Images in cardiovascular medicine: caseous calcification of the mitral annulus

A 78-year-old woman was admitted to our emergency department for subarachnoid hemorrhage. Since a month ago, she was taking warfarin after diagnosis, on transthoracic echocardiogram (TTE), of a suspected large atrial thrombus. The patient, referred to our institution for further investigation, presented asymptomatic; electrocardiogram showed sinus rhythm. TTE revealed an echo dense spherical mass located in the mitral periannular posterior region with moderate mitral regurgitation. Transesophageal echocardiography and cardiac computed tomography confirmed a calcified round mass (2.0 × 2.9 cm) with central areas of echolucency-like liquefaction surrounded by a hyperechogenic structure without systolic flow inside the cavity. The mass was diagnosed as caseous calcification of the mitral annulus (CCMA), a rare finding associated with a benign prognosis, requiring surgery only in the presence of mitral valve dysfunction. The diagnosis of CCMA is, often, misconstrued as thrombus, tumor, or abscess, leading to unnecessary investigations or interventions. Our patient was discharged after discontinuation of warfarin.