Severe Mitral Regurgitation and Heart Failure due to Caseous Calcification of the Mitral Annulus

Abstract

Caseous calcification is a rare form of mitral annular calcification. Echocardiography reveals an echodense mass in the inferior mitral annulus with smooth borders and an echolucent inner core. We present a case where caseous calcification of the mitral annulus caused severe mitral regurgitation, atrial fibrillation and heart failure. Transthoracic echocardiography, transesophageal echocardiography, cardiac mag- netic resonance and computed tomography were performed and ensured the diagnosis. The mass was surgically removed and a prosthetic valve was implanted. We conclude that caseous calcification of the mitral annulus should be considered not only in the differential diagnosis of cardiac masses but also in the background of mitral regurgitation, atrial fibrillation and heart failure. This case also represents the usefulness of multimodal imaging in identifying cardiac masses.

Caseous Calcification of the Mitral Annulus: A Review

“…Another potential cause for this difference is the lower sensitivity of echocardiography compared to autopsy. We expect that the number of recognized cases will continue to rise due to the widespread use and enhancements of the different cardiac imaging modalities …”

“…The precise mechanism involved in liquefaction and caseation in CCMA is not well understood . As the prevalence of CCMA is higher in patients with end‐stage renal disease, especially those on dialysis, an altered calcium phosphate metabolism is implicated in its pathogenesis .…”

“…CCMA is believed to be a benign process; however, it may result in abnormal flow across the mitral valve, commonly chronic mitral regurgitation, and less likely mitral stenosis, and less likely mitral stenosis. Because the mitral annulus lies close to the atrioventricular node and the conduction system, CCMA may cause bradyarrhythmia and atrioventricular blocks …”

“…We expect that the number of recognized cases will continue to rise due to the widespread use and enhancements of the different cardiac imaging modalities. 7,8 CCMA tends to occur in older patients (mean age 69 years) and is associated with hypertension. 3 CCMA typically involves the posterior mitral annulus, 6 and it rarely involves only the anterior annulus or both annuli.…”

Caseous Mitral Annular Calcification Along the Anterolateral Annulus Causing Mild Mitral Regurgitation

“…As seen in the present case, the lesion may occasionally distort the mitral annulus, resulting in mitral regurgitation. 3 More commonly, however, this structure may be misdiagnosed as a cardiac tumor, thrombus, or abscess, which may lead to unnecessary cardiac surgery. Caseous MAC is typically located along the posterior mitral annulus.…”