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Letters to the Editor
Spontaneous Resolution of a Caseous Calcification of the Mitral Annulus
Michele CorrealeI, Giovanni DelucaII, Riccardo IevaI, Matteo Di BiaseI
I University of Foggia, Department of Cardiology - Foggia, Italy
II Andria Hospital, Department of Cardiology - Andria, Italy. Tel: 39 088 173 3652
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">INTRODUCTION</span><p id="para10" class="elsevierStylePara elsevierViewall">An asymptomatic 76-year-old woman with a prior history of mitral annular calcification underwent a transthoracic echocardiographic examination for evaluation&#46; Her risk factor for atherothrombotic disease was hypertension&#44; and she had no prior medical history of hyperlipidemia or diabetes&#46; She was given the following pharmacologic treatments&#58; an angiotensin-converting enzyme &#40;ACE&#41; inhibitor &#40;quinapril 5 mg&#41;&#44; a calcium antagonist &#40;lercanidipine 10 mg&#41;&#44; a loop diuretic &#40;furosemide 25 mg&#41;&#44; and an antiplatelet agent &#40;acetylsalicylic acid 150 mg&#41;&#46; A round&#44; echo-dense structure was visualized in the left atrioventricular groove region &#40;<a class="elsevierStyleCrossRef" href="#f1-cln64_11p1130">Fig&#46; 1</a>&#44; upper panels&#41;&#46; A transesophageal echocardiographic examination &#40;TEE&#41; was performed to better evaluate this intracardiac mass &#40;<a class="elsevierStyleCrossRef" href="#f1-cln64_11p1130">Fig&#46; 1</a>&#44; lower panels&#41;&#46; A large &#40;2&#46;14 &#215; 1&#46;82 cm&#41;&#44; round&#44; echo-dense mass containing central areas of echolucencies &#40;central liquefaction&#41; was revealed by TEE&#46; No acoustic shadowing could be detected behind the mass&#44; suggesting an absence of dense calcium deposition&#46; The mass had sharp and distinct borders&#44; with an echogenicity distinct from that of the adjacent myocardium &#40;<a class="elsevierStyleCrossRef" href="#f2-cln64_11p1130">Fig&#46; 2</a>&#44; left panel&#41;&#46; The echocardiographic findings were consistent with the diagnosis of Caseous Calcification of the Mitral Annulus &#40;CCMA&#41;&#46; The patient was asymptomatic and was treated conservatively&#46; A TEE conducted nine months later revealed the disappearance of the mass &#40;<a class="elsevierStyleCrossRef" href="#f2-cln64_11p1130">Fig&#46; 2</a>&#44; right panel&#41;&#46;</p><elsevierMultimedia ident="f1-cln64_11p1130"></elsevierMultimedia><elsevierMultimedia ident="f2-cln64_11p1130"></elsevierMultimedia></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">DISCUSSION</span><p id="para20" class="elsevierStylePara elsevierViewall">Mitral Annular Calcification &#40;MAC&#41; is a chronic degeneration of the mitral valve fibrous ring involving the posterior annulus&#46; This disorder is common in the elderly&#44; particularly in women&#46;<a class="elsevierStyleCrossRef" href="#bib1">1</a> It may also occur in younger patients with advanced renal disease or other metabolic disorders that result in abnormal calcium metabolism&#46; MAC is a consequence of atherosclerosis&#44; with risk factors identical to those of cardiovascular disease&#46; CCMA is a less-known and rarely described entity&#46; This condition is an extensive &#8220;soft&#8221; periannular calcification&#44; resembling a tumor&#44; that is composed of an admixture of calcium&#44; fatty acids&#44; and cholesterol with a &#8220;toothpaste-like texture&#46;&#8221; CCMA is often misdiagnosed as a myocardial abscess&#44;<a class="elsevierStyleCrossRefs" href="#bib2">2&#44;3</a> a tumor&#44;<a class="elsevierStyleCrossRefs" href="#bib4">4&#44;5&#44;6</a> or a thrombus&#44;<a class="elsevierStyleCrossRef" href="#bib7">7</a> in some cases<a class="elsevierStyleCrossRef" href="#bib2">2</a> leading to unnecessary explorative cardiotomy&#46; Differential diagnosis of round echogenic structures adjacent to the left atrioventricular groove should also include infected mitral calcification&#44; lipomatosis of the atrioventricular groove&#44; and enlarged lymph nodes&#46;<a class="elsevierStyleCrossRef" href="#bib8">8</a> In this case&#44; a correct diagnosis was made according to clinical presentation and echocardiographic findings&#46; Generally&#44; valvular endocarditis is unlikely in the absence of mitral valve regurgitation&#44; fever&#44; or positive blood cultures or laboratory examinations for infectious disease&#46; Clinical signs of malignancy were absent&#46; The round&#44; echodense lobular aspect and mobility of the mass favored the diagnosis of myxoma&#59; however&#44; myxomas seldom originate from valves and are often found attached to the inter-atrial septum in the fossa