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A 44 year old man presented with shortness of breath, extensive dependent oedema, and upper abdominal discomfort six years following a curative left pneumonectomy for a bronchial carcinoma. Investigations included a chest radiograph (panel A), which showed central mediastinal calcification, a computed tomographic scan which identified an anterior mediastinal mass (panel B) but no evidence of tumour recurrence, and an abdominal ultrasound which demonstrated hepatic engorgement. The patient was therefore admitted for intravenous diuretic treatment and further investigation.
A transthoracic echocardiograph was unhelpful because of poor image quality, but a subsequent transoesophageal echocardiogram demonstrated good left and right ventricular function with no significant valvar heart disease and no significant pericardial abnormalities. Cardiac catheterisation demonstrated equalisation of diastolic pressures in all chambers, consistent with a diagnosis of constrictive pericarditis. Fluoroscopic images showed calcification of an anterior mediastinal structure (panel C). It was felt that the clinical and physiological findings were consistent with extrinsic cardiac compression by this anterior mediastinal mass. The patient was therefore referred for surgery where a large calcified haematoma was identified (panel D) and resected with immediate improvement in his clinical status. The pericardium was found to be normal. The haematoma was probably a consequence of the pneumonectomy six years ago with its subsequent calcification resulting in cardiac compression. We would suggest that in cases suggestive of constrictive pericarditis, external cardiac compression should be considered.