Extensive Myocardial Calcification in a Heart Transplant Patient

Keywords
Heart Transplantation/complications; Heart Valve Diseases/surgery; Renal Insufficiency/complications; Shock, Septic

Palavras-chave
Transplante de Coração/complicações; Doenças das Valvas Cardíacas; Insuficiência Renal/complicações; Choque Séptico

Keywords
Heart Transplantation/complications; Heart Valve Diseases/surgery; Renal Insufficiency/complications; Shock, Septic

Palavras-chave
Transplante de Coração/complicações; Doenças das Valvas Cardíacas; Insuficiência Renal/complicações; Choque Séptico

A 33-year-old female patient underwent heart transplantation (Tx) for valvular heart disease, where the surgical procedure was uneventful. Post-Tx, she developed with acute graft dysfunction, acute renal failure (ARF) requiring dialysis and septic shock. Bloodstream infection confirmed by treatment for carbapenemase-producing Klebsiella pneumoniae. Non-contrast-enhanced computed tomography (CT) of the chest and abdomen was done for investigation of the infectious focus and distention of the abdomen and melena, with extensive left ventricular myocardial calcification (MC) not previously found in CT (Figures 1, 2 and 3). A diagnosis of cytomegalovirus (CMV) infection was also confirmed by upper digestive endoscopy findings with diffuse gastroduodenal ulcers and quantitative detection of positive CMV DNA, and the patient received ganciclovir. The patient became refractory to treatment and died.

Figure 1
Coronary non-contrast-enhanced computed tomography scan of the chest with finding of extensive myocardial calcification in the left ventricle.

Figure 2
Sagittal non-contrast-enhanced computed tomography scan of the chest with finding of extensive myocardial calcification in the left ventricle.

Figure 3
Axial non-contrast-enhanced computed tomography scan of the chest with finding of extensive myocardial calcification in the left ventricle.

MC is a rare complication that occurs in critically ill patients. It has various etiologies, and its pathophysiology is not completely elucidated. MC may involve mechanisms of metastatic calcification and dystrophic calcification, as presented in Table 1. It can be the cause of heart failure, sudden death, abnormalities in ventricular wall movement, arrhythmias and restrictive disease.¹

Table 1
Possible myocardial calcification etiologies

Metastatic calcification (Altered serum calcium level)	Dystrophic calcification (Calcium accumulation in necrotic tissues, without hypercalcemia)
Chronic renal failure	Infections
Primary parathyroidism	Extracorporeal membrane oxygenation
Neoplasms	Inflammatory processes
Bone disturbances	Processes myocardial infarction
Medications	Myocarditis

The case demonstrates a correlation with others described in the literature, showing extensive MC in a young patient with anemia, ARF, septic shock,² exposure to extracorporeal membrane oxygenation,³ and high mortality, with the difference being an immunosuppressed post-heart transplant patient. The true meaning of this finding and its reversibility are unknown. However, it is believed to be related to disease severity and poor prognosis, and its identification in clinical practice is important.

Funding

Sources of Funding

There were no external funding sources for this study.

Study Association

This study is not associated with any thesis or dissertation work.

Ethics approval and consent to participate

This article does not contain any studies with human participants or animals performed by any of the authors.

References

• ¹ Nance JW Jr, Crane GM, Halushka MK, Fishman EK, Zimmerman SL. Myocardial calcifications: pathophysiology, etiologies, differential diagnoses, and imaging findings. J Cardiovasc Comput Tomogr. 2015; 9(1):58-67.
• ² Ahmed T, Inayat F, Haq M, Ahmed T. Myocardial calcification secondary to toxic shock syndrome: a comparative review of 17 cases. BMJ Case Rep. 2019 Jan 10;12(1):pii.bcr-2018-228054.
• ³ Kapandji N, Redheuil A, Fouret P, Hékimian G, Lebreton G, Bréchot N,et al. Extensive Myocardial Calcification in Critically Ill Patients. Crit Care Med. 2018;46(7):702-6.

Correspondence

Mailing Address: Sasha B. C. P. Duarte, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP) - Av. Dr. Enéas Carvalho de Aguiar, 44. Postal Code 05403-900, Cerqueira César, São Paulo, SP - Brazil. E-mail: [e-mail]

Author contributions

Author contributions

Acquisition of data: Montemor ML; Writing of the manuscript: Duarte SBCP; Critical revision of the manuscript for intellectual content: Mangini S, Avila MS, Bacal F.

Conflicts of interest

Potential Conflict of Interest

No potential conflict of interest relevant to this article was reported.

Publication Dates

• Publication in this collection
  10 Feb 2020
• Date of issue
  Jan 2020