1. İhsan Alur 1, İbrahim Gökşin 1, Bekir Serhat Yıldız 2, Gökhan Yiğit Tanrısever 1, Tevfik Güneş 1 1 Department of Cardiovascular Surgery, Pamukkale University, Denizli, Turkey 2 Department of Cardiology, Pamukkale University, Denizli, Turkey

2. Case  A 57-year-old male patient presented with the complaints of sweating and respiratory distress on effort  Anamnesis included hospitalization in the cardiology clinics with the diagnosis of supraventricular tachycardia (SVT) attack.

3. Case  ECG: AF and  NYHA was functional class 3 heart failure  Echocardiographical findings were mild mitral regurgitation (MR), left ventricular ejection fraction (EF) 50- 55%.  Diffuse pericardial calcification was observed in the telecardiography (Fig. 1A,1B).

4. Case Figure 1A,1B. Diffuse pericardial calcification in the telecardiography, anteroposterior (A) and lateral (B) views.

5. Case  CAG: revealed complete obstruction at the origin of the circumflex (Cx) coronary artery (100%), a lesion causing 70% stenosis in the proximal part of the left anterior descending (LAD) coronary artery and significant diffuse pericardial calcification (Fig. 2A,2B).

6. Case Figure 2A,2B. Significant diffuse pericardial calcification on the coronary angiography

7. Case  Coronary artery bypass grafting and pericardiectomy were planned for the patient.  Median sternotomy was performed. The pericardium was observed to be calcified, highly cohesive, completely ossified and to have invaded into the myocardial tissue (Fig. 3A,3B).

8. Case Figure 3. A view of the calcification in the operation

9. Case  The calcified pericardium were respectively resected from the ascending aorta, anterior face of the left ventricule, pulmonary artery and right ventricles.  Aorta-LAD distal anastomosis was performed with the saphenous graft.

10. Case  Cx coronary artery anastomosis could not be performed, since the heart could not be elevated due to the pericardial cohesiveness covering the lateral wall of the left ventricle, and the posterior wall of the heart could not be accessed.  Approximately 8-10 mm size of the pericardium was sent for histopathological examination. The surgical specimen was examined and reported as a calcific constrictive pericarditis.

11. Discussion  Pericardium is a serous membrane with a thickness of less than 2 mm under normal conditions.  If it has a thickness of more than 4 mm, the ‘’pericardial constriction’’ term is suggested (1).  (1). Talreja DR, Edwards WD, Danielson GK, Schaff HV, Tajik AJ, Tazelaar HD, et al. Constrictive pericarditis in 26 patients with histologically normal pericardial thickness. Circulation. 2003;108(15):1852-7. (1). Talreja DREdwards WDDanielson GKSchaff HVTajik AJTazelaar HDCirculation.

12. Discussion  Because of both ventricular limitation in CP, biventricular end-diastolic pressure is increased, and ejection volumes of both ventricles are decreased (2).  Furthermore, thickened and calcified pericardium is often in direct contact with the myocardium, reducing the contractility of the cardiac muscle and impairing the diastolic input synchronization and coordination of the ventricles (2).  (2). Yetkin U, Kestelli M, Yilik L, Ergunes K, Kanlioglu N, Emrecan B, et al. Recent surgical experience in chronic constrictive pericarditis. Tex Heart Inst J. 2003;30(1):27-30. Yetkin UKestelli MYilik LErgunes KKanlioglu N Emrecan BTex Heart Inst J.

13. Discussion  The definitive treatment of calcified CP is pericardiectomy. The reported methods for pericardiectomy in the literature are micropneumatic saw (3), Waffle procedure (4) and direct pericardial resection.  (3). Casha A, Chandrasekaran V.Pericardiectomy using an oscillating saw. Ann Thorac Surg. 2000;69(2):613-4.  (4). Shiraishi M, Yamaguchi A, Muramatsu K, Kimura N, Yuri K, Matsumoto H, et al. Validation of Waffle procedure for constrictive pericarditis with epicardial thickening. Gen Thorac Cardiovasc Surg. 2015;63(1):30-7. (4). Shiraishi MYamaguchi AMuramatsu KKimura NYuri KMatsumoto HGen Thorac Cardiovasc Surg.

14. Discussion  The ideal resection is to completely remove the site of the parietal pericardium between the right and left phrenic nerves.  Due to coronary artery disease we performed CABG and partial pericardial resection accompanying CPB in our case.

15. Discussion  Pericardiectomy may have some complications.  These include myocardial or coronary artery injury and related bleeding, atrial/ventricular injury, tamponade, arrhythmia, low cardiac output syndrome, acute renal insufficiency and acute respiratory distress syndrome (2).  (2). Yetkin U, Kestelli M, Yilik L, Ergunes K, Kanlioglu N, Emrecan B, et al. Recent surgical experience in chronic constrictive pericarditis. Tex Heart Inst J. 2003;30(1):27-30.Yetkin UKestelli MYilik LErgunes KKanlioglu N Emrecan BTex Heart Inst J.

16. Conclusion  In conclusion, although the surgery of Concretio cordis is difficult, the patient benefits considerably from the operation.  Pericardiectomy may contribute to these patients symptomatology.