A 66-year-old woman with asymptomatic caseous calcification of the mitral annulus
This article highlights the case of a 66-year-old woman with untreated dyslipidemia (total cholesterol, 276 mg/dL; low-density lipoprotein, 197 mg/dL) and well-controlled arterial hypertension (lisinopril 20 mg orally once a day), no history of chronic or acute kidney disease, and no history of smoking or alcoholism, who was referred to the hospital for further diagnostic evaluation of a rapidly expanding intracardiac mass revealed on The first TTE. The TTE was done five years ago and was unremarkable. TTE revealed an echo dense structure, occupying the atrioventricular groove two years later. The patient was diagnosed with asymptomatic caseous calcification of the mitral annulus.
Case study: caseous calcification of mitral annulus
A three-year follow-up TTE revealed that the lesion had grown in size and had a mild acoustic shadow, and a heart neoplasm was suspected. However, there is no image available. The patient had no symptoms and no clinical signs of infective endocarditis. Clinical examination results were normal, including physical examination and laboratory tests for inflammatory markers (CRP, procalcitonin), troponin level, blood urea, serum creatinine, and blood counts. All of the serial blood cultures came back negative. A 12-lead electrocardiogram revealed a normal sinus rhythm and a left anterior fascicular block.
TTE was the first imaging modality used after admission, followed by TEE. These imaging techniques confirmed the echogenic round lesion measuring 2118 mm in the posterior region of the mitral annulus and the basal segment of the posterior wall of the left ventricle with a smooth border. TTE and TEE revealed no typical morphological features of CCMA, such as a central area of echolucency. These methods revealed the acoustic shadow lurking behind this calcified mass (Figures 1, 2). There was also mild mitral regurgitation and a preserved left ventricular ejection fraction.
Investigation findings
An MRI was performed to further evaluate the lesion. The presence of the mass in the posterior territory of the mitral annulus and the basal segment of the posterior wall of the left ventricle was confirmed by MRI. The mass had a low signal intensity on T1-weighted MRI in comparison to the surrounding myocardium. The mass showed no signal in the centre and a high signal intensity at the edge on the T2-weighted STIR scan. The lesion showed no contrast uptake on first-pass scans on postcontrast MRI; however, late gadolinium enhancement images revealed a non-enhanced central area surrounded by a hyper-enhanced envelope.
To confirm CCMA, a CT scan without contrast was performed. CT revealed a hyperdense, well-defined round mass measuring 201939 mm with a few internal calcification areas and a partially calcified border (Figures 6, 7). The central area of the lesion had an attenuation value range of 410 HU to 650 HU. Attenuation values at the mass’s edge ranged from 723 HU to 1245 HU. The lesion’s internal calcification areas had attenuation values ranging from 1124 HU to 1169 HU.
CCMA was diagnosed based on the results of multimodal imaging. The Heart Team was consulted, and because the CCMA was asymptomatic and there was no significant valvular dysfunction, a conservative approach with regular clinical and imaging assessments was taken. The patient was found to be asymptomatic six months after his diagnosis.
The patient provided informed consent for the anonymous use of their clinical and imaging data.
Conclusions
The present report describes a case of CCMA in an asymptomatic woman who underwent a 3-year imaging follow-up. A considerable increase in the size of the lesion was confirmed using TTE, but the patient remained asymptomatic and had no complications. The patient remains under observation. Long-term imaging follow-up is a key element in understanding the natural history of CCMA.
Our report has a few limitations. First, the imaging follow-up period was quite short (3 years). Second, as lucid identification of the mass was established, a diagnostic biopsy was not performed. Differentiating intracardiac masses may necessitate the use of multimodal imaging techniques. Furthermore, on long-term imaging follow-up, these techniques provide information on the natural history of cardiac masses.
