Caseous calcification of the mitral annulus (CCMA) is a rare echocardiographic finding. It is commonly misdiagnosed as an abscess, tumor or infective vegetation on the mitral valve. Since it is a benign process, differentiating it from malignant intra-cardiac mass is primordial to avoid unnecessary surgery. Various imaging modalities can be complimentary for definitive diagnosis. We present a case of CCMA in a 71-year-old female patient. Her medical history revealed hypertension, diabetes mellitus, hyperlipidaemia and coronary artery disease. She was referred to our department for coronary catheterization because of angina symptoms upon minimal exertion. The lesion was detected during echocardiography and was defined as a mass of heterogeneous content with calcification points, located at the posterior side of the mitral valve annulus. Restricted motion of the posterior leaflet and the mass effect caused only minimal mitral regurgitation. To establish the correct diagnosis, we performed the full spectrum of noninvasive cardiac imaging modalities. Transesophageal echocardiography identified well-organized, composite lesion with regular edges, markedly calcified margins and more echolucent central portion. A computed tomography (CT) was performed, showing a hyperdense mass with hypodense center and a calcified peripheral rim located at the posterior mitral ring. Cardiac magnetic resonance imaging (MRI) showed that the mass was hypointense with respect to the myocardium in the T1 and T2-weighted sequences and only presented late-phase enhancement in the surrounding capsule. Based on the CT and MRI findings, the diagnosis of CCMA was established. The patient was managed conservatively.

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(1) Background: Stent underexpansion is the main cause of stent thrombosis and restenosis. Coronary angiography has limitations in the assessment of stent expansion. Enhanced stent imaging (ESI) methods allow a detailed visualization of stent deployment. We qualitatively compare image results from two ESI system vendors (StentBoost™ (SB) and CAAS StentEnhancer™ (SE)) and report quantitative results of deployed stents diameters by quantitative coronary angiography (QCA) and by SE. (2) Methods: The ESI systems from SB and SE were compared and graded by two blinded observers for different characteristics: 1 visualization of the proximal and distal edges of the stents; 2 visualization of the stent struts; 3 presence of underexpansion and 4 calcifications. Stent diameters were quantitatively measured using dedicated QCA and SE software and compared to chart diameters according to the pressure of implantation. (3) Results: A total of 249 ESI sequences were qualitatively compared. Inter-observer variability was noted for strut visibility and total scores. Inter-observer agreement was found for the assessment of proximal stent edge and stent underexpansion. The predicted chart diameters were 0.31 ± 0.30 mm larger than SE diameters (p < 0.05). Stent diameters by SE after post-dilatation were 0.47 ± 0.31 mm smaller than the post-dilation balloon diameter (p < 0.05). SE-derived diameters significantly differed from QCA; by Bland–Altman analysis the bias was −0.37 ± 0.42 mm (p < 0.001). (4) Conclusions: SE provides an enhanced visualization and allows precise quantitative assessment of stent expansion without the limitations of QCA when overlapping coronary side branches are present.

Cardiovascular disease is the leading cause of mortality in patients with diabetes mellitus (DM). We sought to establish for the first time in Saudi Arabia an intravascular ultrasound (IVUS) profile of DM patients with acute coronary syndrome (ACS). Patients and methods: We retrospectively analyzed 210 IVUS studies in 181 patients hospitalized in King Salman Heart Centre for ACS. IVUS was performed to guide percutaneous coronary interventions (PCI) of borderline moderate lesions. Results: Mean age was 58 ± 10 years, 78% (n = 163) of IVUS studies were performed in men. There were 71% (n = 128) patients with DM. ST elevation myocardial infarction (STEMI) was the most common clinical presentation (47%, n = 88 patients , p < 0.01) and longer lesions (37 ± 12 mm versus 30 ± 8 mm, p < 0.01). A positive remodelling index was observed for patients with and without DM, without significant difference (1.4 versus 1.3 respectively, p = 0.7). Percent plaque volume and obstruction were not different. Conclusion: IVUS demonstrates longer lesions to be treated in DM patients with ACS in Saudi Arabia, however no difference in average plaque burden or remodelling index. These findings are likely to impact our understanding of optimal PCI strategies in DM patients.