PMC5651129_01
Transthoracic 2D (a) and 4D (b) echocardiographic views in parasternal long axis orientation. Parachute-shaped mass (arrows) in LA attached to atrial side of AML and inferoposterior region of left atrial endocardium. LA: left atrium; LV: left ventricle.
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fig1
It was hollow, parachute-shaped, mainly tethered to AML and partially to posterior leaflet and adjoining posterior wall of LA (Figure 1).
Apical 4-chamber view showing the mass (arrows) mimicking anterior leaflet aneurysm. Color Doppler (b) shows systolic flow into the mass in addition to eccentric MR. LV: left ventricle, LA: left atrium, RV: right ventricle, RA: right atrium, and MR: mitral regurgitation.
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fig2
Color Doppler examination revealed a systolic jet both into the cavity of this mass and into the LA (Figure 2).
CMR cine run in the sagittal plane reconfirms the thick-walled parachute mass (arrows) tethered to the tip of AML and LA inferoposterior region. Systolic flow into the mass and significant MR are also evident. LA: left atrium, LV: left ventricle, AML: anterior mitral leaflet, and MR: mitral regurgitation.
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fig3
CMR of the structure was carried out to further delineate the mass and assess the possibility of anterior mitral leaflet aneurysm that was ruled out, supporting the 4D echocardiographic morphological description (Figures 3 and 4).
CMR transverse plane image of the LA mass showing its circular shape in cross-section. LA: left atrium; RA: right atrium.
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fig4
CMR of the structure was carried out to further delineate the mass and assess the possibility of anterior mitral leaflet aneurysm that was ruled out, supporting the 4D echocardiographic morphological description (Figures 3 and 4).
Perioperative image from left atrial access looking at the atrial side of the mass. (A) Parachute-shaped tuberculoma as viewed from above (exposed through LA approach); (B) AML.
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fig5
Left atrial approach was taken to expose the mass and its perioperative evaluation was carried out that matched with the consensus morphology on preoperative imaging assessments (Figure 5).
Histological pictures from biopsy specimens of resected mass. (a) Histological appearance of tuberculous granuloma surrounded by palisaded epithelioid histiocytes (broad arrow) with central caseous necrosis (long arrow), (b) magnified histological picture showing a Langhans giant cell (arrow), and (c) Langhans giant cell (arrow) with ZN staining.
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fig6
Histological evaluation of tissue sample from the growth revealed areas of caseous necrosis with Langhans giant cells (Figure 6).