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\begin{document}

\title{Calcified Amorphous Tumour of Left Ventricle: a Rare Cardiac Tumour}



\author[1]{Rupesh Kumar}%
\author[1]{Vikram Halder}%
\author[1]{Soumitra Ghosh}%
\author[1]{Basant Kumar}%
\author[2]{Subhrashis Niyogi}%
\author[1]{Balamurugan Thirunavukkarasu Thirunavukkarasu}%
\author[1]{Amanjit Bal}%
\affil[1]{Post Graduate Institute of Medical Education and Research}%
\affil[2]{PGIMER}%


\vspace{-1em}



  
  \date{May 17, 2024}


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\selectlanguage{english}
\begin{abstract}
Cardiac calcified amorphous tumor is a rare, non-neoplastic,
pedunculated, intra-cavity mass, with very high preponderance of distal
embolisation. Differentiation from calcified atrial myxoma or calcified
thrombi is very difficult. Histo-pathologic examination is the mainstay
of diagnosis. Treatment is emergency excision. A 46-year-old female
presented with heart failure. On echocardiography, 1.9x1.7 cm
pedunculated mobile mass in left ventricle attached to intraventricular
septum was seen. On cardiac MRI lesion was isointense. The mass was
excised. Histopathology revealed fibrin deposition with eosinophilic
amorphous material in the centre with calcification in the periphery
without any myxomatous tissue. A final diagnosis of CAT was established.%
\end{abstract}%



\sloppy


\textbf{TITLE PAGE}

\textbf{Calcified Amorphous Tumor of Left Ventricle: a Rare Cardiac
Tumour}

\textbf{Authors}

Rupesh Kumar\textsuperscript{1}, Vikram Halder\textsuperscript{1},
Soumitra Ghosh\textsuperscript{2}, Basant Kumar\textsuperscript{2},
Subhrashis Guha Neogi\textsuperscript{3}, Balamurugan
Thirunavukkarasu\textsuperscript{4}, Amanjit Bal\textsuperscript{4}

\begin{enumerate}
\tightlist
\item
  Department of Cardio-Thoracic Surgery, PGIMER, Chandigarh, India
\item
  Department of Cardiology, PGIMER, Chandigarh, India
\item
  Department of Cardio-Thoracic anaesthesia, PGIMER, Chandigarh, India
\item
  Department of histopathology, PGIMER, Chandigarh, India
\end{enumerate}

\textbf{Address for Correspondence}

Dr Basant Kumar, MD, DM

Department of Cardiology,

Advanced Cardiac Centre,

Post Graduate Institute of Medical Education \& Research,

Sector 12, Chandigarh -- 160 012. India.

Telephone No. +91 172 403 7834

Email: basantvimal@gmail.com

\textbf{Short title:} A Rare Calcified Amorphous Tumour of Left
Ventricle

\textbf{Word count:} 1212

\emph{Author List}

Dr. Rupesh Kumar

MS (General Surgery), MCH (Cardio Thoracic Surgery),

Assisstant Professor

Department of CTVS,

Post graduate institute of medical education and research

rkctvs@gmail.com

Dr. Vikram Halder

MS (General Surgery)

Post graduate institute of medical education and research

vikramavnrt@gmail.com

Dr. Soumitra Ghosh

MD (Internal medicine)

Post graduate institute of medical education and research

soumitra183@gmail.com

Dr Basant Kumar,

MD (Internal medicine), DM (Cardiology),

Assisstant Professor,

Post Graduate Institute of Medical Education \& Research,

basantvimal@gmail.com

Dr. Subhrashis Guha Neogi

MD (Anaesthesiology)

Post graduate institute of medical education and research

09renol@gmail.com

Dr. Balamurugan Thirunavukkarasu

MD (Pathology)

Post graduate institute of medical education and research

Bala.potter@gmail.com

Dr Amanjit Bal

MD (Pathology)

Assisstant Professor,

Post Graduate Institute of Medical Education \& Research,

Docaman5@hotmail.com

\textbf{Calcified Amorphous Tumour of Left Ventricle: a Rare Cardiac
Tumour}

\textbf{Abstract}

Cardiac calcified amorphous tumor is a rare, non-neoplastic,
pedunculated, intra-cavity mass, with very high preponderance of distal
embolisation. Differentiation from calcified atrial myxoma or calcified
thrombi is very difficult. Histo-pathologic examination is the mainstay
of diagnosis. Treatment is emergency excision. A 46-year-old female
presented with heart failure. On echocardiography, 1.9x1.7 cm
pedunculated mobile mass in left ventricle attached to intraventricular
septum was seen. On cardiac MRI lesion was isointense. The mass was
excised. Histopathology revealed fibrin deposition with eosinophilic
amorphous material in the centre with calcification in the periphery
without any myxomatous tissue. A final diagnosis of CAT was established.

