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Rugby Ball Cardiac Calcification


 Department of Cardiology, Centre for Heart and Vascular Care, Meitra Hospital, Kozhikode, Kerala, India

Date of Submission06-May-2021
Date of Acceptance26-May-2021
Date of Web Publication06-Jul-2021

Correspondence Address:
Shreetal Rajan Nair,
Sankeerthanam, Kariyaampatta, 33/3842D, Near Arullappadu Devi Temple, Chevarambalam P.O., Kozhikode, Kerala - 673 017
India

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiae.jiae_9_21



How to cite this URL:
Nair SR, Mandalay A, Bhaskaran J, Faizal A. Rugby Ball Cardiac Calcification. J Indian Acad Echocardiogr Cardiovasc Imaging [Epub ahead of print] [cited 2021 Oct 24]. Available from: https://www.jiaecho.org/preprintarticle.asp?id=320785

Calcification on the chest skiagram is a frequent observance in old age. It can involve the heart, tracheal, thyroid cartilages, and other mediastinal structures. C-shaped calcification of mitral annulus, left atrial mural calcification also known as porcelain or coconut left atrium',[1] and egg shell calcification involving lungs in silicosis are classical descriptions. However, it would be of particular interest when it assumes peculiar shapes. We describe a unique type of calcification within the cardiac silhouette which would be of peculiar interest to the readers.

A 65-year-old frail male presented with features of acute heart failure and on evaluation was found to be in pulmonary edema. He was stabilized with diuretics and other antiheart failure medications. Historical review revealed acute coronary syndrome almost 15 years ago. He had poor compliance with medications. Chest skiagram [Figure 1]a and [Figure 1]b showed cardiomegaly with calcification resembling a rugby ball involving the cardiac apex and anterolateral wall. Echocardiography revealed the specks of calcification within the aneurysm wall with severe left ventricular systolic dysfunction [Figure 1]c and [Video Supplementary File 1]. No mural thrombus was detected. Electrocardiogram showed features suggestive of previous anterior wall myocardial infarction in the precordial leads [Figure 1]d. He was later discharged after the optimization of medications and advised regular follow-up.
Figure 1: (a) Posteroanterior chest X-ray showing characteristic 'rugby ball calcification, (b) Lateral chest X-ray confirms the calcification to be confined intracavitary, (c) Aneurysmal dilatation of left ventricular apex (arrows show the aneurysm borders): RA-right atrium; RV-right ventricle; LA-left atrium; LV-left ventricle; AN – Aneurysm; V – Ventricular apex free of thrombus, (d) Electrocardiogram showing features suggestive of old anterior wall myocardial infarction and persistent ST segment elevation

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[Additional file 1]

Video Supplementary File 1: Left ventricular apical aneurysm: Aneurysmal dilatation of left ventricular apex with specks of calcium within the aneurysm wall.

Cardiac calcification can occur at a multitude of locations: Aorta, valves, pericardium, and myocardium. Calcification usually occurs in areas where the tissue is dead or degeneration exists (dystrophic calcification). Calcification of ventricular aneurysm is not a common entity. It is recognized that congestive heart failure is the most common presentation followed by angina, ventricular arrhythmias, and embolization. Previous reports of calcification of left ventricular aneurysm have been described[2],[3],[4] but not so frequent and hence the significance of the case. The management of symptomatic ventricular aneurysm depends on the presentation, the general condition of the patient, the comorbidities, and overall clinical profile. Management decision may vary from conservative management to more aggressive strategies such as surgical treatment of aneurysm. Calcification of ventricular aneurysm is not a good prognostic indicator, especially when surgery is planned and a more conservative line of treatment would be preferred in such cases. Other systemic causes of calcification[5] should be searched for in such cases. However, no obvious causes could be discerned in this case.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Nair SR, Sajeev CG. Coconut left atrium. IHJ Cardiovasc Case Rep 2019;3:79-80.  Back to cited text no. 1
    
2.
Nakajima O, Sano I, Akioka H. Images in cardiovascular medicine. Marked calcified left ventricular aneurysm. Circulation 1997;95:1974.  Back to cited text no. 2
    
3.
Lee BK, Atwood JE. Images in clinical medicine. Calcified left ventricular aneurysm. N Engl J Med 2003;348:918.  Back to cited text no. 3
    
4.
Harrison-Gómez C, Harrison-Ragle A, Arceo-Navarro A. Images in cardiovascular medicine. A ring in the heart: Calcified left ventricular aneurysm. Circulation 2007;115:e376-7.  Back to cited text no. 4
    
5.
Dalinka MK, Melchior EL. Soft tissue calcifications in systemic disease. Bull N Y Acad Med 1980;56:539-63.  Back to cited text no. 5
    


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