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      Unusual Appearance of Mitral Annular Calcification Mimicking Intracardiac Tumor Prompting Early Surgery

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          Although mitral annular calcification (MAC) is usually easy to diagnose by transthoracic echocardiography, we experienced a rare case with MAC which looked like an intracardiac tumor. The patient who had been on chronic hemodialysis for 20 years was admitted to our hospital because of dyspnea. Transthoracic echocardiography showed a mass with severe calcification on the anterior mitral annulus and mean mitral gradient of 20 mm Hg. Because of the suspicion of the intracardiac calcified tumor that restricted mitral valve motion causing mitral obstruction, she underwent resection of the mass and mitral valve replacement. Pathological findings showed that the mass had a calcified envelope containing liquefied necrotic eosinophilic material with lympocytic infiltrate inside consistent with MAC. We should consider a possibility of MAC when we see a severe calcified mass attached to the mitral annulus in a patient on long-term hemodialysis.

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          Most cited references 4

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          Caseous calcification of the mitral annulus: a neglected, unrecognized diagnosis.

          Mitral annular calcification is a common echocardiographic finding. Caseous calcification is a rare variant seen as a large mass with echolucencies that resembles a tumor, occasionally resulting in exploratory cardiotomy. The aim of this study was to assess the prevalence of caseous calcification of the mitral annulus, to evaluate patient characteristics and the echocardiographic variables for diagnosing this entity, and to describe the clinical outcome on follow-up of such patients. Caseous calcification was defined as a large, round, echo-dense mass with smooth borders situated in the periannular region, with no acoustic shadowing artifacts and containing central areas of echolucencies resembling liquefaction. Eighteen patients were diagnosed by 2-dimensional echocardiography as having caseous calcification of the mitral annulus. One had calcification of the tricuspid annulus. Nine patients underwent transesophageal echocardiographic studies. A typical finding of a round, sometimes semilunar, large, echo-dense, soft mass with central echolucencies seen on both transthoracic and in particular transesophageal echocardiography, resembling a periannular mass, was demonstrated. The mass was posteriorly located in all mitral patients. Transesophageal echocardiography added limited information. Three patients underwent mitral valve replacement. The operative findings were a solid mass adherent to the posterior portion of the mitral valve. Sectioning revealed a toothpaste-like, white, caseous material. Sixteen (84%) patients were treated conservatively. On follow-up of 3.8 +/- 2.4 years, 4 patients died of unrelated causes. The characteristic appearance of a large, soft, echo-dense mass containing central areas of echolucencies resembling liquefaction at the posterior periannular region of the mitral valve on 2D echocardiography is compatible with the diagnosis of caseous abscess. Such a finding should not be confused with a tumor. Transesophageal echocardiography does not appear to contribute to the diagnosis. This rather impressive lesion appears to carry a benign prognosis.
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            Tumors of the cardiac valves: imaging findings in magnetic resonance imaging, electron beam computed tomography, and echocardiography.

            We describe the findings from various cross-sectional imaging modalities in patients with cardiac valve adherent masses. The techniques are discussed, and imaging findings are compared with the results of cardiac surgery. All three patients had neurological symptoms and/or cardiac murmurs. Transthoracic and/or transesophageal echocardiography revealed the cardiac mass in all three. For differentiation of thrombus and cardiac neoplasm magnetic resonance imaging (MRI) was also performed in all three patients and electron-beam computed tomography (EBCT) in two. Fast segmented cine gradient-echo MRI techniques provided mass depiction in all patients, while T1-weighted spin-echo imaging failed in mass detection in one patient. None of the patients showed evidence of valve regurgitation or stenosis in flow sensitive cine MRI. EBCT excluded mass calcifications in both patients and reliably demonstrated the valve attached lesions. Although echocardiography is the modality of choice in evaluating cardiac masses and especially valve attached masses, MRI and EBCT provide additional information about tissue characteristics and allows an excellent overview of the cardiac and paracardiac morphology. Fast segmented cine gradient-echo MRI is especially able to depict even small tumors attached to rapidly moving cardiac valves, and valve competence can be easily assessed within the same examination.
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               E. Maher (1987)

                Author and article information

                S. Karger AG
                September 2006
                29 September 2006
                : 106
                : 3
                : 164-166
                Departments of Cardiology and Cardiothoracic Surgery, National Cardiovascular Center, Osaka, Japan
                92827 Cardiology 2006;106:164–166
                © 2006 S. Karger AG, Basel

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                Figures: 2, References: 5, Pages: 3
                Case Report


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