Mitral annulus caseous calcification mimicking cardiac mass in asymptomatic patient – multimodality imaging approach to incidental echocardiographic finding

Abstract

SummaryBackgroundCaseous calcification of mitral annulus is rather rare echocardiographic finding with prevalence of 0.6% in pts. with proven mitral annular calcification and 0.06% to 0.07% in large series of subjects in all ages. Echocardiographic images of caseous calcification are often heterogenous due to calcium and lipid deposits, and the masses show hyperechogenic and hypoechogenic areas. However the appearance of caseous calcification can imitate that of abscess, tumors and cysts, surgical treatment may not be needed when there is no obstruction.Case Report76-year old obese (BMI 32 kg/m2), female patient with history of hypertension, stable coronary artery disease, diabetes type 2 and hyperlipidemia presented with no symptoms of mitral valve dysfunction and had no abnormalities on physical exam. Transesophageal echocardiography identified well-organized, composite, immobile lesion (22×15 mm) localized in the posterior part of the mitral annulus, with markedly calcified margins, and no significant impact on the valve function. In computed tomography (CT) lesion was described as calcified (24×22×17.5 mm), connected with posterior leaflet and posterior part of the mitral annulus, reducing posterior leaflet mobility. CT brought the suggestion of caseous mitral annular calcification. Coming to a conclusion, bearing in mind no mitral valve dysfunction at that time, patient was offered conservative treatment.ConclusionsAlthough caseous mitral annular calcification is typically an incidental finding, accurate recognition is needed to avoid mistaking the lesion for a tumor or abscess, which may result in unnecessary cardiac surgery. However this entity is diagnosed on cardiac MRI, multi-modality imaging, especially non-contrast CT, allows for the confident, prospective diagnosis.

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

“…And surgical treatment may not be needed when there is no obstruction. This entity is diagnosed on cardiac MRI, multi-modality imaging, especially non-contrast computed tomography (CT), and allows for the confident and prospective diagnosis [11,12].…”

Dynamic nature of caseous mitral annular calcification

“…2 In rare circumstances with unclear triggers, the central core of the MAC undergoes the benign process of caseous necrosis giving it a putty-like appearance. Both low 3–6 and high 1, 7–8 CT attenuation properties have been described in the central regions of caseous MAC. In this patient, cardiac CT established the initial diagnosis of caseous MAC and demonstrated a configuration change with progressive caseous necrosis noted in the follow-up study.…”

Caseous calcification of the mitral annulus: computed tomography features

“…The symptoms, when present, correspond to palpitations, dyspnea, and syncope ( 11 ) . The prognosis of caseous degeneration of the mitral annulus is good, especially in patients who are asymptomatic, although some patients develop severe symptomatic valvular dysfunction; in the latter group of patients, the prognosis is poor and surgery should be considered ( 9 , 12 ) .…”