Characterization of a calcified intra-cardiac pseudocyst of the mitral valve by magnetic resonance imaging including T1 and T2 mapping
- Ursula Reiter†1Email author,
- Gert Reiter†2,
- Martin Asslaber3,
- Drago Dacar4,
- Ralph Maderthaner1,
- Josepha Binder5,
- Andreas Greiser6,
- Meinrad Beer7 and
- Michael Fuchsjäger1
© Reiter et al.; licensee BioMed Central Ltd. 2014
Received: 16 November 2013
Accepted: 17 January 2014
Published: 28 January 2014
Even though intra-cardiac cystic lesions are extremely unusual in adults, they should be considered in the differential diagnosis of patients presenting with valvular masses. Cardiac magnetic resonance imaging has emerged as modality of choice for non-invasive characterization of cardiac masses.
We report a case of an intra-cardiac mass of the mitral valve in a 51-year old male, detected by echocardiography after transient ischemic attack and retinal artery occlusion. Cardiac magnetic resonance (CMR) imaging was performed at 3 T to evaluate and characterize the lesion prior to surgery. Diagnosis of a calcified left-ventricular pseudocyst of the mitral valve was confirmed by histological evaluation.
This case presents the unusual finding of contrast uptake in an intra-cardiac cystic lesion and points to the potential of T1 and T2 mapping for assisting in the characterization and diagnosis of intra-cardiac masses by CMR.
Intra-cardiac cystic lesions are extremely unusual in adults. Classified as benign tumors predominantly involving the cardiac valves and supporting structures, intra-cardiac cysts have been recognized as a cause of intra-cavity flow obstruction, arrhythmia, and valvular dysfunction and have been associated with a risk of embolization [1–3].
Whereas echocardiography is the mainstay imaging technique for the detection of intra-cardiac tumors, multi-parametric cardiac magnetic resonance (CMR) imaging has become the modality of choice for non-invasive characterization of cardiac masses . Comprehensive CMR imaging protocols for the evaluation of cardiac tumors including cine steady-state free precession (SSFP) sequences, black-blood T1- and T2-weighted turbo spin-echo (TSE) imaging with and without fat saturation before and after contrast enhancement, first-pass perfusion and early and late gadolinium enhancement (LGE) have been introduced, providing substantial information on the extent, morphology and vascularization of cardiac lesions . Discrimination of intra-cardiac masses based on image signal intensity patterns, however, remains challenging because of their qualitative nature.
Techniques enabling the quantification of cardiac T1 and T2 magnetic relaxation times within reasonable breath-hold periods [6–9] have yielded remarkable evidence in objective identification of ischemic and non-ischemic myocardial injuries [10–12]. As these magnetic relaxation times provide information about tissue composition on standardized scale (in milliseconds), they may have the potential to further improve the differentiation of cardiac tumors. The application of T1 and T2 mapping for characterization of intra-cardiac masses has not been reported to date.
For pre-surgical evaluation of localization, extend and nature of the mass, the patient was referred for 3 T CMR imaging (Magnetom Trio, Siemens AG, Healthcare Sector, Erlangen, Germany). Differential diagnoses of the mass included caseous calcification of the valvular annulus, valvular calcified thrombus, calcified tumor (calcified myxoma or papillary fibroelastoma of mitral valve), or intra-cardiac cystic lesion. A comprehensive, ECG-gated CMR imaging protocol was carried out in breath-hold and included prototype T1 and T2 mapping sequences.
Reported CMR signal intensity characteristics of histologically confirmed intra-cardiac cystic lesions
Reichelt et al. 
Blood cyst of the papillary muscle
Park et al. 
Blood cyst of the papillary muscle
Roubelakis et al. 
Blood cyst of the tricuspid valve
Enhanced border, non-enhanced core
Centella et al. 
Blood cyst in the right atrium
Tran et al. 
Cystic lesion of the atrio-ventricular node
Saito et al. 
Cystic lesion of the atrio-ventricular node
Shayingca et al. 
Cystic lesion of the papillary muscle
Surgery and histological diagnosis
Histologic evaluation revealed a calcified pseudocystic mass of the mitral valve. 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). Malignancy was ruled out.
An intra-cardiac cystic lesion can show contrast agent uptake. CMR enables evaluation of location, size, shape, mobility, and texture of an intra-cardiac lesion. T1 and T2 mapping before and after contrast agent application might provide quantitative information on the nature of a lesion’s content, possibly improving the non-invasive diagnosis and differentiation of intra-cardiac tumors.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Cardiac magnetic resonance
Fast low angle shot
Late gadolinium enhancement
Modified look-locker inversion recovery
Transient ischaemic attack
The authors thank Ada Muellner, MS, for editing the manuscript.
