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This 78 y.o. man presented with left scapular pain. He has a history of smoking (100+ pack-yrs); and, a history of prostate cancer treated with localized radiotherapy.
No palpable abnormality in region of left scapula; physical exam was unrevealing.
Anterior and posterior planar images of the chest from a nuclear medicine bone scan (obtained 2 hours after injection of Technitium-99m HDP) demonstrate abnormal radiopharmaceutical accumulation within the left ventricular walls of the heart.
Posterior-anterior chest radiograph and contrast-enhanced cardiac computed tomography (CT) demonstrate curvilinear subendocardial calcification in the inferobasilar wall of the heart. A metallic pacemaker wire is in place with tip projecting in the expected location of the right ventricle.
• Heart attack (myocardial ischemia / necrosis)
• Mediastinal mass (eg. malignancy)
Dx: Calcifying Myocardium from previous infarction
Dx Confirmed by: Imaging and history, with cardiology correlation
- Read Further investigation of the patient’s cardiac history revealed that he had sustained a left ventricle inferobasilar wall myocardial infarction (MI) four years earlier (occluded left circumflex coronary artery). Prior echocardiography exams noted moderate aortic stenosis as well as a severely hypokinetic inferobasilar LV wall related to the history of MI.
As the patient had also been noticing a recent increase in bilateral leg swelling, an echocardiogram was repeated. The exam demonstrated persisting severe hypokinesis of the inferobasilar wall with mild generalized LV diastolic dysfunction. Moderate aortic stenosis (valve area 0.9cm2) with bicuspid aortic valve and mild LV hypertrophy was unchanged.
Detecting and recognizing calcification related to the heart on nuclear medicine bone scans and other imaging modalities may have important clinical implications. For example, the amount of coronary artery calcification correlates with the severity of coronary artery disease (CAD), and calcification of the aortic or mitral valve may indicate hemodynamically significant valvular stenosis.
This case demonstrates the classic finding of myocardial calcium deposition from prior MI. Approximately 8% of patients who sustain a large myocardial infarction develop myocardial calcification, with anterolateral wall LV infarcts most commonly seen in association with LV aneurysm.
Other causes for calcification within the walls of the heart may include myocarditis and amyloid deposition. Soft tissue calcium deposition can be seen in a wide variety of disease processes (inflammation, infarction and necrosis, metastatic calcification in renal failure, and hypercalcemia of any cause); however, the exact mechanism for cardiac activity as seen on nuclear medicine bone scans is debated, and the degree of cardiac activity on bone scan may differ from visualized calcification on CT imaging.
Localizing calcification to the walls of the heart versus within the pericardium is important as pericardial calcification is strongly associated with constrictive pericarditis.
In summary, correct assessment of cardiac calcification location is important in disease diagnosis and management.
References
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1. Agatson AS. Quantification of coronary artery calcification and associated coronary artery disease in asymptomatic young men. J Am Coll Cardiol. 1992;19:1167-72.
2. Duerinckx AJ, Higgins CB. Valvular heart disease. Radiol Clin North Am. May 1994;32(3):613-30.
3. Janssen S, Piers DA, van Rijswijk MH, Meijer S, Mandema E. Soft tissue uptake of Tc-99m-diphosphonate and Tc-99m-pyrophosphate in amyloidosis. Eur J Nucl Med. 1990;16:663–670.
4. Loutfi I, Collier BD, Mohammed AM. Nonosseous Abnormalities on Bone Scans. J Nuc Med Tech 2003; 31:149–153.
5. Silberstein EB, Francis MD, Tofe AJ, Slough CL. Distribution of Tc-99m-Sn diphosphonate and free Tc-99m pertechnetate in selected hard and soft tissues. J Nucl Med. 1975;16:58–6
Coronary arteries:
Almost always due to atherosclerosis.
Pericardium:
Sequela of pericarditis. Seen around right ventricle, posterior left ventricle, atrioventricular groove. Can be associated with constrictive pericarditis (restriction of ventricular filling causing heart failure).
Myocardium:
Usually sequela of infarction. Left ventricle involved, usually near apex. Can be associated with a ventricular aneurysm.
Valves:
Aortic valve leaflets:
Posterior to pulmonic valve, anterior and superior to mitral valve. Usually associated with aortic stenosis.
Aortic valve annulus:
Usually in conjunction with leaflet calcification.
Mitral valve leaflets:
Inferior and posterior to aortic valve. Sequela of rheumatic heart disease. Associated with mitral stenosis.
Mitral valve annulus:
Usually normal in the elderly. Can be associated with conduction disturbance or mitral insufficiency.
Pulmonic valve:
Rare. Associated with pulmonic stenosis.
Tricuspid valve:
Very rare.
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