Cardiac and Vascular Calcification




Key Points




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    Calcification may occur within numerous structures within the heart and also within the great blood vessels.


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    Greater penetration and optimal “windowing” favor depiction of the calcification. Often the lateral radiograph favors depiction of calcification by avoiding superimposition of the heart onto the spine.


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    The significance of the presence of calcification depends widely depending on the location and cause, as well as other factors. For example, pericardial calcification may or may not be associated with constrictive physiology, whereas myocardial calcification is synonymous with myocardial dysfunction.





Technical Issues


Cardiac and vascular calcifications are always signs of disease and are therefore noteworthy.


Cardiac and vascular calcification is often better appreciated with an overexposed radiograph and is best appreciated when seen on a tangential plane, thus rendering the calcification very dense and therefore visually more obvious. When seen en-face, a layer of calcification is visible at its thinnest and is therefore least apparent. Superimposition of other shadows (the heart itself, or in particular, the spine) often, if not usually, obscures calcification that would be apparent if projected free of other structures. Areas to scrutinize are those with greater likelihood to calcify (the aortic and mitral valves and annuli, the left ventricular walls, the diaphragmatic pericardial surface, and atrioventricular grooves), and those areas where calcification is most readily appreciated.




Sites of Cardiac Calcification


Pericardial Calcification


Pericardial calcification ( Figs. 27-1 to 27-4 ) is most prominent in the interventricular and atrioventricular grooves, and lateral to the right atrial and ventricular walls ( Graphic 27-1 ). When looking for pericardial calcification, it is necessary to scrutinize the lateral chest radiograph well, particularly the diaphragmatic surface. Pericardial calcification does not usually involve the left heart as much the right heart, and it does not often involve the apex (which, if calcified, is far more often due to prior infarction). Pericardial calcification should prompt serious consideration of the diagnosis of constrictive pericarditis, and clinicians should seek other radiographic and clinical features of constriction.




Figure 27-1


Posteroanterior (PA) and lateral chest radiographs of a patient with a bileaflet mechanical aortic valve prosthesis and a single tilting disc mitral prosthesis of the Medtronic-Hall type. There is marked cardiomegaly in particular with massive enlargement of the left atrium, right atrium, and right ventricle. Somewhat visible on the PA radiograph, but much more visible on the lateral chest radiograph, is a peel of pericardial calcification best seen tangentially along the diaphragmatic surface of the heart. The patient was subsequently proven at surgery to have pericardial constriction as a result of having multiple previous valvular surgeries. As well, there is right pleural calcification.



Figure 27-2


Pericardial calcification without constriction. The frontal radiograph is largely unremarkable, but the lateral radiograph reveals a surprising amount of pericardial calcification. The patient, despite having this degree of pericardial calcification, did not have constrictive physiology.



Figure 27-3


Residual calcification postpericardiectomy. This patient had undergone pericardial resection years before and presented with recurrent findings. There was prominent pericardial calcification, particularly under the heart, where pericardiectomy is often incomplete.



Figure 27-4


Chest radiographs, non–contrast-enhanced axial computed tomography (CT) images, and steady-state free precession cardiac magnetic resonance (CMR) images of a patient with an aortic bileaflet occluder prosthesis and a Medtronic-Hall mitral prosthesis. There are multiple signs of left atrial dilation: a bump at the left upper heart border from left atrial appendage dilation, gross splaying of the carina, a displaced right heart border, and narrowing of the main bronchi. Apparent on the lateral radiograph and non–contrast-enhanced CT scan images is pericardial calcification, a result presumed to be from three prior cardiac surgeries. The calcification is low signal and virtually inapparent on CMR imaging.



Graphic 27-1


Lateral chest projection: pericardial calcification. Note the extensive plaquelike calcification, depicted principally in the atrioventricular grooves.


Myocardial Calcification ( Figs. 27-5 to 27-9 )


A calcified ventricular aneurysm is seen as a fine dense line when viewed on edge and is consistent with an old transmural infarction. On the frontal chest radiograph, an anterolateral, or apical, calcified aneurysm may be visible. Rarely, a calcified septal aneurysm may be seen on a lateral chest radiograph. Myocardium may calcify following traumatic injury as well as postinfarction.




Figure 27-5


Dual chamber pacer leads, cardiomegaly, and a bulging and calcified left heart border due to a calcified chronic left ventricular aneurysm. As are often associated with left ventricular aneurysms, there are signs of heart failure.



Figure 27-6


A calcified postinfarction left ventricular aneurysm. The cardiothoracic ratio is increased and there is pulmonary vascular congestion with indistinct hila and peribronchial cuffing. On both the frontal and lateral radiographs, a mostly fine thin “shell” of calcification is visible—a calcified left ventricular apical aneurysm. The left upper heart border is straightened by left atrial appendage enlargement, consistent with the pulmonary venous congestion from the left ventricular failure.



Figure 27-7


Chest radiographs and corresponding non–contrast-enhanced computed tomography (CT) scan images. There is moderate cardiomegaly and a very prominent shell of calcification of an aneurysm of the left ventricle over its anterior and lateral walls. The calcification is faintly and elegantly seen on the chest radiographs and rather heavily and coarsely seen on the non–contrast-enhanced CT scan images due to partial volume averaging CT artifact.



Figure 27-8


There is a right-sided dual chamber pacemaker, and endotracheal tube lying low at the carinal level, with electrocardiogram electrodes over the heart. There is moderate cardiomegaly and a faintly but definitely visible rounded left ventricular calcified apical aneurysm.



Figure 27-9


The posteroanterior chest radiograph is notable for sternotomy wires and a long length of vascular clips along a mobilized left internal thoracic artery. Only on the lateral chest radiograph is calcification of a left ventricular apical aneurysm apparent; it is seen on the zoomed image ( middle right image ). The computed tomography scans corroborate the calcification of the chronically infarcted myocardium.

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Apr 10, 2019 | Posted by in General Surgery | Comments Off on Cardiac and Vascular Calcification

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