Spontaneous mitral valve perforation associated with mitral annular calcification-related calcified amorphous tumor assessed by three-dimensional transesophageal echocardiography

Excerpt

A 76-year-old male was referred for the newly developed grade 3/6 pan-systolic murmur at the apex. Blood examination showed negative inflammatory findings and almost normal renal function. He had a history of Streptococcus agalactiae bacteremia for 4 months previously, but antibiotics administration for 10 days improved inflammatory findings, and thereafter the patient remained in an afebrile state. No vegetations or valvular heart disease were found on transthoracic echocardiography (TTE), and no murmur was audible. Conversely, TTE and transesophageal echocardiography at this time showed a highly mobile echogenic spindle-shaped mass attached to the medial part (P3) of the posterior mitral leaflet (PML) with severe mitral annular calcification (MAC). PML perforation with moderate mitral regurgitation was also detected just below the mass (Fig. 1). Although brain magnetic resonance imaging confirmed no evidence of embolism, he underwent surgical mass resection and repair of PML perforation given the risk of embolism. Intraoperative findings confirmed MAC with a calcified mass attached to segment P3 and PML perforation with a similar size to the mass; however, there were no gross findings suggesting infective endocarditis (IE). Histopathologically, the resected mass showed hyalinized and calcified tissue with small fibrous material without bacterial infection, which was consistent with calcified amorphous tumor (CAT).

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