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\begin{document}

\title{Extensive Intramyocardial Calcifications: Value of Multimodality Imaging}



\author[1]{Fabiola Sozzi}%
\author[2]{Laura Iacuzio}%
\author[1]{Marco Schiavone}%
\author[2]{Filippo Civaia}%
\author[1]{Stefano Carugo}%
\author[2]{Franck Levy}%
\author[2]{Armand Eker}%
\affil[1]{Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico}%
\affil[2]{Centre Cardio-Thoracique de Monaco}%


\vspace{-1em}



  
  \date{May 17, 2024}


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\selectlanguage{english}
\begin{abstract}
Massive myocardial calcification is a very rare finding. Accurate
identification and characterization may help the clinicians to determine
the etiology and clinical significance. In this case, the diagnostic
pathway excluded previous myocardial infarction, myocarditis and
calcium-phosphate disorders. A possible dystrophic etiology was
considered. There are no standardized imaging features available to
classify specific subtypes of intramyocardial calcifications. The
relative merits of cardiac computed tomography and magnetic resonance in
providing complimentary diagnostic information for calcific myocardial
lesions is shown. Knowledge of the potential etiology and their imaging
patterns are important to provide a concise and accurate differential
diagnosis.%
\end{abstract}%



\sloppy


\textbf{Extensive Intramyocardial Calcifications:}

\textbf{Value of Multimodality Imaging}

Fabiola B Sozzi MD*, Laura Iacuzio MD, Marco Schiavone MD*, Filippo
Civaia MD, Stefano Carugo MD*, Franck Levy MD, Armand Eker, MD

Cardiothoracic Centre CCM, Monaco, MC and

*Fondazione Ospedale Policlinico, IRCCS, Milan, IT

\textbf{Running title:} ``A Rare Case of Intramyocardial
Calcifications''.

\textbf{Word count:} 250 words.

\textbf{Keywords:} Intramyocardial Calcifications. Cardiac CT. Cardiac
MRI.

\textbf{Address for correspondence:}

Fabiola B Sozzi

Monaco Cardiothoracic Centre

Avenue d'Ostende 11

98004 Monaco

Ph +39 3295662258

Email fabiola\_sozzi@yahoo.it



\textbf{ABSTRACT}

Massive myocardial calcification is a very rare finding. Accurate
identification and characterization may help the clinicians to determine
the etiology and clinical significance. In this case, the diagnostic
pathway excluded previous myocardial infarction, myocarditis and
calcium-phosphate disorders. A possible dystrophic etiology was
considered. There are no standardized imaging features available to
classify specific subtypes of intramyocardial calcifications. The
relative merit of cardiac computed tomography and magnetic resonance
imaging in providing complimentary diagnostic information for calcific
myocardial lesions is shown. Knowledge of the potential etiology and
their imaging patterns are important to provide a concise and accurate
differential diagnosis.

An 81-year-old woman, affected by Horton disease and with previous
history of rheumatic fever, was hospitalized for acute chest pain.
Physical examination and EKG were not significant. Chest X-Ray showed a
diffuse hypodense lobulated area in the left ventricle (Figure 1: A).
The echocardiogram revealed diffuse aortic and mitral calcifications
with mild stenosis, marked septum and antero-lateral asymmetric
hypertrophy, with extensive antero-lateral calcifications (Figure 1: B,
Video 1). Non-contrast computed-tomography (CT) highlighted widespread
amorphous confluent calcifications in the left ventricular wall, with
septal sparing, extended to the mitral-aortic annulus and both coronary
arteries (Figure 1: C-C1 showing VRT reconstruction and C2 MPR
axial-view, Video 2). Cardiac magnetic resonance 3,0 T presented the
following: septal hypertrophy, antero-lateral wall thickening with areas
of intramyocardial signal-alteration, surrounded by normal myocardium
matching the CT calcifications. Areas of low-signal were shown in
multiple sequences: SSFP-cine in 4-chambers {[}4C{]} (Figure 2: D, Video
3) and in short-axis {[}SAX{]} (Figure 2: D1); T1-weighted-spin-echo in
4C (Figure 2: E) and SAX (Figure 2: E1); STIR in 4C (Figure 2: F).
T1-native-mapping in 4C focused on diffuse septum and lateral fibrosis
with low-signal (550 ms, normal range: 1150-1250 ms) compatible with
calcifications (Figure 2: G). After contrast-gadolinium injection,
PSIR-sequence showed intramyocardial hypersignal in the lateral wall
both in 4C and SAX, Figure 2: H-H1 respectively). Coronary angiography
documented significant disease that required revascularization.
Extensive intramyocardial calcifications are extremely rare (1). In our
case the diagnostic pathway excluded previous myocardial infarction,
myocarditis and calcium-phosphate disorders. A possible dystrophic
etiology was considered according also to the rheumatic disease. There
are no standardized imaging features available to classify specific
subtypes of intramyocardial calcifications (2). The combination of
imaging pattern and potential etiology plays a key role in
characterizing calcifications and deriving its clinical impact.

\textbf{REFERENCES}

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.

Marciniak A, Marciniak M, Chiribiri A, et al. Multimodality imaging of
extensive caseating intramyocardial calcification secondary to lymphoma.
Circ Cardiovasc Imaging. 2015;8(4):e002750.

\textbf{FIGURE LEGEND}

\textbf{Figure 1: A.} Chest X-Ray showing a diffuse hypodense lobulated
area in the left ventricle

\textbf{Figure 1: B, Video 1.} 2D-Echocardiogram revealing diffuse
aortic and mitral calcifications with mild stenosis, marked septum and
antero-lateral asymmetric hypertrophy, with extensive antero-lateral
calcifications.

\textbf{Figure 1: C, C1.} CT-VRT reconstruction of the left ventricle,
respectively axial view and focus on the coronal view.

\textbf{Figure 1: C2, Video 2.} Non-contrast CT MPR-axial view presents
widespread calcifications in the left ventricular wall extended to the
mitral-aortic annulus and both coronary arteries.

\textbf{Figure 2: D, D1, Video 3.} CMR SSFP-cine 4-chambers and
short-axis views respectively showing lateral and antero-lateral wall
thickening with areas of intramyocardial low signal, surrounded by
normal myocardium.

\textbf{Figure 2: E, E1.} CMR T1weighted-spin-echo 4-chambers and
short-axis view respectively show thickening of the lateral and
antero-lateral wall with areas of low-signal.

\textbf{Figure 2: F.} CMR STIR 4-chambers showing lateral thickening
with areas of low-signal.

\textbf{Figure 2: G.} CMR T1-native-mapping demonstrate diffuse septum
and lateral fibrosis with low-signal in correspondence of the
calcifications in the lateral wall (grey-light blue areas).

\textbf{Figure 2: H, H1.} CMR PSIR-sequences in 4-chamber view and
short-axis view respectively. After contrast-gadolinium injection,
intramyocardial hypersignal (gadolinium enhancement) is shown in the
antero-lateral wall.\selectlanguage{english}
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