Serial Cardiac Magnetic Resonance Imaging of a Rapidly Progressing Liquefaction Necrosis of Mitral Annulus Calcification Associated With Embolic Stroke
2012; Lippincott Williams & Wilkins; Volume: 125; Issue: 22 Linguagem: Inglês
10.1161/circulationaha.111.043182
ISSN1524-4539
AutoresOn Chen, Nripen Dontineni, Ghaith Nahlawi, Geetha P. Bhumireddy, Seol Young Han, Yakoub Katri, Iosif Gulkarov, Daniel Ciaburri, Anthony J. Tortólani, Richard Lazzaro, Terrence J. Sacchi, Joshua Socolow, John F. Heitner,
Tópico(s)Cardiac Imaging and Diagnostics
ResumoHomeCirculationVol. 125, No. 22Serial Cardiac Magnetic Resonance Imaging of a Rapidly Progressing Liquefaction Necrosis of Mitral Annulus Calcification Associated With Embolic Stroke Free AccessBrief ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessBrief ReportPDF/EPUBSerial Cardiac Magnetic Resonance Imaging of a Rapidly Progressing Liquefaction Necrosis of Mitral Annulus Calcification Associated With Embolic Stroke On Chen, MD, Nripen Dontineni, MD, Ghaith Nahlawi, MD, Geetha P. Bhumireddy, MD, Seol Young Han, MD, Yakoub Katri, MD, Iosif M. Gulkarov, MD, Daniel G. Ciaburri, MD, Anthony J. Tortolani, MD, Richard S. Lazzaro, MD, Terrence J. Sacchi, MD, Joshua A. Socolow, MD and John F. Heitner, MD On ChenOn Chen From the New York Methodist Hospital Cardiovascular Magnetic Resonance Center, Brooklyn, NY. , Nripen DontineniNripen Dontineni From the New York Methodist Hospital Cardiovascular Magnetic Resonance Center, Brooklyn, NY. , Ghaith NahlawiGhaith Nahlawi From the New York Methodist Hospital Cardiovascular Magnetic Resonance Center, Brooklyn, NY. , Geetha P. BhumireddyGeetha P. Bhumireddy From the New York Methodist Hospital Cardiovascular Magnetic Resonance Center, Brooklyn, NY. , Seol Young HanSeol Young Han From the New York Methodist Hospital Cardiovascular Magnetic Resonance Center, Brooklyn, NY. , Yakoub KatriYakoub Katri From the New York Methodist Hospital Cardiovascular Magnetic Resonance Center, Brooklyn, NY. , Iosif M. GulkarovIosif M. Gulkarov From the New York Methodist Hospital Cardiovascular Magnetic Resonance Center, Brooklyn, NY. , Daniel G. CiaburriDaniel G. Ciaburri From the New York Methodist Hospital Cardiovascular Magnetic Resonance Center, Brooklyn, NY. , Anthony J. TortolaniAnthony J. Tortolani From the New York Methodist Hospital Cardiovascular Magnetic Resonance Center, Brooklyn, NY. , Richard S. LazzaroRichard S. Lazzaro From the New York Methodist Hospital Cardiovascular Magnetic Resonance Center, Brooklyn, NY. , Terrence J. SacchiTerrence J. Sacchi From the New York Methodist Hospital Cardiovascular Magnetic Resonance Center, Brooklyn, NY. , Joshua A. SocolowJoshua A. Socolow From the New York Methodist Hospital Cardiovascular Magnetic Resonance Center, Brooklyn, NY. and John F. HeitnerJohn F. Heitner From the New York Methodist Hospital Cardiovascular Magnetic Resonance Center, Brooklyn, NY. Originally published5 Jun 2012https://doi.org/10.1161/CIRCULATIONAHA.111.043182Circulation. 2012;125:2792–2795Mitral 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.CaseA 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.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.Download figureDownload PowerPointFigure 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.Download figureDownload PowerPointFigure 2. Computed tomography image performed on first admission. This is a 5-chamber view; black arrow indicates a soft tissue mass at the level of the mitral valve and left ventricle, with significant calcification.Download figureDownload PowerPointFigure 3. Serial CMR imaging. Serial CMR studies performed over 1 month. Cine images (TrueFISP sequence) presented in 4-chamber views on the top and short-axis views at the level of the mitral valve on the bottom. A and B, images obtained during initial presentation; white arrows show a hypointense solid mass (4.3×1.8 cm) at the level of the mitral valve that is extending in to the left atrium and left ventricle. C and D, Images obtained 20 days later, as part of the workup for a source of an embolic stroke. The white arrows point to the mass that has increased in size (5.1×2.2) and appears to be semisolid with clearing of the center. E and F, Images obtained after biopsy 31 days after initial presentation. The white arrows point to the mass that has transformed in to a fluid-filled cystic cavity. CMR indicates cardiac magnetic resonance.Download figureDownload PowerPointFigure 4. T1-weighted image. CMR T1-weighted image, short-axis view at the level of the mitral valve. Arrow points to the mass that appears to be hyperintense. CMR indicates cardiac magnetic resonance.Download figureDownload PowerPointFigure 5. T2-weighted image. CMR T2-weighted image, short-axis view at the level of the mitral valve. Arrow points to the mass that appears to be hypointense. CMR indicates cardiac magnetic resonance.Download figureDownload