ovalis region&#46; Instead&#44; specific echocardiographic features of CCMA favor the diagnosis&#58; a large&#44; round echodense mass in the posterior periannular mitral region that is heterogeneous and contains central echolucent areas of necrosis&#46; The density of the mass suggested calcification and ruled out a thrombus diagnosis&#46;</p><p id="para30" class="elsevierStylePara elsevierViewall">Harpaz and colleagues conducted a prospective series of echocardiographic examinations to define the echocardiographic appearance&#44; prevalence&#44; and prognosis of CCMA&#46;<a class="elsevierStyleCrossRef" href="#bib9">9</a> They described the typical echocardiographic appearance of CCMA as a large&#44; round&#44; echo-dense mass with smooth borders situated in the periannular region&#44; lacking acoustic shadowing artifacts&#44; and containing central areas of echolucencies resembling liquefaction&#46; They emphasized that it is possible to make a correct diagnosis by transthoracic examination alone&#44; since no additional significant information was obtained by TEE in the 19 cases they examined&#46; In this patient&#44; however&#44; TEE gave a more precise and detailed image of the mass and a better definition of the motion of the posterior mitral leaflet&#46;</p><p id="para40" class="elsevierStylePara elsevierViewall">Recently&#44; we<a class="elsevierStyleCrossRef" href="#bib10">10</a> have confirmed that CCMA is a rare and benign condition &#40;14 patients with CCMA&#44; 0&#46;64&#37; of all mitral annular calcifications&#44; 0&#46;068&#37; of all studies&#41;&#46; This study revealed no clinical characteristics typical of patients with CCMA&#46; However&#44; CCMA did tend to occur in older patients&#44; and all 14 patients with CCMA had hypertension&#46; We suggested that CCMA may be a dynamic process based on the observation that three patients with MAC progressed to CCMA and three patients with CCMA reverted back to MAC during the study period&#46;</p><p id="para50" class="elsevierStylePara elsevierViewall">It is important to differentiate between CCMA and MAC&#59; the former is a larger&#44; well-delineated structure surrounded by clear borders with a distinct echolucency and a &#8220;softer&#8221; appearance that is less reflective and does not have acoustic shadowing&#46; When a CCMA is perforated&#44; a large amount of toothpaste-like&#44; milky&#44; caseous material is exuded from the mass&#46; This material it is not truly calcific&#44; but rather consists of caseous&#44; putty-like material&#46; After the material is removed&#44; only a calcified envelope remains&#46; In the case of large dense deposits of calcifications in the left atrioventricular groove&#44; significant acoustic shadowing artifacts may rule out the diagnosis of CCMA&#46; However&#44; if the calcified envelope of the CCMA is very large&#44; acoustic shadowing could result in an erroneous non-diagnosis of CCMA&#46;<a class="elsevierStyleCrossRef" href="#bib10">10</a></p><p id="para60" class="elsevierStylePara elsevierViewall">The mechanisms involved in the liquefaction necrosis of CCMA are not well understood&#46; Hypercholesterolemia and dissolution of lipid-laden macrophages might be implicated&#59; high serum cholesterol is associated with MAC and may be responsible for liquefaction necrosis&#46;</p><p id="para70" class="elsevierStylePara elsevierViewall">The peculiarity of this case is in its spontaneous resolution ten months later&#46; A previous similar case<a class="elsevierStyleCrossRef" href="#bib11">11</a> in the literature showed a spontaneous resolution of a CCMA&#46; In this previous case&#44; the patient had a prior history of hemodialysis treatment&#44; but no change was made in the hemodialysis regimen&#46; In another similar case<a class="elsevierStyleCrossRef" href="#bib12">12</a> with a prior history of hemodialysis treatment&#44; the reduction of the mass was observed after treatment with low calcium hemodialysis&#44; so the authors suggested that the acute change in the serum calcium level might have contributed to the dissolution of the mass&#46; In our case&#44; we hypothesize that central liquefaction and dissolution of the material through a rupture of external wall occurred without evident clinical consequences&#46;</p><p id="para80" class="elsevierStylePara elsevierViewall">In order to avoid misdiagnoses of CCMA as tumors&#44; abscesses&#44; or thrombi by echocardiographers&#44; it is important that knowledge of this rare lesion becomes more widespread&#46;</p></span></span>"
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

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Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos