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Liquefaction Necrosis of Mitral Annulus Calcification

2008; Lippincott Williams & Wilkins; Volume: 117; Issue: 12 Linguagem: Francês

10.1161/circulationaha.107.729905

1524-4539

Gianluca Di Bella, Pier Giorgio Masci, Javier Gáname, Steven Dymarkowski, Jan Bogaert,

Cardiac Imaging and Diagnostics

HomeCirculationVol. 117, No. 12Liquefaction Necrosis of Mitral Annulus Calcification Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessReview ArticlePDF/EPUBLiquefaction Necrosis of Mitral Annulus CalcificationDetection and Characterization With Cardiac Magnetic Resonance Imaging Gianluca Di Bella, Pier Giorgi Masci, Javier Ganame, Steven Dymarkowski and Jan Bogaert Gianluca Di BellaGianluca Di Bella From the Medical Imaging Centre, UZ Leuven, Leuven, Belgium. , Pier Giorgi MasciPier Giorgi Masci From the Medical Imaging Centre, UZ Leuven, Leuven, Belgium. , Javier GanameJavier Ganame From the Medical Imaging Centre, UZ Leuven, Leuven, Belgium. , Steven DymarkowskiSteven Dymarkowski From the Medical Imaging Centre, UZ Leuven, Leuven, Belgium. and Jan BogaertJan Bogaert From the Medical Imaging Centre, UZ Leuven, Leuven, Belgium. Originally published25 Mar 2008https://doi.org/10.1161/CIRCULATIONAHA.107.729905Circulation. 2008;117:e292–e294A transthoracic echocardiogram of a 68-year-old man complaining of exercise-related retrosternal chest pain revealed a dense, echogenic, calcified nodular structure at the posterior side of the mitral valve annulus (Figure 1). The patient was referred for cardiac magnetic resonance imaging (MRI). T1-weighted fast spin-echo (FSE) (Figure 2A) showed a well-defined structure (28 mm in diameter) with a homogeneous, slightly hyperintense center and a hypointense rim (Figure 2A, arrows) located between the posterior mitral valve leaflet and adjacent left ventricular myocardium. Fat suppression did not alter signal characteristics (Figure 2B, arrows). On T2 short-τ inversion-recovery FSE, the structure was devoid of signal (Figure 2C, arrows). Dynamic imaging using steady-state free-precession cine MRI in the horizontal long-axis plane (Figure 2D and Movie I) and in the short-axis plane (Figure 3A and Movie II) obtained through the mitral valve plane showed a non- or at most minimally deforming mass moving in synchronicity with the surrounding left ventricular myocardium (arrows) and presence of moderately severe mitral regurgitation (Figure 2D, black arrowheads, and Movie I). Myocardial perfusion MRI in the horizontal long-axis (Movie III) showed a hyperintense appearance of the structure before contrast administration but no evidence of enhancement during the first pass. Although FSE after contrast administration (Figure 2E, arrows) did not show enhancement, strong peripheral enhancement was found 10 minutes after contrast administration with the use of the contrast-enhanced inversion-recovery technique (Figure 2F, arrowhead, and Figure 3B, arrows). On the basis of the above findings, a presumptive diagnosis of a centrally liquefied mass containing a high-protein or hemorrhagic content with a thick inflammatory and/or fibrotic wall that was likely partially calcified was made. A resting ECG was unremarkable (Figure 4), whereas cardiac catheterization confirmed the calcified nature of the lesion (Figure 5). During surgery, a centrally liquefied structure was found posterolaterally in the left ventricle attached to a thickened posterior mitral valve leaflet. Incision into the lesion revealed a dark yellow fluid. The wall was fibrotically thickened, containing areas of either calcification or inflammation, which led to the diagnosis of liquefaction necrosis of mitral annulus calcification. Culture of the fluid was negative. The patient underwent mitral valve replacement and coronary artery bypass graft surgery. Download figureDownload PowerPointFigure 1. Transthoracic echocardiography with the parasternal long-axis view shows a dense, echogenic, calcified nodular structure at the posterior border of the mitral valve annulus (arrowheads).Download figureDownload PowerPointFigure 2. Axial plane imaging with a variety of cardiac MRI sequences. T1-weighted FSE images without (A) and with (B) fat suppression are shown. C, T2 short-τ inversion-recovery FSE. D, Steady-state free-precession cine MRI obtained along the horizontal long-axis at early systole. E, T1-weighted FSE after administration of gadolinium-diethylenetriamine pentaacetic acid. F, Contrast-enhanced inversion-recovery MRI obtained 10 minutes after contrast administration.Download figureDownload PowerPointFigure 3. Steady-state free-precession cine MRI (A) and contrast-enhanced inversion-recovery MRI (B) in cardiac short-axis view at the basal ventricular level.Download figureDownload PowerPointFigure 4. Resting ECG.Download figureDownload PowerPointFigure 5. Cardiac catheterization (right anterior oblique view) shows an oval soft tissue structure with inhomogeneous calcified border at the left ventricle base (arrowheads).Mitral annulus calcification is a common degenerative disorder in the elderly, particularly in women and in patients with kidney disease.1–2 Liquefaction necrosis of the posterior mitral annulus is a rare and atypical variant of mitral annulus calcification that is usually associated with a benign prognosis and was recently identified as an unusual evolution of mitral annulus calcification.2 The core of liquefaction necrosis comprises amorphous eosinophilic acellular fluid, and the surrounding rim contains macrophages and lymphocytes as well as multiple areas of calcification and necrotic zones.1 Use of a comprehensive MRI approach is helpful to characterize the different components and to rule out other diseases.The online-only Data Supplement, which contains Movies I through III, is available with this article at http://circ.ahajournals.org/cgi/content/full/ 117/12/e292/DC1.DisclosuresNone.FootnotesCorrespondence to Jan Bogaert, MD, PhD, Medical Imaging Centre, UZ Leuven, Herestraat 49, B-3000 Leuven, Belgium. E-mail [email protected] kuleuven.ac.beReferences1 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 Yokoyama N, Konno K, Suzuki S, Isshiki T. Serial assessment of liquefaction necrosis of mitral annulus calcification by echocardiography and multislice computed tomography. Circulation. 2007; 115: e1–e2.LinkGoogle Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article 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, 26:3, (221-224), Online publication date: 1-Sep-2022. 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Pouliquen G, Fresse-Warin K and Crochet D (2009) Diagnostic d'une masse calcifiée intrapariétale adjacente à la valve mitrale postérieure : à propos de 4 cas, Journal de Radiologie, 10.1016/S0221-0363(09)74026-0, 90:5, (597-604), Online publication date: 1-May-2009. March 25, 2008Vol 117, Issue 12 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.107.729905PMID: 18362237 Originally publishedMarch 25, 2008 PDF download Advertisement SubjectsCardiovascular SurgeryComputerized Tomography (CT)