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An elderly patient with significant aortic regurgitation presented with heart failure. Dilation of the aortic root precluded a transcatheter anatomic site valve implantation, and prohibitive operative risk ruled against surgical implantation. A bail-out transcatheter implantation of the aortic valve in the descending aorta was successfully carried out with satisfactory outcomes.

Background Constrictive pericarditis (CP), also known as Pick’s disease, is a sequela of chronic inflammation of the pericardium. Pericardial calcification is a common occurrence in CP; however, extensive egg-shell like calcification is rare. Our case, highlights, how a multi-modality imaging in a middle aged female helped to diagnose chronic constrictive pericarditis (CCP) with egg-shell like calcification encasing the heart. Case summary Middle aged female with features of right heart failure, was diagnosed as CP based on two-dimensional echocardiography and cardiac catheterization. Computed tomography (CT) scan chest showed extensive egg-shell like calcification encasing the heart, suggestive of calcific CP. Subsequently, she underwent pericardiectomy, through median sternotomy approach and is currently on follow-up with asymptomatic cardiac status. Discussion Extensive pericardial calcification encasing the heart like an egg-shell is rare in CCP. Likelihood of incomplete pericardial resection is high in calcific CP and hence a median sternotomy is preferred over anterolateral thoracotomy. A preoperative non-contrast CT scan defines the thickness, anatomic extent the calcification and its adherence to myocardium and surrounding structures. A reconstructed volume-rendered image delineates the extent of calcification precisely, thus determining the optimum surgical approach. A multi-modality imaging in CP, especially in calcific CP, is thus of paramount importance.