Caseous Necrosis of Mitral Annulus

Abstract

Masses or mass-like lesions located in proximity to mitral valve encompass a wide range of differential diagnoses including neoplasias, abscesses, thrombi, and rarely caseous calcification of mitral annulus. Due to asymptomatic presentation, its diagnosis is usually incidental. Echocardiography is the first choice of imaging in evaluation. Cardiac computed tomography (CT) is helpful in establishing diagnosis by showing dense calcifications while cardiac magnetic resonance imaging (MRI) is used primarily as a problem solving tool. Imaging in evaluation of mitral annulus caseous calcification is essential in order to prevent unnecessary operations.

Chameleonic appearance of caseous calcification of the mitral valve – still a problem for its appropriate management

“…Here it is described as a welldefined mass, either hypointense in both T1-and T2weighted sequences [24,25], or hyperintense in the central area with a hypointense rim in T1, discrete from the surrounding myocardium and as a mass with a hypodense central area with a high intensity ring in T2-weighted sequences [1]. In postcontrast studies, there is no contrast enhancement on first-pass sequences, but peripheral late gadolinium enhancement may be detected [2].…”

“…There are several types of echo-dense masses that may be encountered on the native mitral valve ring and/or cusps. The most commonly described are myocardial abscesses, vegetations in infective endocarditis, thrombi and tumoral masses, which may include hemangioma of the mitral valve, intramural myxoma, leiomyosarcoma and/or fibroelastoma [1][2][3][4]. An estimated prevalence of approximately 0.6% of all cases of caseous mitral annulus calcification (MAC) can be sometimes mobile or produce mobile projections, which can embolize and be a source of stroke [5].…”

Caseous calcification of the mitral annulus: case report and brief review

“…Diagnosis of CCMA is most commonly made by typical imaging findings; for example, on echocardiogram CCMA is typically located within the posterior portion of the mitral annulus, has echolucency centrally with a surrounding hyperechogenic rim, and does not show flow or acoustic shadow 9 . Cardiac magnetic resonance and computed tomography are similarly characteristic and can be used for diagnosis 10 …”

“… 9 Cardiac magnetic resonance and computed tomography are similarly characteristic and can be used for diagnosis. 10 …”

Asymptomatic Caseous Calcification of the Mitral Annulus in a 66-Year-Old Woman with 3-Year Imaging Follow-Up

“…In the case of CCMA, no acoustic shadowing artifacts and no flow are noted on color Doppler. CCMA is attached to the mitral annulus and is typically located in the posterior portion of the mitral annulus, but rarely in the anterior portion of the mitral annulus or both parts of the mitral annulus [ 3 , 5 , 6 , 20 – 22 ]. On CT without contrast, CCMA appears as a hyperdense round or semilunar mass with a calcified envelope, placed in the peri-annular territory of the mitral valve.…”