Multimodality imaging of exuberant mitral annular calcification in a patient presenting with transient ischaemic attack

Abstract

An 81-year-old woman presented to the emergency department with sudden onset weakness of the right side of the body, which had caused her to fall through a glass door and injure her arm. She also had expressive dysphasia. The patient had a previous medical history of hypertension, hypercholesterolaemia and spondylosis. More than a decade ago she had been labelled as suffering from 'angina', based on asymptomatic ST-segment depression during stage 2 of a Bruce protocol. There was no history of rheumatic fever.Her weakness and expressive dysphasia resolved completely in 90 minutes. On examination, the arterial pulse was regular and normal in character, blood pressure was 138/72 mmHg in the right arm and the heart rate was 80 bpm. The patient's electrocardiogram showed sinus rhythm with occasional ventricular ectopic beats. The first heart sound was loud and there was a pansystolic murmur grade 3/6 at the mitral area. Neurological examination performed by the admitting physician was normal. Figure 1 Zoomed, slightly off-axis apical four-chamber view, demonstrating a globular mass with a hypoechoic centre, in the lateral segment of the mitral annulus. Figure 2Transoesophageal echocardiographic appearances of the mass, in a four-chamber view. The relationship with the mitral valve is better appreciated than on the transthoracic scan. The mass is located on the ventricular aspect of the annulus and distorts the posterior mitral leaflet slightly.

Risk of Cerebral Embolization with Caseous Calcification of the Mitral Annulus: Review Article

“…However, there is no consensus on the optimal management for CCMA, as stated by Elgendy and Conti [13] in a recent review article. The authors suggest that, in most cases, conservative management for this lesion is sufficient, and that anticoagulation should be considered only in patients with CCMA who present with embolic manifestations [18, 22, 28]. In contrast, several authors recommend surgical intervention for associated mitral valvular dysfunction (either stenosis or regurgitation), embolic manifestations, or when it is impossible to rule out the possibility of a tumor.…”