPs in the 4C, 2C and SA views (Figs. 2-4) show a band of calcification in the pericardium, encircling the heart, 2cms. distal the AV groove. This was the cause of the constrictive pericarditis. At surgery, most of the calcification was removable and the patient's physiology improved virtually immediately.
Calcific constrictive pericarditis is often not well appreciated on MRI. Though CMR should be the first modality to be used in patients with restrictive physiology (also to differentiate an infiltrative cardiomyopathy), if the MRI suggests a pericardial pathology, which is not well appreciated on the anatomy images, it would be a good idea to perform a plain CT scan to look for pericardial calcification.
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