A 70-year-old man with a dense history of chronic illnesses—including paroxysmal atrial fibrillation (AF), combined systolic and diastolic heart failure, cirrhosis, COPD, hypothyroidism, prior alcohol and tobacco use, and a history of pleural effusion—presented to the hospital with two weeks of sharp bilateral back pain, diffuse muscle aches, and four days of worsening breathlessness and palpitations.
In the emergency department, he was found to be in acute hypoxic respiratory failure with an SpO₂ of 83%, improving with BiPAP followed by low-flow oxygen. He was also tachycardic with AF and rapid ventricular response (RVR) at 142 bpm, managed with IV metoprolol. Physical exam revealed coarse lung sounds, tachypnea, irregular pulse, and significant bilateral leg edema. Chest X-ray showed striking new pericardial calcifications, absent in prior imaging.
He was admitted to the ICU for further evaluation. Labs revealed mild hyponatremia, coagulopathy (INR 3.42), and transaminitis, all suggestive of worsening hepatic dysfunction. A CT scan confirmed pericardial calcifications, prompting a cardiology consult. Echocardiography showed an EF of 45%, septal bounce, and diastolic interventricular septal shift—all signs pointing to constrictive physiology. CT thorax confirmed the diagnosis: calcific constrictive pericarditis (CP).
His clinical course was turbulent, marked by fluctuating blood pressures, recurrent AF with RVR, and episodes of altered mentation. These were managed with diuretics, beta-blockers, and lactulose. Yet, he continued to exhibit signs of cardiohepatic syndrome: intractable dyspnea, abdominal distension, and persistent edema. An arterial blood gas one week in showed compensated respiratory acidosis—pH 7.34, pCO₂ 73.2, HCO₃⁻ 40.3—reflecting COPD decompensation.
Despite extensive workup including negative tuberculosis screening, no reversible etiology for CP was identified. Given his advanced age, multiorgan disease, and the high surgical risk of pericardiectomy, the team opted for conservative, palliative-focused management.
• The case illustrates how calcific constrictive pericarditis (CaCP) can exacerbate pre-existing conditions such as heart failure, atrial fibrillation, cirrhosis, and COPD, creating a challenging clinical scenario.
• Early detection of CaCP using chest X-ray, echocardiography, and CT imaging is critical for timely diagnosis, especially when symptoms are nonspecific or overlap with other chronic conditions.
• Although CaCP is rare, it significantly impairs diastolic filling and cardiac output, contributing to systemic effects like cardiohepatic syndrome and worsening respiratory status.
• Optimal care requires coordinated management across cardiology, hepatology, pulmonology, and palliative care, particularly in patients who are not surgical candidates.
• In elderly patients with severe comorbidities, conservative and palliative approaches may be more appropriate than high-risk surgical interventions like pericardiectomy.
Varun Kasula, Vikram Padala, Jagroop Doad, et al. Lessons From a Complex Case of Calcific Constrictive Pericarditis: A Case Report. Case Reports in Cardiology. 2025;2025(1). doi:https://doi.org/10.1155/cric/5514172
