Ruptured caseous calcification of the mitral annulus.

Area of Science:

• Cardiology
• Radiology
• Pathology

Background:

• Mitral annular calcification (MAC) is a common degenerative process affecting the mitral valve annulus, with prevalence increasing with age and associated with cardiovascular risk factors.
• Caseous calcification of the mitral annulus (CCMA) is a rare, benign variant of MAC, often presenting as an echodense mass on the mitral valve annulus.
• CCMA requires differentiation from other cardiac masses such as tumors, thrombi, or vegetations.

Observation:

• An 85-year-old female with hypertension and a systolic murmur presented with findings suggestive of a rare MAC variant on echocardiography.
• Transthoracic echocardiography revealed independent mobile echodensities, prompting further investigation with transesophageal echocardiography.
• The case confirmed CCMA, characterized by a calcified mass with an echolucent, liquid-like center on the posterior mitral annulus, typically without acoustic shadowing.

Findings:

• CCMA is a rare condition with a reported prevalence of 0.06%-0.6% among patients with MAC.
• Echocardiography is effective for initial diagnosis and characterization of MAC and CCMA.
• Multi-modality imaging, including transesophageal echocardiography, CT, and MRI, aids in accurate diagnosis and exclusion of differential diagnoses.

Implications:

• Accurate diagnosis of CCMA using imaging techniques prevents unnecessary invasive interventions.
• Understanding CCMA's distinct imaging features is crucial for differentiating it from malignant cardiac tumors or other pathologies.
• This case highlights the importance of considering rare variants of common conditions in clinical practice.