Calcium Jacket of Left Ventricle: An Aristocracy of the Monster

Case Summary

A 67-year-old hypertensive gentleman, with a history of anterior wall ST elevation myocardial infarction, thrombolyzed with streptokinase 15 years earlier, underwent elective bare metal stent in the right postero-lateral ventricular branch. He had moderate left ventricular systolic dysfunction and was kept on medical management for moderate lesions in left anterior descending and left circumflex coronary arteries.

Now he presented with hemodynamically unstable ventricular tachycardia (VT) which was terminated with 200J of direct current cardioversion (Figure 1A). The baseline electrocardiogram showed bifascicular block (Figure 1B). His troponin T and NT-proBNP were elevated. Cardiogenic shock improved with conservative management. Chest X-ray showed a round calcific ring on the left side of cardiac silhouette (Figure 2A). The echocardiogram revealed dilated left ventricle, severe systolic dysfunction with thinning and akinesia of anterior and apical segments of left ventricle along with a hyperechoic probable calcific rim of lesion along endocardial border with backscatter reflections (Figure 2B, Supplementary videos 1 and 2). During coronary angiogram, fluoroscopy confirmed the presence of rim of dystrophic calcification of the likely non-viable myocardium (Figure 3A, 3B). Localization and its schematic depiction have been given in Figure 4A–C, Supplementary videos 3 and 4. Electrocardiogram during VT having north-west axis, small r and deep S in V6 with right bundle branch block pattern in V1 also suggested VT exit from left ventricular apex. Coronary angiogram showed left main shaft severe stenosis with significant in-stent restenosis of right coronary artery stent. He underwent dual chamber implantable cardioverter defibrillator (ICD) and angioplasty for left main coronary artery and right coronary lesion. Myocardial dystrophic calcification in long term survivors of myocardial infarction has been reported. ¹ It is associated with poor prognosis. The calcifications correspond to areas of un-excitability and represent a fixed boundary of re-entry circuits acting as substrate for scar related re-entrant VT.^{2, 3} Although it indicates likely non-viable myocardium, our decision to re-vascularize left main coronary artery was to protect the left circumflex territory. This case emphasizes that dystrophic myocardial calcification, which can sometimes be picked up in routine chest X-ray, can cause scar-related VT. Although cardiac CT or magnetic resonance imaging would have given better idea of the extent of involvement, it could not be done, which was a limitation of this report.

OPEN IN VIEWER Figure 1.

A. Wide-complex Tachycardia with North-west Axis Suggesting Ventricular Tachycardia; B. Post-termination Sinus Electrocardiogram Showing Prolonged PR Interval With Right Bundle Branch Block.

OPEN IN VIEWER Figure 2.

A. Chest X-ray Showing a Round Calcific Ring (Arrows) in Left Cardiac Silhouette, Post-ICD Implantation; B. Echocardiogram in Modified Short Axis Apical View Showing Hyperechoic Probable Calcific Rim (Arrowhead) Along Endocardial Border of Left Ventricle with Backscatter Reflections (Arrows).

OPEN IN VIEWER Figure 3.

Plain Fluoroscopy Confirming the Presence of Calcific Round Shadow with Well Circumscribed Border Due to Dystrophic Calcification of the Likely Non-viable Myocardium.

OPEN IN VIEWER Figure 4.

A. LAO 38°, Caudal 33° View Showing Apical LAD Territories are Calcified, Arrowheads and Arrows Indicate Septal and Anterior Wall Calcification respectively; B. LAO 40°, Cranial 10° View Showing the Same; C. Schematic Depiction of the Walls Involved and Probable Location of the Calcification Has Been Marked in LAO, Cranial View. LAO - Left anterior oblique.