We report a rare case of a pedunculated calcified amorphous tumor (CAT) of the left ventricle attached by a stalk to the membranous septum in a 74-year-old woman who presented with a cerebrovascular accident. We believe this is the first report of a CAT attached to the membranous septum.

Although one of the most important differential diagnoses of cardiac masses in cancer patients is metastasis from the underlying tumor, it may also be caused by benign etiologies. In this article, we describe cardiac calcified amorphous tumor, which is one of the benign causes of cardiac masses, in a patient with colon cancer.

The patient is a 73-year-old woman. She presented with dysarthria, and a head MRI revealed multiple acute cerebral infarctions in the bilateral cerebral hemisphere and cerebellar hemisphere. Transesophageal echocardiography after admission revealed a 16 mm large mobile calcification of the mitral annulus (caseous calcification of the mitral annulus; CCMA) on the posterior apex of the mitral valve annulus. Since the CCMA had a high risk of relapse, and a new infarction was detected on the 8th day, resection of the mass and mitral valve replacement surgery were performed. CCMA is a subtype of mitral annular calcification (MAC). When calcification progresses from the MAC state to form a mass, it is called a calcified amorphous tumor; CAT. Reports of embolic cerebral infarction caused by CAT are rare, but this is a rare report of an embolic cerebral infarction from CCMA presenting as CAT.

BACKGROUND: Calcified amorphous tumor (CAT) of the heart is a rare non-neoplastic intracardiac mass, a calcium deposition surrounded by amorphous fibrous tissue, and possibly causes cerebral embolism. Even rarer is CAT associated with infection, and no CAT with antecedent infection has been reported to our knowledge. In addition, although some CAT in patients on hemodialysis has been reported to grow rapidly, no case has been reported on CAT that grew and diminished rapidly in a short period of time. Here, we report the case of an 82-year-old Japanese woman with normal renal function who developed multiple cerebral infarctions due to CAT that grew rapidly, associated with inflammation from an antecedent infection, and diminished rapidly by detachment of fibrin on the mass surface and antithrombotic drugs.
METHODS: The patient developed fever after dental treatment and found musical hallucination on the left ear worsened in degree and frequency. In a nearby clinic, she was treated with antibiotics, and her body temperature turned to normal in approximately 1 month. She presented to our hospital for workup on the worsened musical hallucination. Magnetic resonance imaging (MRI) showed multiple cerebral infarctions, and transthoracic echocardiography (TTE) revealed an immobile hyperechoic mass with an acoustic shadow arising from a posterior cusp of the mitral valve. CAT was suspected and treated with apixaban and aspirin. Follow-up MRI and TTE showed newly developed multiple cerebral infarctions and rapidly diminished CAT. Cardiac surgery was performed to resect the CAT. The pathological findings showed calcifications surrounded by amorphous fibrous tissue including fibrin, indicating CAT. The patient\'s symptoms improved and no cerebral infarctions recurred in 4 months follow-up.
CONCLUSIONS: Inflammation from an antecedent infection can cause CAT to grow rapidly. Fibrous tissue including fibrin may attach to the surface of CAT, resulting in multiple cerebral infarctions. Fibrous tissue may detach and disappear by antithrombotic drugs, leading to a rapid diminishment of CAT in size.

An 80-year-old woman with a history of eosinophilic granulomatosis with polyangiitis, cardiac hypertrophy, and diabetes called for an ambulance after developing chest pain. She was diagnosed with acute myocardial infarction (AMI), and coronary angiography revealed occlusion of the right coronary artery. Coronary aspiration was performed, and coronary aspirate was white with calcified factor. After percutaneous coronary intervention, transthoracic echocardiography performed on day 25 revealed a hyperechoic mobile mass originating from the anterior mitral leaflet. As a mobile or rapidly increasing mass carries a high risk of embolism, we decided to perform surgical resection. Preoperative cerebral magnetic resonance imaging showed asymptomatic cerebral infarction, suggesting embolism by the cardiac mass. Resection of the cardiac mass was performed by cardiac surgeons. Microscopic pathology of cardiac mass revealed nodules of calcification and fibroblasts, leading to diagnosis of calcified amorphous tumor (CAT). Furthermore, the microscopic pathology of the coronary aspirate showed calcification, fibrin, and vascular endothelial cells. The pathological similarity of the cardiac mass and coronary aspirate indicated that the AMI has been caused by CAT. CAT causes systemic embolization; however, only 1 case of MI caused by CAT has been reported. We therefore experienced a rare case in which CAT caused AMI. .

