Abstract 4337649: The Toothpaste Heart: Striking Imaging of a Multisystem Calcific Cardiovascular Case in a Young Male with ESRD

Introduction: Extensive vascular and valvular calcification is typically seen in older adults with longstanding cardiovascular disease. In younger patients, it often reflects complex systemic pathology. Case Presentation: A 44-year-old male presented with central, burning chest pain that worsened when lying flat and improved when upright, shortly after a dialysate adjustment and suspected leakage. His relevant history included cocaine-associated NSTEMI at age 22, non-ischemic cardiomyopathy with LVEF 30% diagnosed at age 39, and ESRD secondary to proliferative glomerulonephritis with monoclonal deposits. He underwent kidney transplant at age 27 but resumed peritoneal dialysis by age 29. Investigations: Coronary angiography revealed new triple-vessel CAD. Echocardiography showed LVEF 35%, moderately reduced RV function, low-flow low-gradient aortic stenosis, moderate-to-severe mitral annular calcification (MAC), mild mitral stenosis, and pulmonary hypertension. Non-contrast ECG-gated cardiac CT showed a 25 × 62 mm calcified apical mass, diffuse coronary and vascular calcifications, pleural calcifications, calcified pulmonary nodules, and dramatic “toothpaste-like” MAC suggestive of caseous transformation. Management: Despite extensive structural disease, the patient remained hemodynamically stable. A multidisciplinary heart team—including general cardiology, heart failure, and cardiothoracic surgery—guided evaluation. CT surgery was consulted for CABG consideration; further workup included a PET-FDG scan for myocardial viability. Pericardiectomy was discussed due to concern for constrictive pericarditis in the setting of pericardial calcifications, though right heart catheterization did not show hemodynamic findings of constriction. Ultimately, CABG was deferred due to patient stability and preference to delay intervention. Medical therapy included heparin, dual antiplatelet therapy, statin initiation, and renal-adjusted guideline-directed heart failure treatment. Conclusion: This case highlights extreme cardiovascular and extraosseous calcification in a young patient with ESRD and chronic heart failure. The “toothpaste” appearance of the mitral annulus suggests caseous transformation, a rare MAC variant. While vascular calcification is common in ESRD, this represents a severe form of CKD–mineral bone disorder. Multidisciplinary care is essential in managing overlapping cardiac, renal, and metabolic conditions, and in guiding personalized risk stratification.