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Images In Medicine
doi: 10.4103/0970-258X.253170
PMID: 30829236

The heart in an eggshell

Arun Gopalakrishnan, Krishna Kumar Mohanan Nair, Narayanan Namboodiri, Ajitkumar Valaparambil
 Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India

Corresponding Author:
Narayanan Namboodiri
Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala
How to cite this article:
Gopalakrishnan A, Mohanan Nair KK, Namboodiri N, Valaparambil A. The heart in an eggshell. Natl Med J India 2018;31:123
Copyright: (C)2018 The National Medical Journal of India

A 41-year-old woman presented with recent onset of abdominal distension and swelling of feet along with New York Heart Association Class III dyspnoea on exertion. Her blood pressure was 100/60 mmHg. The jugular venous waveforms were elevated till the angle of her jaw. The x-descent was conspicuous and the y-descent was visible. The precordium showed mild lateral systolic retraction. There was no pulmonary hypertension. ECG showed 1 mm ST depression and T inversion in inferolateral leads and no pathological Q waves. Chest X-ray revealed a radiopaque shadow around the heart [Figure - 1]a. A plain CT scan of the chest showed the heart almost completely encased in a calcific shell [Figure - 1]b. There was no history of tuberculosis. A diagnosis of calcific constrictive pericarditis was confirmed.[1] The coronary arteries were normal on angiography. A fluoroscopic projection at the time of coronary angiography before pericardiectomy revealed a characteristic black-egg sign (video available at The patient underwent surgical pericardiectomy with relief of symptoms and is doing well on follow-up. The use of plain anteroposterior fluoroscopic projection potentially permits a diagnosis of calcific constrictive pericarditis during coronary angiography without the need for a CT scan.

Figure 1: (a) Chest X-ray in posteroanterior projection showing a radiopaque shadow around the heart. Mild pulmonary venous congestion is evident. Distended superior vena cava is also seen, (b) Plain CT scan shows the heart almost fully encased in a calcific shell. Video (available at Fluoroscopic projection in anteroposterior view showing a dark shadow encasing the heart (black-egg sign)

Conflicts of interest. None declared

Kameda Y, Funabashi N, Kawakubo M, Uehara M, Hasegawa H, Kobayashi Y, et al. Heart in an eggshell: Eggshell appearance calcified constrictive pericarditis demonstrated by three-dimensional images of multislice computed tomography. Int J Cardiol 2007;120:269-72.
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