Concomitant Aortic Valve Neocuspidization and Resection of a Cardiac Calcified Amorphous Tumor in a Hemodialysis...

Cardiac calcified amorphous tumor (CAT) is an uncommon nonneoplastic intracardiac lesion associated with end-stage renal disease; mobile lesions carry an embolic risk and are generally resected. A 62-year-old man on maintenance hemodialysis was found to have a mobile verrucous mass 17 mm long on the anterior mitral leaflet and a separate immobile calcified lesion, 19 × 12 mm, at the base of the posterior mitral leaflet, together with moderate aortic regurgitation, left ventricular dilatation, a left ventricular ejection fraction of 41%, and pulmonary hypertension. Infective endocarditis was considered unlikely because blood cultures were negative and there was no inflammatory response; a noninfective thrombotic lesion was suspected, but four months of warfarin produced no regression of either lesion. Because open-heart surgery was required for the mobile mass, the aortic valve was addressed at the same operation. Each prosthetic option carried a disadvantage: a bioprosthesis could undergo accelerated structural deterioration in the same calcifying environment, and a mechanical valve would require lifelong anticoagulation, which in dialysis carries a bleeding hazard and may itself promote calcification. Aortic valve neocuspidization with glutaraldehyde-treated autologous pericardium was therefore chosen as an individualized alternative, with transaortic resection of the mobile mass; the immobile lesion was left unresected because of its proximity to the atrioventricular groove and left circumflex artery. Histology confirmed CAT. Aspirin was continued while warfarin was not resumed. Over three years of echocardiographic and 45 months of clinical follow-up, the reconstructed valve remained free of stenosis and paravalvular leak, ventricular function improved, the unresected lesion did not enlarge, and no thromboembolic or bleeding event occurred, although aortic regurgitation progressed to a mild-to-moderate degree.