Reduced Size of Liquefaction Necrosis of Mitral Annular Calcification in Chronic Renal Failure by Using Low Calcium Concentration Hemodialysis

Abstract

itral annular calcification is a degenerative process that is commonly seen in the elderly, especially in women, and is usually recognized on Mmode and 2-dimensional echocardiography as a dense echo band moving parallel with the left ventricular free wall beneath the posterior mitral leaflet. 1,2 Chronic renal failure is one of the predisposing factors of this condition. 1,3 We report a case of liquefaction necrosis of a mitral annular calcification mimicking an intracardiac tumor, 4-8 in which both gallium-67 ( 67 Ga)-citrate and technetium-99m-methylene diphosphate ( 99m Tc-MDP) uptake was noted, in a patient with chronic renal failure that had been managed by hemodialysis for 11 years. The size of the liquefaction necrosis was reduced with low calcium concentration hemodialysis. Case ReportAn asymptomatic 58-year-old woman who had been on hemodialysis for 11 years because of chronic renal failure came to hospital for examination of an abnormal intracardiac mass, which had been found incidentally during an annual echocardiographic examination, and which had not been seen the year before. The patient's blood pressure was 126/72 mmHg. The heart rate was 76 beats/min with regular rhythm. The fourth heart sound and a grade 3/6 systolic ejection murmur were heard at the apex. Slightly anemic conjunctivae, dry skin and mildly distended abdomen due to ascites were seen. Laboratory studies were as follows: red blood cell count 367×10 4 /mm 3 , hemoglobin 11.3 g/dl, C-reactive protein <0.3 mg/dl, blood sugar 86 mg/dl, serum cholesterol 222 mg/dl, blood urea nitrogen 40 mg/dl, creatinine 7.1 mg/dl, calcium 2.4 mmol/L, phosphorus 2.7 mmol/L, alkaline phosphatase 308 U/L and the intact parathyroid hormone level 888 pg/ml. The patient had been given calcium carbonate and erythropoietin to correct the hypocalcemia and anemia, and pulse therapy of 1,25-dihydroxycholecalciferol (1,25(OH)2D3) had also been performed for secondary hyperparathyroidism approximately 6 months before presentation.Transthoracic echocardiography demonstrated an echogenic 2.0×2.0×2.0 cm spherical mass with an internal echolucent area at the base of the posterior mitral leaflet and the lateral portion of the mitral annulus (Fig 1 a,b). No mitral regurgitation on Doppler color flow mapping was seen and there was normal left ventricular wall motion, although a small amount of pericardial effusion was noted.A high-density mass was observed at the base of the posterior mitral leaflet on computed tomography (CT) and a low-intensity mass was observed in the same area on magnetic resonance imaging (MRI) using the field echo technique; both these masses were compatible with calcification (Fig 2). Single photon emission CT with 67 Ga-citrate (Fig 3) and 99m Tc-MDP scintigraphy (Fig 4) revealed focal uptake at the same site as the spherical mass seen on echocardiography. Parathyroid scintigraphy by subtraction of thallium-201-chloride and 99m Tc-pertechnetate scan revealed 4 hypertrophied parathyroids compatible with secondary hyperparathyroidism due to chronic ...

Mitral annular calcification and brown tumor of the rib in a child with chronic renal failure

“…Mitral annular calcification mimics tumorlike myxoma, vegetation or an abscess of infective endocarditis, or thrombus attached inside the left atrium. The most important complications are thromboembolic events [3]. Herein, we report a mitral annular calcification with left atrial masses and brown tumor in the anteriorlateral right thorax in a 13-year-old girl with a 5-year history of CAPD.…”

“…Secondary HPT plays a key role in the etiological basis of extraskeletal calcifications, such as soft tissue [3,4,5,6,7]. Clinically significant lesions of the soft tissue, particularly of the heart and vessels, are rare, especially in pediatric patients with secondary HPT [5].…”

“…Clinically significant lesions of the soft tissue, particularly of the heart and vessels, are rare, especially in pediatric patients with secondary HPT [5]. Chronic renal failure has been suggested as a risk factor for mitral annular calcification, a degenerative process of the mitral annulus [3,4]. Mitral annular calcification mimics tumorlike myxoma, vegetation or an abscess of infective endocarditis, or thrombus attached inside the left atrium.…”

“…The classic histological form is osteitis fibrosa cystica (brown tumor), which is attributed to secondary hyperparathyroidism (HPT) [1,2]. Although soft tissue calcification has been regarded as rare in children, it is a common complication of uremia in adult patients and has been implicated as a cause of ischemic necrosis, cardiac arrhythmias and respiratory failure [3,4,5,6]. Herein, we report the case of a 13-year-old patient with echo-dense masses at the base of the mitral leaflets mimicking intracardiac tumor and brown tumor localized in the region of the anterior-lateral between the 5-7th right ribs.…”

Caseous calcification and liquefaction of the mitral annulus: a diagnostic confounder

“…Even unnecessary explorative cardiotomies for such lesions have been reported in the past when they were misdiagnosed as abscesses or cardiac tumors [4,5]. Recently, reports have been published defining the characteristics of such lesions with different imaging modalities such as echocardiography [1], multi-slice CT [8,9], cardiac magnetic resonance imaging [8,9] and single photon emission CT [9].…”