Infective calcified amorphous tumor on mitral valve and critical course of left ventricular rupture

Abstract

Calcified amorphous tumor is a rare intracavitary cardiac lesion and an accompanying infection is extremely rare. A 76-year-old woman was transferred to our hospital because of cerebral infarction. Echocardiography and chest computed tomography showed a calcified large mobile mass on the posterior mitral valve that was diagnosed with a calcified amorphous tumor. Moderate aortic regurgitation and severe mitral regurgitation were also confirmed. Her blood culture detected Gamella sp. We surgically dissected this infective calcified amorphous tumor. The border between this infective tumor and the mitral annulus was unclear because of severe infection and necrotic tissue. After careful complete resection, the healthy ventricular muscle was exposed and we performed annular reconstruction with bovine pericardial patches. And we replaced the aortic and mitral valves using bioprosthesis. While weaning from cardiopulmonary bypass, however, left ventricular rupture occurred twice. Despite successful repair of left ventricular rupture, which controlled bleeding, she died from multi-organ failure on postoperative day 6. An infective calcified amorphous tumor in such a critical case has not been reported previously. The calcified amorphous tumor probably become serious when the infection occurred. In this situation, the utmost caution should be paid to the patient. <Learning objective: Calcified amorphous tumor (CAT) is a rare non-neoplastic intracavitary cardiac lesion. There have been some reports of CATs but they are extremely rare with accompanying infection or critical situations. Our patient was a 76-year-old female with infective CAT who suffered from cerebral infarction, and she died from multi-organ failure despite best surgical treatment. CAT probably become serious when the infection occurred. In this situation, the utmost caution should be paid to the patient.>.

Keywords: Calcified amorphous tumor; Infective endocarditis; Left ventricular rupture.

Fig. 1

Preoperative transthoracic echocardiography and contrast enhanced chest computed tomography, and intraoperative findings of posterior mitral leaflet formed with a calcified tumor. (a) Echocardiography, long-axis view, shows a calcified tumor with a mosaic echoic lesion (arrow) (37 × 24 mm) at the annulus of the posterior mitral leaflet. (b) Chest computed tomography shows the calcified tumor (arrow) at the posterior mitral annulus. (c) Posterior mitral leaflet formed a calcified tumor (arrowhead) with vegetation. Ao, aorta; LA, left atrium; LV, left ventricle.

Fig. 2

Operative procedure of the range of debridement, the mitral valve replacement, and the repair of the LV rupture. (a) After the complete debridement of the CAT, mitral annular reconstruction was performed using bovine pericardial patch on the exposed LV muscle. Mitral valve replacement was performed by the half-and-half technique, everting mattress sutures at the posterior mitral annulus and non-everting mattress sutures in the anterior mitral annulus. (b) The first type III LV rupture occurred with ejection of the stent post of the prosthetic valve. (c) The rupture site was sandwiched using bovine pericardial patches by interrupted mattress sutures, filling with BioGlue® (CryoLIfe, Inc., Kennesaw, GA, USA). (d) The second LV rupture occurred at the cranial part of the repaired site with ejection of the stent post. (e) We repaired the LV rupture using the same method with the large bovine pericardial patches. CAT, calcified amorphous tumor; LV, left ventricular; CPB, cardiopulmonary bypass; GCV, great cardiac vein; MCV, middle cardiac vein; CS, coronary sinus; Ao, aorta; LA, left atrium. .

Fig. 3

Pathological examination of the infected calcified tumor. (a) Histopathological examination revealed multiple nodular calcification (arrow head) and fibrous connective tissue. (b) The small arrow showed accumulation of neutrophils in the tissue. (c) The abscess was formed by Gram-positive cocci (large arrow).