Title: Unusual Case of Congestive Heart Failure:  Cardiac Magnetic Resonance Imaging and Histopathologic Findings in Cobalt Cardiomyopathy

Summary

A 69-year-old woman came to the authors with symptoms of congestive heart failure, a heart condition that leads to buildups of fluid in the lungs. She had a history of hypertension, mild kidney problems, and hip replacements on both hips. An ultrasound showed her heart’s left ventricle was pumping blood at a rate of 25% to 30% (a normal rate is 55% or higher). The left ventricle is a chamber in the heart responsible for pumping most of our blood. The ultrasound also revealed some fluid around the patient’s heart. Doctors tested the fluid and found no infection or malignant cells.

Over the next four months, the patient’s heart function declined rapidly, leading to many hospitalizations for congestive heart failure and low blood pressure.

An MRI of her heart revealed that her left ventricle had a normal size and thickness, but it was pumping blood at a severely low rate (14%). Her right ventricle was also a normal size, but it was also not pumping blood adequately. Several areas of her heart (specifically, the subepicardial lateral walls, left atrial wall and the right atrial wall) were enlarged.

The patient mentioned that her Depuy metal on metal hip implant had been squeaking for two years and that she planned to have it removed because it had been recalled. She had high cobalt and chromium levels in her blood.

Because of the concerning heart images and her high cobalt and chromium levels, the doctors performed what is called a right-heart catheterization, an operation where a small tube is inserted into the right side of the heart. This tube then carries blood to the lungs. The doctors also tested a sample of her heart tissue.

Lab tests found that the cells of her heart muscles were enlarged and had some scarring and inflammation. They also found symptoms of dilated cardiomyopathy (DCM), a condition where the heart’s ability to pump blood is decreased because the left ventricle is enlarged and weakened, probably because of the patient’s high cobalt levels. Additionally, they found signs of cobalt cardiomyopathy, a type of heart disease caused by cobalt poisoning. However, the levels of cobalt in the patient’s heart muscles could not be obtained.

The patient’s condition then deteriorated until she went into cardiogenic shock, a condition where the heart cannot pump enough blood to meet the body’s needs. She had to receive advanced heart failure support, have her hip implant removed, and was diagnosed with cobalt-caused heart disease. After having her metal-on-metal (MoM) hip implant replaced with a ceramic implant, she had a stroke and died.

Recently, there have been many reports of cobalt-caused heart disease due to MoM hip implants failing. When this occurs, the heart disease can usually be reversed by removing the hip implant.

Other reports of cobalt-caused heart disease have shown similar heart malfunction symptoms, such as the buildup of fluid around the heart and decreased blood-pumping ability.

Conclusion

The authors feel that fluid around the heart and significant inflammation of the heart walls might indicate cobalt-caused heart disease in future cases. Thus, the authors suggest that, when cobalt-caused cardiomyopathy is suspected, doctors should find out what kind of MoM implant the patient has, test the cobalt levels in the patient’s blood, perform heart ultrasounds and MRIs, and also test the cobalt levels of the heart muscles if possible.

Reference

Khan, A., Verma, R., Bajpai, A.,, Mackey-Bojack, S. Circ Cardiovas Imaging. 2015;8: doi: 10.1161/CIRCIMAGING.115.003352

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