Serial Cardiac Magnetic Resonance Imaging of a Rapidly Progressing Liquefaction Necrosis of Mitral Annulus Calcification Associated With Embolic Stroke

O. Chen, N. Dontineni, G. Nahlawi, G. P. Bhumireddy, S. Y. Han, Y. Katri, I. M. Gulkarov, D. G. Ciaburri, A. J. Tortolani, R. S. Lazzaro, T. J. Sacchi, J. A. Socolow (+1 others)
2012 Circulation  
M itral annulus calcification (MAC) is a common finding in the elderly. A rare manifestation of MAC is liquefaction necrosis that can be mistaken for a tumor or an abscess. Because its course is most often benign, a correct diagnosis is imperative to avoid unnecessary workup or treatment. Case A 76-year-old woman with history of hypertension and dyslipidemia presented with chest pain and elevated cardiac enzymes. A coronary angiogram revealed no significant coronary artery disease.
more » ... sease. Echocardiogram ( Figure 1 ) revealed a large, solid mass within the atrioventricular groove and the lateral wall of the left ventricle. There was moderate calcification of the mitral valve annulus. Computed tomography scan of the chest ( Figure 2 ) revealed a soft tissue density inseparable from the region of the mitral valve and the left ventricular wall. Cardiac magnetic resonance (CMR) showed a large mass involving the basal lateral wall near the atrioventricular groove, extending into the left atrium ( Figure 3A and 3B). The mass was slightly hyperintense on T1 ( Figure 4 ) and hypointense on T2 imaging ( Figure 5 ). The mass was homogenous on delayed enhancement with a bright ring (Figure 6 ), the characteristics were not changed with fat saturation, and it was avascular by perfusion ( Figure 7) . The patient was discharged from the hospital with a scheduled outpatient workup to continue. The patient returned 2 weeks later, however, with an acute stroke in Ͼ1 arterial distribution, and workup for an embolic source commenced. A CMR ( Figure 3C and 3D) revealed no left ventricular thrombus; the mass increased in size and changed in consistency, appearing semisolid. The patient underwent a left thoracotomy for a biopsy, which revealed a thick whitish fluid (Figure 8 ) thought to be Figure 1. Echocardiography images before and after biopsy. A, 4-chamber view performed on presentation, reveals a soft tissue mass involving the atrio-ventricular groove, the left atrium, and left ventricle. There is moderate calcification of the mitral valve. B, 4-chamber view performed after biopsy. The mass has decreased in size and appears cystic. White arrows indicate the mass.
doi:10.1161/circulationaha.111.043182 pmid:22665887 fatcat:wrc753otlvhgvgy7bal4n6m2sm