A 56-year-old man was admitted on our intensive care unit with septic shock after 10 days of diarrhea, shortly after he had visited India. He had no relevant previous medical history. Blood and fecal cultures grew various pathogens, including Shigella flexneri. ECG showed diffuse ST elevation with PR depression (Figure 1), and laboratory results revealed significant troponin (peak level of 5.72 ng/mL) and creatine phosphokinase-MB (peak level of 117 ng/mL) release, most likely caused by a perimyocarditis in the setting of Shigella sepsis. Further diagnostic evaluation revealed hairy cell leukemia. After initial improvement of his clinical condition and treatment with rituximab and prednisolone, he was readmitted to the intensive care unit with respiratory failure and new-onset left ventricular dysfunction as was observed with echocardiography. Compared with the prior tracing, his ECG now showed microvoltages in the extremity leads, this time with normal ST segments ( Figure 2). Computed tomographic imaging revealed extensive myocardial calcification of the left ventricle that was not seen on previous computed tomographic images (Figures 3 and 4). Comparable images of a pronounced dense myocardium with normal aspect of the endocardial layer were observed with transesophageal echocardiography (Figure 5). Serum levels of calcium were repeatedly not elevated during the admittance.Localized myocardial calcification is commonly observed after myocardial infarction. Diffuse calcification, however, is a rare phenomenon. Interestingly, similar cases of extensive left ventricular calcification after a period of severe sepsis have been described previously. 1-3 Two different pathophysiological mechanisms resulting in calcium deposition in cardiac myocytes can be distinguished. 4 First, significant disturbances in calcium metabolism can lead to metastatic calcification, as is occasionally observed in patients with chronic renal failure. Furthermore, calcium may accumulate in necrotized cardiac myocytes, which is known as dystrophic calcification. The latter mechanism is believed to underlie myocardial calcification in the setting of myocardial infarc-Figure 1. ECG at day 1 of admission showing diffuse concave ST elevation with PR depression (arrow).

A 73-year-old man had a DDD pacemaker implanted in 1991 for symptomatic high-degree atrioventricular block. Because of atrial lead dysfunction, a new atrial lead was implanted in 1998. Ten years later, the patient experienced unexplained ascites and edema with progressive exertional dyspnea, for which he was referred. Chest radiography showed a loop of the ventricular lead at the level of the tricuspid valve (Figure 1). Transthoracic echocardiography demonstrated an enlarged right atrium. The mean diastolic gradient across the tricuspid valve was 15 mm Hg with a peak pressure drop of 29 mm Hg without tricuspid regurgitation (Figure 2). No other abnormalities were found. Transesophageal echocardiogram revealed looping of one of atrial leads at the level of the tricuspid valve but could not visualize the exact anatomic position of the leads and the cause of the tricuspid valve stenosis (Figure 3).A cardiac computed tomography (CT) revealed 2 atrial leads in the right atrial free wall. However, the ventricular

ObjectivesPatients with prosthetic heart valves may require assessment for coronary artery disease. We assessed whether valve artefacts hamper coronary artery assessment by multidetector CT.MethodsECG-gated or -triggered CT angiograms were selected from our PACS archive based on the presence of prosthetic heart valves. The best systolic and diastolic axial reconstructions were selected for coronary assessment. Each present coronary segment was scored for the presence of valve-related artefacts prohibiting coronary artery assessment. Scoring was performed in consensus by two observers.ResultsEighty-two CT angiograms were performed on a 64-slice (n = 27) or 256-slice (n = 55) multidetector CT. Eighty-nine valves and five annuloplasty rings were present. Forty-three out of 1160 (3.7%) present coronary artery segments were non-diagnostic due to valve artefacts (14/82 patients). Valve artefacts were located in right coronary artery (15/43; 35%), left anterior descending artery (2/43; 5%), circumflex artery (14/43; 32%) and marginal obtuse (12/43; 28%) segments. All cobalt-chrome containing valves caused artefacts prohibiting coronary assessment. Biological and titanium-containing valves did not cause artefacts except for three specific valve types.ConclusionsMost commonly implanted prosthetic heart valves do not hamper coronary assessment on multidetector CT. Cobalt-chrome containing prosthetic heart valves preclude complete coronary artery assessment because of severe valve artefacts.Key Points• Most commonly implanted prosthetic heart valves do not hamper coronary artery assessment• Prosthetic heart valve composition determines the occurrence of prosthetic heart valve-related artefacts• Björk–Shiley and Sorin tilting disc valves preclude diagnostic coronary artery segment assessment

ObjectiveCardiac guidelines recommend that the decision to perform coronary angiography (CA) in patients with Non-ST-Elevation Acute Coronary Syndrome (NST-ACS) is based on multiple factors. It is, however, unknown how cardiologists weigh these factors in their decision-making. The aim was to investigate the importance of different clinical characteristics, including information derived from risk scores, in the decision-making of Dutch cardiologists regarding performing CA in patients with suspected NST-ACS.DesignA web-based survey containing clinical vignettes.Setting and participantsRegistered Dutch cardiologists were approached to complete the survey, in which they were asked to indicate whether they would perform CA for 8 vignettes describing 7 clinical factors: age, renal function, known coronary artery disease, persistent chest pain, presence of risk factors, ECG findings and troponin levels. Cardiologists were divided into two groups: group 1 received vignettes ‘without’ a risk score present, while group 2 completed vignettes ‘with’ a risk score present.Results129 (of 946) cardiologists responded. In both groups, elevated troponin levels and typical ischaemic changes (p<0.001) made cardiologists decide more often to perform CA. Severe renal dysfunction (p<0.001) made cardiologists more hesitant to decide on CA. Age and risk score could not be assessed independently, as these factors were strongly associated. Inspecting the factors together showed, for example, that cardiologists were more hesitant to perform CA in elderly patients with high-risk scores than in younger patients with intermediate risk scores.ConclusionsWhen deciding to perform in-hospital CA (≤72 hours after patient admission) in patients with suspected NST-ACS, cardiologists tend to rely mostly on troponin levels, ECG changes and renal function. Future research should focus on why CA is less often recommended in patients with severe renal dysfunction, and in elderly patients with high-risk scores. In addition, the impact of age and risk score on decision-making should be further investigated.

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