Images in cardiovascular medicine. Pericardial hematoma after primary angioplasty complicated by coronary rupture

Spontaneous pericardial hematoma with familial amyloid polyneuropathy

There are more than a few risks of hemorrhage complication in patients with amyloidosis. Although most cases with amyloidosis exhibit minor bleeding manifestations, they can be occasionally associated with life-threatening problems. To our knowledge, there are only a few cases of spontaneous pericardial hematoma associated with amyloidosis. We here report a patient who suddenly died of cardiac tamponade with massive pericardial hematoma 7 years after the diagnosis of familial amyloid polyneuropathy (FAP). A 69-year-old female with FAP with cardiogenic shock was admitted to our emergency room. Although she previously underwent permanent pacemaker implantation for atrial fibrillation with slow ventricular response, electrocardiogram showed a critical pacing failure. Emergent telemetry check revealed a sudden extreme increase of pacing capture threshold in the right ventricle. Maximum pacing voltage could not improve the critical condition, and she died 7 h after arrival. Autopsy showed a massive pericardial hematoma in the right ventricular free wall, and microscopic examination revealed typical amyloid deposition in the arterial wall of the pericardium. In this case, it is assumed that a sudden rupture of fragile pericardial vessels with amyloid deposition led to the lethal pericardial hematoma.

Increased arterial calcification in Paget's disease of bone

When examining radiographs of patients with Paget's disease of bone (PD), we often observed calcification of the aorta and iliac or femoral arteries. The processes of extraosseous calcification or mineralization are very close to the mechanisms regulating mineralization of bone tissue. The aim of our study was to quantify the number, extent (length and thickness), and type (arteriosclerotic or medial arterial calcification) of vascular calcification in patients with Paget's disease and to compare them with those of controls, in order to discover whether PD is accompanied by increased calcification. Vascular calcification was quantified on the aorta, the iliac arteries, and their branches, the femoral, gluteal, and pelvic arteries of 42 patients with Paget's disease and 36 control subjects. Of the PD subjects, 52.4% had arteriosclerotic calcification versus 30.6% of controls (P = 0.05), and 38.6% of PD patients had medial arterial calcification versus 11.1% of controls (P = 0.05). The mean length of calcification was greater in PD patients: 1.93 +/- 2.85 cm versus 0.84 +/- 1.69 cm in controls (P = 0.04). The thickness of calcification was also greater in PD patients: 1.24 +/- 1.30 mm versus 0.56 +/- 0.94 mm (P = 0.01). Patients with Paget's disease more frequently had medial arterial or arteriosclerotic calcification than controls. These calcifications were longer and thicker. Our clinical study therefore confirms that abnormal vessel wall calcification and bone remodeling in Paget's disease are probably linked, although the mechanism of this relation is as yet unexplained.

Magnetic resonance evaluation of the pericardium

Magnetic resonance (MR) is well suited to imaging the pericardium. High resolution images synchronized with the cardiac cycle can be obtained in any plane. The wide field of view allows additional anatomical and functional information to be obtained from adjacent structures such as the aorta, pleura, lungs and mediastinum. MR is particularly useful in cases of pericardial constriction without an associated effusion, in patients with complex or loculated pericardial effusions and in pericardial tumours. In this article we illustrate the characteristic MR features of a variety of pericardial pathologies.

Vascular calcification

Vascular calcification is an active and modifiable process involved in many disease entities, including atherosclerosis, cardiac valve disease and calcific uremic arteriolopathy. It occurs with distinct characteristics at different sites in the vessel wall. The mechanism by which calcification is induced remains uncertain; the roles of bone matrix and extracellular matrix proteins, estrogen and vitamin D are being further defined in animal models and clinical trials. Some risk factors for calcific uremic arteriolopathy and cardiac valve calcification, both disproportionately affecting chronic hemodialysis patients, have been identified in observational studies.