PMC3906877_01
2D echocardiography and multi-slice CT findings. Echocardiography (A) showed an echolucent mass with a highly echogenic rim (arrow) attached to the mitral valve. Transverse (B) and coronal (C) chest CT images showed a mass (arrows) adhering to the posterior mitral valve leaflet with peripheral calcification.
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F1
Echocardiography documented a mass of 26 mm x 24 mm attached to the mitral valve (Figure 1A), medium degree mitral and tricuspid regurgitation, and thrombosis of the aortic arch and descending aorta. Thoracic computed tomography (CT) confirmed the presence of a calcified lesion on the mitral valve of unclear extent (Figure 1B,C); no signs of thrombosis of the aorta were found.
Diastolic steady-state free-precession MR images of the mass in short-axis (A), 4-chamber (B) and 3-chamber (C) orientations. The mass (arrows) appears in the left ventricle, with a hyperintense core compared to myocardium and isointense to blood, adherent to the posterior papillary muscle and thickened posterior mitral valve leaflet.
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Turbo spin-echo (TSE) T1-weighted (A), TSE T2-weighted (B) and fat-saturated TSE T2-weighted (C) MR images in 4-chamber orientation. The mass is isointense to myocardium in the T1-weighted image and displays hyperintense signal on T2-weighted sequences with hypointense regions (arrows).
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F3
T1- and T2-weighted TSE images were acquired in end-diastole. The mass was isointense to myocardium on T1-weighted images (Figure 3A) and hyperintense to myocardium on T2-weighted images (Figure 3B,C).
First-pass perfusion images in short-axis (A), 3-chamber (B) and 4-chamber (C) orientations, along with the signal intensity-time curve (D) of myocardium and the mass. First-pass images show the mass as hypointense when the contrast agent arrives in the myocardium. Areas 1 and 2 in (C) show the regions of interest wherefrom signal intensity-time curves of myocardium (ROI 1) and mass (ROI 2) were derived in 4-chamber view. LV = left ventricle.
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There were no signs of myocardial infiltration (Figure 4A-C). Semi-quantitative tissue analysis was performed by manually segmenting the lesion in 4-chamber orientation; the results showed low contrast uptake in the lesion (Figure 4D).
Late-gadolinium-enhancement imaging. Images of the lesion in 3-chamber orientation acquired with a three-dimensional inversion recovery FLASH sequence (contiguous slices A through D). Inversion time was chosen to zero the mass. Arrows indicate subtle contrast enhancement in the mass and massive enhancement of the surface.
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Imaging of late gadolinium enhancement, acquired by inversion recovery gradient-echo sequences 10 minutes after contrast agent injection, demonstrated a thin, circumferential rim of contrast enhancement around the core of the mass and massive enhancement of the surface in multiple imaging planes (Figure 5).
Pre-contrast T2 map (A) as well as T1 maps obtained before (B) and 15 minutes after (C) contrast agent application in 4-chamber view. Mean pre-contrast T1, pre-contrast T2 and post-contrast T1 relaxation times of the lesion were 2220 +- 144 ms, 151 +- 17 ms and 925 +- 37 ms, respectively. Mean pre-contrast T1, pre-contrast T2 and post-contrast T1 relaxation times for blood were 1654 +- 47 ms, 147 +- 26 ms, and 271 +- 10 ms, and for myocardium 1144 +- 56 ms, 46 +- 4 ms, and 448 +- 25 ms, respectively.
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To further analyse the content and the observed contrast agent uptake of the lesion, pre-contrast T1 and T2 and post-contrast T1 relaxation times were evaluated from single-breath-hold modified Look-Locker inversion recovery (MOLLI) and T2 preparation-based T2 mapping sequences by manually segmenting the lesion (Figure 6).
Surgical (A,B) and histological (C,D) findings. The smoothly-shaped mass was attached to the mitral valve and the posterior left ventricular wall (A). The inner wall of the lesion consisted of cobblestone-shaped structures (B). Prepared low-power haematoxylin and eosin (H&E stain) photomicrograph with 10x magnification demonstrated a calcified mass adherent to myocardium (C). 20x H&E stain images of the lesion's wall showed calcified vessels, residues of blood and regions of chronic inflammation (D).
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During surgery a smooth-shaped, white-yellowish mass was found on the ventricular side attached to the mitral valve and the posterior left ventricular wall (Figure 7A). The structure contained a cloudy fluid and presented with a villous inner wall consisting of cobblestone-shaped structures (Figure 7B). Surrounded by a fibrous, calcified envelope, the wall of the lesion contained a dense layer of connective tissue with multiple occluded vessels and calcifications, without an inner epithelial layer (Figure 7C) and with signs of a chronic inflammatory process indicating chronic endocarditis (Figure 7D).