690
19. Schmermund A, Mo¨hlenkamp S, Berenbein S, Pump H, Moebus S, Roggenbuck U et al. Population-based assessment of subclinical coronary atherosclerosis using electron-beam computed tomography. Atherosclerosis 2006;185:177 –82. 20. Ka¨lsch H, Lehmann N, Mo¨hlenkamp S, Hammer C, Mahabadi AA, Moebus S et al. Prevalence of thoracic aortic calcification and its relationship to cardiovascular risk factors and coronary calcification in an unselected population-based cohort: the Heinz Nixdorf Recall Study. Int J Cardiovasc Imaging 2013;29:207 –16. 21. Elias-Smale SE, Odink AE, Wieberdink RG, Hofman A, Hunink MG, Krestin GP et al. Carotid, aortic arch and coronary calcification are related to history of stroke: the Rotterdam study. Atherosclerosis 2010;212:656 –60. 22. Takasu J, Budoff MJ, O’Brien KD, Shavelle DM, Probstfield JL, Carr JJ et al. Relationship between coronary artery and descending thoracic aortic calcification as detected by computed tomography: the Multi-Ethnic Study of Atherosclerosis. Atherosclerosis 2009;204:440 –6. 23. McDonald DA. The velocity of blood flow in the rabbit aorta studied with high-speed cinematography. J Physiol 1952;118:328–39. 24. Harloff A, Simon J, Brendecke S, Assefa D, Helbing T, Frydrychowicz A et al. Complex plaques in the proximal descending aorta: an underestimated embolic source of stroke. Stroke 2010;41:1145 –50. 25. Gronewold J, Hermann DM, Lehmann N, Kro¨ger K, Lauterbach K, Berger K et al. Ankle-brachial index predicts stroke in the general population in addition to classical risk factors. Atherosclerosis 2014;233:545 –50.
IMAGE FOCUS
doi:10.1093/ehjci/jev026 Online publish-ahead-of-print 6 March 2015
.............................................................................................................................................................................
Extensive myocardial calcification after acute myocarditis Felipe Dı´ez-delhoyo1*, Eduardo Zatarain-Nicola´s1, Esther Pe´rez-David1, Maria Luisa Sa´nchez-Alegre2, and Francisco Ferna´ndez-Avile´s2 1 Department of Cardiology, Hospital General Universitario Gregorio Maran˜o´n, Instituto de Investigacio´n Sanitaria del Hospital Gregorio Maran˜o´n, Complutense University, School of Medicine, C/Dr. Esquerdo 46, Madrid 28007, Spain and 2Department of Radiology, Hospital General Universitario Gregorio Maran˜o´n, Instituto de Investigacio´n Sanitaria del Hospital Gregorio Maran˜o´n, Madrid, Spain
* Corresponding author. Tel: +34 91 426 5882; Fax: +34 91 586 8276, E-mail: [email protected]
A 32-year-old male was admitted into the hospital due to acute heart failure. He had a recently diagnosed HIV infection with high viral load, primary haemophagocytic syndrome under immunosuppressive therapy, and CMV infection. Cardiac biomarkers were increased (high-sensitive T-Troponin 1350ng/L; NTproBNP 21.000 ng/L). The 2D-echocardiogram showed global hypokinaesia and depressed left ventricular ejection fraction (LVEF). A computed tomography (CT) observed normal heart density (Panel A). Cardiac magnetic resonance (CMR) showed mid-wall late gadolinium enhancement (LGE) at the mid-distal interventricular septum (Panels B and C); thus, acute myocarditis was diagnosed. At discharge, full recovery of LVEF was confirmed. Two months later, due to a cryptogenic organizing pneumonia, a new CT demonstrated an extensive myocardial calcification in the middistal septum (Panel D), correlating with the area of LGE in CMR. A new CMR revealed persistence of LGE without myocardial oedema in T2-Stir sequences (Panel E). Transthoracic echocardiogram confirmed the appearance of a septal hyperintensity in the mentioned location (Panel F) and normal LVEF. Patient’s follow-up 1 year later has been uneventful, and the cardiac calcification persists. Myocardial calcifications have been related to acute myocarditis in animal models, histological samples, and case reports, though it is infrequent. Viral infections and immunosuppressive status have been proposed as risk factors; nevertheless, history and prognosis are unknown. Progressive resorption of calcium has been described, suggesting that the deposit may be related to myocardial inflammation. Interestingly, calcification has not disappeared during follow-up in our patient despite good clinical course. Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2015. For permissions please email: [email protected].
Downloaded from http://ehjcimaging.oxfordjournals.org/ at United Arab Emirates University on March 21, 2016
12. Di Tullio MR, Sacco RL, Savoia MT, Sciacca RR, Homma S. Aortic atheroma morphology and the risk of ischemic stroke in a multiethnic population. Am Heart J 2000; 139:329–36. 13. Wong ND, Gransar H, Shaw L, Polk D, Moon JH, Miranda-Peats R et al. Thoracic aortic calcium versus coronary artery calcium for the prediction of coronary heart disease and cardiovascular disease events. JACC Cardiovasc Imaging 2009;2:319–26. 14. Budoff MJ, Nasir K, Katz R, Takasu J, Carr JJ, Wong ND et al. Thoracic aortic calcification and coronary heart disease events: the multi-ethnic study of atherosclerosis (MESA). Atherosclerosis 2011;215:196 –202. 15. Ka¨lsch H, Lehmann N, Berg MH, Mahabadi AA, Mergen P, Mo¨hlenkamp S et al. Coronary artery calcification outperforms thoracic aortic calcification for the prediction of myocardial infarction and all-cause mortality: the Heinz Nixdorf Recall study. Eur J Prev Cardiol 2014;21:1163 –70. 16. Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 1993;24:35– 41. 17. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003;289: 2560 –72. 18. Wilson PW, D’Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation 1998;97: 1837 –47.
D.M. Hermann et al.
19. Schmermund A, Mo¨hlenkamp S, Berenbein S, Pump H, Moebus S, Roggenbuck U et al. Population-based assessment of subclinical coronary atherosclerosis using electron-beam computed tomography. Atherosclerosis 2006;185:177 –82. 20. Ka¨lsch H, Lehmann N, Mo¨hlenkamp S, Hammer C, Mahabadi AA, Moebus S et al. Prevalence of thoracic aortic calcification and its relationship to cardiovascular risk factors and coronary calcification in an unselected population-based cohort: the Heinz Nixdorf Recall Study. Int J Cardiovasc Imaging 2013;29:207 –16. 21. Elias-Smale SE, Odink AE, Wieberdink RG, Hofman A, Hunink MG, Krestin GP et al. Carotid, aortic arch and coronary calcification are related to history of stroke: the Rotterdam study. Atherosclerosis 2010;212:656 –60. 22. Takasu J, Budoff MJ, O’Brien KD, Shavelle DM, Probstfield JL, Carr JJ et al. Relationship between coronary artery and descending thoracic aortic calcification as detected by computed tomography: the Multi-Ethnic Study of Atherosclerosis. Atherosclerosis 2009;204:440 –6. 23. McDonald DA. The velocity of blood flow in the rabbit aorta studied with high-speed cinematography. J Physiol 1952;118:328–39. 24. Harloff A, Simon J, Brendecke S, Assefa D, Helbing T, Frydrychowicz A et al. Complex plaques in the proximal descending aorta: an underestimated embolic source of stroke. Stroke 2010;41:1145 –50. 25. Gronewold J, Hermann DM, Lehmann N, Kro¨ger K, Lauterbach K, Berger K et al. Ankle-brachial index predicts stroke in the general population in addition to classical risk factors. Atherosclerosis 2014;233:545 –50.
IMAGE FOCUS
doi:10.1093/ehjci/jev026 Online publish-ahead-of-print 6 March 2015
.............................................................................................................................................................................
Extensive myocardial calcification after acute myocarditis Felipe Dı´ez-delhoyo1*, Eduardo Zatarain-Nicola´s1, Esther Pe´rez-David1, Maria Luisa Sa´nchez-Alegre2, and Francisco Ferna´ndez-Avile´s2 1 Department of Cardiology, Hospital General Universitario Gregorio Maran˜o´n, Instituto de Investigacio´n Sanitaria del Hospital Gregorio Maran˜o´n, Complutense University, School of Medicine, C/Dr. Esquerdo 46, Madrid 28007, Spain and 2Department of Radiology, Hospital General Universitario Gregorio Maran˜o´n, Instituto de Investigacio´n Sanitaria del Hospital Gregorio Maran˜o´n, Madrid, Spain
* Corresponding author. Tel: +34 91 426 5882; Fax: +34 91 586 8276, E-mail: [email protected]
A 32-year-old male was admitted into the hospital due to acute heart failure. He had a recently diagnosed HIV infection with high viral load, primary haemophagocytic syndrome under immunosuppressive therapy, and CMV infection. Cardiac biomarkers were increased (high-sensitive T-Troponin 1350ng/L; NTproBNP 21.000 ng/L). The 2D-echocardiogram showed global hypokinaesia and depressed left ventricular ejection fraction (LVEF). A computed tomography (CT) observed normal heart density (Panel A). Cardiac magnetic resonance (CMR) showed mid-wall late gadolinium enhancement (LGE) at the mid-distal interventricular septum (Panels B and C); thus, acute myocarditis was diagnosed. At discharge, full recovery of LVEF was confirmed. Two months later, due to a cryptogenic organizing pneumonia, a new CT demonstrated an extensive myocardial calcification in the middistal septum (Panel D), correlating with the area of LGE in CMR. A new CMR revealed persistence of LGE without myocardial oedema in T2-Stir sequences (Panel E). Transthoracic echocardiogram confirmed the appearance of a septal hyperintensity in the mentioned location (Panel F) and normal LVEF. Patient’s follow-up 1 year later has been uneventful, and the cardiac calcification persists. Myocardial calcifications have been related to acute myocarditis in animal models, histological samples, and case reports, though it is infrequent. Viral infections and immunosuppressive status have been proposed as risk factors; nevertheless, history and prognosis are unknown. Progressive resorption of calcium has been described, suggesting that the deposit may be related to myocardial inflammation. Interestingly, calcification has not disappeared during follow-up in our patient despite good clinical course. Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2015. For permissions please email: [email protected].
Downloaded from http://ehjcimaging.oxfordjournals.org/ at United Arab Emirates University on March 21, 2016
12. Di Tullio MR, Sacco RL, Savoia MT, Sciacca RR, Homma S. Aortic atheroma morphology and the risk of ischemic stroke in a multiethnic population. Am Heart J 2000; 139:329–36. 13. Wong ND, Gransar H, Shaw L, Polk D, Moon JH, Miranda-Peats R et al. Thoracic aortic calcium versus coronary artery calcium for the prediction of coronary heart disease and cardiovascular disease events. JACC Cardiovasc Imaging 2009;2:319–26. 14. Budoff MJ, Nasir K, Katz R, Takasu J, Carr JJ, Wong ND et al. Thoracic aortic calcification and coronary heart disease events: the multi-ethnic study of atherosclerosis (MESA). Atherosclerosis 2011;215:196 –202. 15. Ka¨lsch H, Lehmann N, Berg MH, Mahabadi AA, Mergen P, Mo¨hlenkamp S et al. Coronary artery calcification outperforms thoracic aortic calcification for the prediction of myocardial infarction and all-cause mortality: the Heinz Nixdorf Recall study. Eur J Prev Cardiol 2014;21:1163 –70. 16. Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 1993;24:35– 41. 17. Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003;289: 2560 –72. 18. Wilson PW, D’Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation 1998;97: 1837 –47.
D.M. Hermann et al.
