Not All Cysts on Valves are Abscesses

BACKGROUND: Valvular heart tumors are considered a rare entity but can put patients at high risk of complications. Valvular papillary fibroelastomas are considered the second most common tumor after myxoma. Other differential diagnoses should include organized thrombi, vegetation or abscess, and calcified lesions. It is crucially important to evaluate echocardiographic images to determine the cause based on size, morphology, and mobility. Mitral annular calcification (MAC) is a common degenerative process in which prevalence increases with patients on long-term dialysis. It can have impacts such as arrhythmia, embolic phenomena, or valve insufficiency. There is no specific treatment of MAC, but targeting the associated complications is the goal of atherosclerotic risk factors modifications, antiarrhythmics if needed, and antithrombotic medications.
CASE REPORT: We present the case of a 68-year-old man with a medical history of diabetes and end-stage renal disease requiring frequent hemodialysis who was admitted to our facility because of an altered mental status. He was found to have elevated cardiac enzymes in further work-up indicated by cardiology. His transthoracic echocardiogram (TTE) initially showed a suspicious mass at the mitral valve (MV), which required subsequent transesophageal echocardiogram (TEE) evaluation. Further findings of the TEE were suggestive of calcification at the base of the anterior leaflet of the MV, with possible degenerative changes. Endocarditis was successfully ruled out after negative blood cultures and evaluation by an infectious disease consultant. Due to the strong echocardiographic evidence of MAC, the cardiology consultant recommended no further imaging studies or biopsy.
CONCLUSIONS: There is a wide range of differential diagnoses of valvular heart tumors. Careful clinical history and physical examination are crucial in the process of evaluation. It is important to consider other entities such as vegetation, abscess, or calcification to determine the treatment plan. Current evaluation tools such as echocardiograms will help in identifying those lesions based on their size and morphological characteristics. MAC is considered a common finding, especially in dialysis patients. There is no definitive treatment for MAC, but it is important to address the associated conditions as they arise with individual treatment. Our case report provides a rare presentation of mitral valve mass requiring extensive evaluation. The literature is limited in terms of valvular tumors and our discussion will focus on MAC and its clinical significance.

Keywords: Abscess, Cysts, Mitral Valve