PowerPointFigure 6. CMR delayed-enhancement images, 10 minutes after injection of gadolinium. A, 4-chamber view with white arrow pointing to the mass. B, Short-axis view through the basal left ventricle with white arrow pointing to the mass in the anterolateral segment. In both images, the mass appears to be homogeneous with a bright ring. CMR indicates cardiac magnetic resonance.Download figureDownload PowerPointFigure 7. CMR first pass perfusion image in a short-axis view at the level of the mitral valve. The white arrow points to the mass that remains avascular during contrast enhancement of the left ventricle. Asterisk indicates bright contrast-enhanced left ventricular chamber. CMR indicates cardiac magnetic resonance.The patient returned 2 weeks later, however, with an acute stroke in >1 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 pus, leading to initiation of antibiotics. Cytology (Figure 9A) was negative for malignancy but showed macrophages and microcalcification consistent with a calcified cyst. Tissue pathology (Figure 9B and 9C) revealed fragments of fibrocollagenous tissue with calcifications and fragments of normal myocardial tissue. Fluid cultures were negative.Download figureDownload PowerPointFigure 8. Surgical biopsy. Images taken during thoracotomy and biopsy; the white arrow indicates caseous fluid obtained after biopsy needle was removed.Download figureDownload PowerPointFigure 9. Cytology and pathology. A, Light microscopy examination of fluid obtained during biopsy, a thin preparation using the Papanicolaou stain. Asterisk indicates source fluid containing calcification (blue); black arrows, red blood cells. B and C, pathology, light microscopy examination of tissue obtained on biopsy. Cell block treated with hematoxylin and eosin. Black arrow indicates fibrocollagenous tissue with calcification; asterisk, normal myocardial cells.On follow-up CMR (Figure 3E and 3F), the mass appeared to be a fluid-filled cystic cavity with a hypoechoic center. An echocardiogram confirmed these changes.DiscussionMAC is a common finding in the elderly; it is more common in women and patients with chronic kidney disease. The morbidity due to MAC is mostly associated with the hemodynamic effects on the mitral valve. A less common manifestation of MAC is liquefaction necrosis. Its prevalence is unclear and estimated to be 0.067% among all patients and 0.63% among patients with MAC.1 The exact mechanism causing this disease is not clear, but it appears to be associated with a surge in serum calcium. Echocardiographic follow-up revealed MAC to be a dynamic process with some cases transforming from a solid mass to liquefaction and regression or even complete resolution.2In our case, serial CMR studies support the theory of a dynamic spectrum of this disease. In our patient, the mass exhibited rapid progression with changes in consistency over 1 month starting as a homogeneous mass on the first scan, with progressive changes over 1 month to a fluid-filled cavity. The use of CMR in the workup of liquefaction necrosis of MAC has been reported in only a few cases thus far; however, with the advantage of being able to determine tissue characterization, CMR is an ideal imaging modality. The findings in these previous reports were consistent with the findings in our patient. Liquefaction necrosis has been described as a well-demarcated structure involving the mitral annulus, with a hyperintense center on T1-weighted images, no change on fat saturation sequences, and absence of enhancement on first pass perfusion. Delayed enhancement imaging reveals a hyperenhanced ring and absence of enhancement in the center.3T1-weighted images cause tissue that has a short T1 relaxation time to be hyperintense, such as fat, sebaceous material, hemorrhagic products, proteinaceous fluid, and gadolinium-based contrast. T2-weighted images cause tissue to be hyperintense that have a long T2 relaxation time which generally occurs with water or edema (ie, as seen with many tumors). Calcium generally will have a hypointense signal on both T1- and T2-weighted images. This mass had similar CMR characteristics on T1- and T2-weighted imaging as previously described.3 The slightly hyperintense signal within the core of the mass on T1-weighted imaging is likely due to the high proteinaceous fluid content within the calcified wall. Because of the low water content and high protein content, the center of the mass was hypointense on T2-weighted imaging. The hyperenhanced ring on delayed enhanced imaging can be attributable to fibrotic myocardium surrounding the cystic mass that is likely a by-product of the high content of activated macrophages and lymphocytes and their respective cytokine damage of surrounding myocardium.When biopsied, a caseous fluid consisting of calcium, cholesterol, and fatty acids was obtained leaving a calcified envelope.1,2 In our case, a similar fluid