Cardiac calcified amorphous tumors are rare non-neoplastic intracavitary masses. Herein, we report a case of a 75-year-old woman who presented with dyspnea on exertion and multiple cerebral infarctions 3 months prior. Transthoracic echocardiography showed severe mitral regurgitation from the posterior mitral leaflet with valve perforation and severe mitral annular calcification. In addition, we observed a 13 mm mobile high echogenic mass, suggesting healed infective endocarditis. The mass was successfully resected, and the mitral valve was replaced with a bovine pericardial patch for the decalcified annulus. Histopathological examination confirmed cardiac calcified amorphous tumor; the postoperative course was uneventful. Mitral valve replacement and annulus patch repair effectively prevented postoperative recurrent systemic embolization. .

BACKGROUND: Unlike Escherichia coli bacteremia, which is common, E. coli endocarditis is uncommon, particularly in patients with native valve, leading to its delayed diagnosis.
METHODS: We present a case of infective endocarditis caused by E. coli in a 78-year-old Japanese man with type 2 diabetes, involving persistent bacteremia and vegetation on the mitral valve (measuring 18 × 4.2 mm in diameter). He presented with recurrent fever after antimicrobial treatment for pyelonephritis. He received antibiotic therapy for 6 weeks and required surgical removal of a calcified amorphous tumor and vegetation with mitral valvuloplasty 7 days after admission. Despite an episode of multiple cerebral infarctions, he recovered fully from the infection.
CONCLUSIONS: Follow-up blood cultures should be performed for Gram-negative bacilli bacteremia among patients with unknown focus and an atypical clinical course after treatment. Early diagnosis and aggressive surgical intervention are paramount to achieving good clinical outcomes.

A 61-year-old woman who underwent hemodialysis presented with heart failure. Echocardiography revealed multiple mobile masses in the left atrium. The masses were excised, and histopathologic examination revealed calcified amorphous tumors. Here, we present several echocardiography images, including 3-dimensional transesophageal echocardiography, demonstrating the revolving masses in the left atrium. (Level of Difficulty: Intermediate.).

Calcified amorphous tumor is a rare intracavitary cardiac lesion and an accompanying infection is extremely rare. A 76-year-old woman was transferred to our hospital because of cerebral infarction. Echocardiography and chest computed tomography showed a calcified large mobile mass on the posterior mitral valve that was diagnosed with a calcified amorphous tumor. Moderate aortic regurgitation and severe mitral regurgitation were also confirmed. Her blood culture detected Gamella sp. We surgically dissected this infective calcified amorphous tumor. The border between this infective tumor and the mitral annulus was unclear because of severe infection and necrotic tissue. After careful complete resection, the healthy ventricular muscle was exposed and we performed annular reconstruction with bovine pericardial patches. And we replaced the aortic and mitral valves using bioprosthesis. While weaning from cardiopulmonary bypass, however, left ventricular rupture occurred twice. Despite successful repair of left ventricular rupture, which controlled bleeding, she died from multi-organ failure on postoperative day 6. An infective calcified amorphous tumor in such a critical case has not been reported previously. The calcified amorphous tumor probably become serious when the infection occurred. In this situation, the utmost caution should be paid to the patient. .

Cardiac calcified amorphous tumor (CAT) is a rare, non-neoplastic, intra-cavity cardiac mass. Only a few cases have been described in the literature. A 46-year-old Indian female presented with decompensated heart failure. On echocardiography, 1.9 x 1.7 cm pedunculated mobile mass in the left ventricle attached to the intraventricular septum was seen. On cardiac magnetic resonance imaging (MRI), the lesion was isointense. Histopathology of the excised mass revealed fibrin deposition with eosinophilic amorphous material in the center with the periphery of the lesion showing calcification without any myxomatous tissue. A final diagnosis of CAT of the heart was established. CAT is composed of calcium deposits in the background of amorphous degenerating fibrinous material. It presents as a pedunculated mass in any chamber of the heart with a very high preponderance of distal embolization. Differentiation from calcified atrial myxoma, calcified thrombi, or other cardiac neoplasms is very difficult. Histopathological examination is the mainstay of diagnosis. Treatment is emergency excision to prevent distal embolization. CAT is a rare non-neoplastic tumor, which is mainly a tissue diagnosis after its resection.