Case 2-2010: massive myocardial calcification in an elderly woman.

81-year-old woman with known history of severe aortic stenosis, severe tricuspid regurgitation and mitral regurgitation was referred with dyspnoea, peripheral oedema and palpitations because of acute decompensation of chronic heart failure. In medical history, the patient denied any other prior or chronic disease apart from osteoarthritis. On physical examination, the patient had a blood pressure of 117/70 mmHg, an irregular pulse, heart rate of 120 beats per minute, and a respiratory rate of 18 breaths per minute. Her temperature was 36.3 °C. A loud systolic ejection murmur grade 4/6 was audible over the aortic valve; jugular veins were distended, lower limbs edema spread to knees. ECG showed atrial fibrillation with heart rate 120/ min and non-specific ST-T changes. Laboratory investigations revealed blood urea nitrogen concentration of 11.5 mmol/l, creatinine 78 μmol/l and uric acid 490 μmol/l; plasma calcium and phosphate level were within the normal limits and markers of myocardial necrosis were negative. Chest X-ray demonstrated dilatation of the upper zone pulmonary vessels and opacity in the area of the left ventricle (Fig. 1). Two-dimensional echocardiography revealed calcified aortic stenosis (systolic peak/mean gradient 91/51 mmHg, aortic valve area was 0.35 cm2/m2 according to planimetry and 0.45 cm2/m2 calculated by the continuity equation) (5), moderate mitral regurgitation with annular calcification (Fig. 2) and tricuspid regurgitation. The ejection fraction of the left ventricle was 31 % and there was left ventricular hypertrophy and moderate pulmonary hypertension. Hyperechogenic tissue areas were detected in the interventricular septum and in the left ventricular wall (Fig. 3). During hospitalization the patient underwent DC-cardioversion. After diuretic treatment she was hemodynamically stable and heart catheterization with coronary angiography was planned. But few days later, however, the patient suddenly died.