was obtained and was initially thought to be pus by gross inspection; however, cultures were negative.ConclusionThe clinical course of MAC is usually benign and rarely requires intervention. The recognition of this disease and its distinct imaging features is essential to avoid unnecessary workup, surgical procedures, or treatment. However, an association with embolic stroke and mitral valve dysfunction has been described; surgical replacement of the mitral valve should be considered in those cases.4CMR is an excellent imaging modality for the diagnosis of liquefaction necrosis because of the ability for tissue characterization via T1- and T2-weighted sequences, perfusion, fat saturation, and postcontrast sequences, and for follow-up of progression and assessment of the effect on mitral valve function, as well.DisclosuresNone.FootnotesCorrespondence to John F. Heitner, MD, Director of Non-Invasive Cardiology, Division of Cardiology, New York Methodist Hospital, 506 6th St, 2 Buckley Pavilion, Brooklyn, NY 11215. E-mail [email protected]orgReferences1. Harpaz D, Auerbach I, Vered Z, Motro M, Tobar A, Rosenblatt S. Caseous calcification of the mitral annulus: a neglected, unrecognized diagnosis. J Am Soc Echocardiogr. 2001; 14: 825– 831. CrossrefMedlineGoogle Scholar2. Deluca G, Correale M, Ieva R, Del Salvatore B, Gramenzi S, Di Biase M. The incidence and clinical course of caseous calcification of the mitral valve: a prospective echocardiographic study. J Am Soc Echocardiogr. 2008; 21: 828– 833. CrossrefMedlineGoogle Scholar3. Di Bella G, Masci PG, Ganame J, Dymarkowski S, Bogaert J. Liquefaction necrosis of mitral annulus calcification detection and characterization with cardiac magnetic resonance imaging. Circulation. 2008; 117: e292– e294. LinkGoogle Scholar4. Stamou SC, Braverman AC, Kouchoukos TK. Caseous calcification of the anterior mitral valve annulus presenting as intracardiac mass. J Thorac Cardiovasc Surg. 2010; 140: e9– e10. CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Tanaka Y, Hamatani Y, Iguchi M, Minami K, Ishigami K, Ikeda S, Masunaga N, Abe M, Kono T and Akao M (2022) Caseous calcification of mitral annulus evaluated by multi-modality imaging including cardiac magnetic resonance parametric mapping, Journal of Cardiology Cases, 10.1016/j.jccase.2022.04.019, Online publication date: 1-May-2022. Li Z, Zhao Z, Cai Z, Sun Y, Li L, Yao F, Yang L, Zhou Y, Zhu H, Fu Y, Wang L, Fang W, Chen Y and Kong W (2020) Runx2 (Runt-Related Transcription Factor 2)-Mediated Microcalcification Is a Novel Pathological Characteristic and Potential Mediator of Abdominal Aortic Aneurysm, Arteriosclerosis, Thrombosis, and Vascular Biology, 40:5, (1352-1369), Online publication date: 1-May-2020. Choi Y, Kim H, Kwon H, Chun E, Ko S, Yoo S, Choi S and Jin K (2017) Cardiac CT and MRI for Assessment of Cardioembolic Stroke, Cardiovascular Imaging Asia, 10.22468/cvia.2016.00045, 1:1, (13), . Fukushima N, Yoshizawa H, Iijima M, Nagashima Y, Yamasaki K, Hagiwara N and Kitagawa K (2017) Recurrent ischemic stroke as a result of caseous calcifications of the mitral annulus under dual anti‐platelet therapy, Neurology and Clinical Neuroscience, 10.1111/ncn3.12143, 5:6, (181-182), Online publication date: 1-Nov-2017. Dietl C, Hawthorn C and Raizada V Risk of Cerebral Embolization with Caseous Calcification of the Mitral Annulus: Review Article, The Open Cardiovascular Medicine Journal, 10.2174/1874192401610010221, 10:1, (221-232) Sagnier S, Poli M, Oysel-Mestre M, Corneloup O, Debruxelles S, Renou P, Rouanet F and Sibon I (2015) Caseous calcification of the mitral annulus associated with stroke: Report of two cases, Revue Neurologique, 10.1016/j.neurol.2014.07.019, 171:2, (157-160), Online publication date: 1-Feb-2015. Hart R, Diener H, Coutts S, Easton J, Granger C, O'Donnell M, Sacco R and Connolly S (2014) Embolic strokes of undetermined source: the case for a new clinical construct, The Lancet Neurology, 10.1016/S1474-4422(13)70310-7, 13:4, (429-438), Online publication date: 1-Apr-2014. Kamperidis V, de Graaf M, Broersen A, Ahmed W, Sianos G, Delgado V, Dijkstra J, Bax J and Scholte A (2014) Prognostic Value of Aortic and Mitral Valve Calcium Detected by Contrast Cardiac Computed Tomography Angiography in Patients With Suspicion of Coronary Artery Disease, The American Journal of Cardiology, 10.1016/j.amjcard.2013.11.027, 113:5, (772-778), Online publication date: 1-Mar-2014. Elgendy I and Conti C (2013) Caseous Calcification of the Mitral Annulus: A Review, Clinical Cardiology, 10.1002/clc.22199, (n/a-n/a), Online publication date: 1-Aug-2013. June 5, 2012Vol 125, Issue 22 Advertisement Article InformationMetrics © 2012 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.111.043182PMID: 22665887 Originally publishedJune 5, 2012 PDF download Advertisement SubjectsComputerized Tomography (CT)Imaging
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