- Lodha A, Patel J, Haran M, Sadiq A, Shani J: Blood cyst of the mitral valve: a rare cause of stroke. Echocardiography. 2009, 26 (6): 736-738.PubMedView Article
- Ayati M, Gori T, Münzel T: Lesions of the mitral valve as a cause of central retinal artery occlusion: presentation and discussion of two cases. Echocardiography. 2010, 27: E1-E3.PubMedView Article
- Khan T, El-Sharkawy S, Schafer F: A heart within the heart-a rare congenital cause of an embolic stroke. BMJ Case Rep. 2012, doi: 10.1136/bcr.10.2011.5027
- Hundley WG, Bluemke DA, Finn JP, Flamm SD, Fogel MA, Friedrich MG, Ho VB, Jerosch-Herold M, Kramer CM, Manning WJ, Patel M, Pohost GM, Stillman AE, White RD, Woodard PK, American College of Cardiology Foundation Task Force on Expert Consensus Documents: ACCF/ACR/AHA/NASCI/SCMR 2010 expert consensus document on cardiovascular magnetic resonance: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. J Am Coll Cardiol. 2010, 55 (23): 2614-2662.PubMedView Article
- Motwani M, Kidambi A, Herzog BA, Uddin A, Greenwood JP, Plein S: MR Imaging of cardiac tumors and masses: a review of methods and clinical applications. Radiology. 2013, 268 (1): 26-43.PubMedView Article
- Messroghli DR, Plein S, Higgins DM, Walters K, Jones TR, Ridgway JP, Sivananthan MU: Human myocardium: single-breath-hold MR T1 mapping with high spatial resolutionreproducibility study. Radiology. 2006, 238 (3): 1004-1012.PubMedView Article
- Xue H, Shah S, Greiser A, Guetter C, Littmann A, Jolly MP, Arai AE, Zuehlsdorff S, Guehring J, Kellman P: Motion correction for myocardial T1 mapping using image registration with synthetic image estimation. Magn Reson Med. 2012, 67 (6): 1644-1655.PubMedPubMed CentralView Article
- Huang TY, Liu YJ, Stemmer A, Poncelet BP: T2 measurement of the human myocardium using a T2-prepared transient-state TrueFISP sequence. Magn Reson Med. 2007, 57: 960-966.PubMedView Article
- Kellman P, Aletras AH, Mancini C, McVeigh ER, Arai AE: T2-prepared SSFP improves diagnostic confidence in edema imaging in acute myocardial infarction compared to turbo spin echo. Magn Reson Med. 2007, 57 (5): 891-897.PubMedPubMed CentralView Article
- Wassmuth R, Prothmann M, Utz W, Dieringer M, von Knobelsdorff-Brenkenhoff F, Greiser A, Schulz-Menger J: Variability and homogeneity of cardiovascular magnetic resonance myocardial T2-mapping in volunteers compared to patients with edema. J Cardiovasc Magn Reson. 2013, 15: 27-PubMedPubMed CentralView Article
- Pedersen SF, Thrysøe SA, Robich MP, Paaske WP, Ringgaard S, Bøtker HE, Hansen ES, Kim WY: Assessment of intramyocardial hemorrhage by T1-weighted cardiovascular magnetic resonance in reperfused acute myocardial infarction. J Cardiovasc Magn Reson. 2012, 14: 59-PubMedPubMed CentralView Article
- Ferreira VM, Piechnik SK, Dall’Armellina E, Karamitsos TD, Francis JM, Choudhury RP, Friedrich MG, Robson MD, Neubauer S: Non-contrast T1-mapping detects acute myocardial edema with high diagnostic accuracy: a comparison to T2-weighted cardiovascular magnetic resonance. J Cardiovasc Magn Reson. 2012, 14: 42-PubMedPubMed CentralView Article
- Monti L, Renifilo E, Profili M, Balzarini L: Cardiovascular magnetic resonance features of caseous calcification of the mitral annulus. J Cardiovasc Magn Reson. 2008, 10: 25-PubMedPubMed CentralView Article
- Roubelakis A, Moorjani N, Modi A, Harden S, Ohri SK: Right ventricular blood cyst causing outflow tract obstruction in an adult. J Card Surg. 2012, 27 (4): 452-454.PubMedView Article
- Park MH, Jung SY, Youn HJ, Jin JY, Lee JH, Jung HO: Blood cyst of subvalvular apparatus of the mitral valve in an adult. J Cardiovasc Ultrasound. 2012, 20 (3): 146-149.PubMedPubMed CentralView Article
- Bernstein MA, King KF, Zhou XJ: Handbook of MRI Pulse Sequences. 2004, Burlington, San Diego, London: Elsevier Academic Press
- Vidmar J, Sersa I, Kralj E, Tratar G, Blinc A: Discrimination between red blood cell and platelet components of blood clots by MR microscopy. Eur Biophys J. 2008, 37: 1235-1240.PubMedView Article
- Reichelt A, Khaladj N: MRT einer Blutzyste an der Mitralklappe. Fortschr Röntgenstr. 2013, 185: 68-69.
- Centella T, Moya JL, Muñoz M, Reguero EM: Giant endocardial blood cyst in the right atrium: echocardiographic and magnetic resonance imaging features. Circulation. 2008, 117: 3250-3251.PubMedView Article
- Tran TT, Starnes V, Wang X, Getzen J, Ross BD: Cardiovascular magnetic resonance diagnosis of cystic tumor of the atrioventricular node. J Cardiovasc Magn Reson. 2009, 11: 13-PubMedPubMed CentralView Article
- Saito S, Kobayashi J, Tagusari O, Bando K, Niwaya K, Nakajima H, Yamagishi M, Yagihara T, Kitamura S: Successful excision of a cystic tumor of the atrioventricular nodal region. Circ J. 2005, 69: 1293-1294.PubMedView Article
- Shayingca T, Andronikou S, Truter R, Reid E: MRI finding of a papillary muscle cyst: a differential diagnosis. Cardiovasc J Afr. 2012, 23 (10): e5-6.PubMedView Article
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2261/14/11/prepub
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