\textbf{Key words:} Calcified amorphous tumor, Nonneoplastic Mass,
Echocardiography

\textbf{Learning Objectives:}

\begin{enumerate}
\tightlist
\item
  CAT is a rare non-neoplastic tumour of the heart
\item
  CAT is a differential diagnosis of calcified atrial myxoma, calcified
  thrombi and other calcium containing tumours of the heart
\item
  Treatment is emergency excision to prevent distal embolisation
\item
  Histo-pathologic examination is the mainstay of diagnosis
\end{enumerate}

\textbf{Introduction}

Cardiac calcified amorphous tumour is a rare non-neoplastic cardiac mass
which is composed of amorphous fibrinous material and calcium. This
tumour was first described by Reynolds and colleague.{[}1{]} Most common
site is mitral annulus followed by right atrium, right ventricle, left
ventricle,left atrium,tricuspid annulus.{[}2{]} Clinicopathologically it
mimics as calcified Myxoma and calcified thrombi and on transthoracic
echocardiography it is very difficult to distinguish between this
entity. Patients may present with dyspnea (due to obstruction) or
clinical features of distal embolisation. Echocardiography is the
primary modality for diagnosis but histopathological examination is the
gold standard. As there is risk of distal embolisation early surgery is
needed followed by histopathological confirmation.

\textbf{Case presentation}

A 46 year old female patient present to emergency with decompensated
heart failure with cardiogenic shock and renal shutdown. She is known
case of chronic kidney disease (stage 4) on medication and one episode
of thromboembolic cerebrovascular accident (right fronto-parietal
infarct) 2 month ago.

After initial medical optimization echocardiography was done.On
echocardiography (Figure 1)) 1.9x1.7 cm pedunculated mobile mass in left
ventricle which is attached to intraventricular septum with left
ventricular ejection fraction 40-45\%. On cardiac MRI (Figure 2)
isointense lesion in left ventricle which is attach to endocardium
through a narrow pedicle. As per institutional protocol coronary
angiography done and on angiography mid part of left anterior desceding
(LAD) artery is 70 to 80 percent stenosed and posterior descending
artery(PDA) is 80 percent stenosed.

Patient was taken for surgery. (Figure 3) After sternotomy left internal
mammary artery and right sided great saphenous vein (RSVG) were
harvested. After heparinization aorto bicaval cannulation was done and
cross clamp was applied. Right atrium was opened atrial septum was
incised. Then left ventricular mass was resected and intraatrial septum
and right atrium was closed .RSVG was anastomosed to PDA and ascending
aorta and LIMA was anatomosed to LAD. Then gradually crossclamp was off
and decannilation was done. After application of intercostals drain and
pacing wire sternum was closed.Immediately after operation ventilation
time was 12 hours and vasoactive inotropic score was 28. Intensive care
unit stay and hospital stay were 4 days and 7 days respectively.

Histopathology of the tumour revealed fibrin deposition with
eosinophilic amorphous material in the centre with periphery of the
lesion showing calcification. No myxomatous tissue was seen (Figure 4)

On 6 month followup there was no recurrent mass and functional status of
the patient was NYHA II.

\textbf{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{]}

\textbf{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.

\textbf{Acknowledgements}

None

\textbf{Conflicts of interest}

None for any of the authors

\textbf{Informed consent}

Informed consent was obtained from patient for the publication of this
case report

\textbf{References-}

\textbf{1.} Reynolds C., Tazelaar H. D., Edwards W. D. Calcified
amorphous tumor of the heart (cardiac CAT) Human Pathology.
1997;28(5):601--606. doi: 10.1016/S0046-8177(97)90083-6.

\textbf{2.} Hemptinne Q D , Canni\selectlanguage{ngerman}ère D D , Vandenbossche J C, Unger P .
Cardiac calcified amorphous tumor: A systematic review of the
literature. IJC Heart \& Vasculature 7 (2015) 1--5

\textbf{3.} Kawata T, Konishi H, Amano A, Daida H. Wavering calcified
amorphous tumour of the heart in a haemodialysis patient. Interact
Cardiovasc Thorac Surg 2013; 16:219--20.

\textbf{4} . Gupta R, Hote M, Ray R.Calcified amorphous tumor of the
heart in an adult female: a case report .J Med Case Reports. 2010; 4:
278.

5. Y\selectlanguage{polish}ı\selectlanguage{english}lmaz R, Demir A A, \selectlanguage{ngerman}Önür I,Y\selectlanguage{polish}ı\selectlanguage{english}lbazbayhan D, Dursun M. Cardiac
calcified amorphous tumors: CT and MRI findings . Diagn Interv Radiol
2016; 22:519--524

\textbf{6.} Tazelaar HD, Locke TJ, McGregor CGA.. Pathology of
surgically excised primary cardiac tumors. .Mayo Clin Proc.
1992;67:957--65. doi: 10.1016/S0025-6196(12)60926-4.

\textbf{Figure Legends:}

Figure 1A: 2-D echocardiography, PLAX view showing 1.9x1.7 cm
pedunculated mass in the left ventricle

Figure 1B: 3-D echocardiography showing 1.9x1.7 cm pedunculated mobile
mass in left ventricle attached to intraventricular septum

Figure 2: Cardiac MRI showing isointense mass in left ventricle attached
to endocardium of interventricular septum through a narrow pedicle

Figure 3A: Tail of the mass in the left ventricle attached to the
interventricular septum(trans right atrial approach)

Figure 3B-Mass in left ventricle after retracting the tricuspid leaflet

Figure 4A: Low magnification view of calcified amorphous tumour. There
is fibrin deposition with eosinophilic amorphous material in the centre
(H\&E 10X)

Figure 4B: Periphery of the lesion showing bluish calcification (H\&E
40X)

Figure 4C: Focal ossification highlighted by grungy amphophilic
material~ (H\&E 40X)

Figure 4D: Martius Scarlet Blue stain highlighting the fibrin as red
colour (MSB ; 40x)\selectlanguage{english}
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