Discussion
Primary cardiac tumour is rare and most common tumour is atrial Myxoma. Calcified amorphous tumour (CAT) is a rare cardiac mass. This tumour is more common in female than in male. Most of the affected patients are of fifth decade.
Pathogenesis of the tumour is formation of thrombus due to hypercoagulability and abnormal calcium and phosphorus metabolism. Growth rate of calcified amorphous tumour is slow but growth rate of calcified amorphous tumour associated with mitral annular calcification is fast. Most common location is mitral annulus which is commonly due to previous mitral annular calcification and it is commonly due to end stage renal disease. Other affected chambers of the heart according to incidence are right atrium, right ventricle, left ventricle, left atrium and tricuspid annulus.[2]
Most common presenting symptom is dyspnea on exersion due to obstruction of the blood flow. Other presenting features are angina, syncope (due to distal embolism), pulmonary embolism, systemic embolism and rarely patient may be diagnosed incidentally. Other associated diseases are valvular heart disease ,end stage renal disease, hyperparathyroidism.Chances of embolic events is more in calcified amorphous tumour with mitral annular calcification.[3]
On echocardiography CAT is described as pedunculated calcified mass. Size may vary from small puntate lesion to very large mass. Myxoma is mobile mass and 20 % of atrial Myxoma are calcified. Cardiac fibroma is calcified intra myocardial mass in which commonly left ventricle is involved. Other cause of cardiac calcification are end stage renal disease and thrombus.[4] On CT scan or MRI calcified amorphous tumour are either irregular, ovoid, triangular, spherical or tubular. On configuration mass is either polypoid or infiltrative with or without broad base and distribution of calcification is partial or diffuse. On cardiac MRI homogenous appearance with low signal intensity on T1 and T2 weighted spin echo sequences without post gadolinium contrast enhancement in early and delayed sequences.[5]
Patients are treated with operative management. After midline sternotomy aorto bicaval or aorto atrial cannulation is done according to the chamber involved.Right atrial and right ventricular lesion are approached through right atrium. Left atrial lesions are approached through left atrium or right atrium.Left ventricular lesion are approached through left atrium. Ventricular approach are not preferred because of increased chance of ventricular tachycardia. On histopathological examination deposition of heterogeneous calcium with surrounding amorphous eosinophilic and fibrinous material is found.[6] Immediate postoperative outcome is good with very less chance of recurrence.[2]
Conclusion: Calcified amorphous tumour is rare tumour. Early detection and management is needed to prevent complication. Recurrence is rare. Since clinico-echocardiographical presentation is similar, histopathological diagnosis is mandatory.