Metastatic Myocardial Calcification

BACKGROUND: Metastatic myocardial calcification (MMC) is a rare complication of chronic kidney disease-mineral bone disorder (CKD-MBD), potentially mimicking infiltrative cardiomyopathies on cardiac imaging. CASE SUMMARY: A 30-year-old woman on peritoneal dialysis for IgA nephropathy presented with recurrent chest pain, elevated troponin, and severe hypertension. Coronary angiography was normal. Echocardiography revealed severe left ventricular hypertrophy. Initial cardiac magnetic resonance imaging showed focal edema; a follow-up study demonstrated diffuse midwall late gadolinium enhancement with myocardial nulling, raising concern for amyloidosis, but a markedly reduced native T1 challenged this diagnosis. Noncontrast computed tomography showing diffuse myocardial hyperattenuation confirmed MMC in the setting of severe secondary hyperparathyroidism and concurrent metastatic pulmonary calcification. Management included intensified CKD-MBD therapy and parathyroidectomy. DISCUSSION: MMC can closely mimic amyloidosis on magnetic resonance imaging. Multimodality imaging is essential for accurate diagnosis. TAKE-HOME MESSAGES: Multimodality imaging is key in differentiating infiltrative diseases. MMC should be considered in dialysis patients with secondary hyperparathyroidism.