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(Circulation. 2007;116:e114-e115.)
© 2007 American Heart Association, Inc.

Images in Cardiovascular Medicine

Caseous Calcification of the Mitral Annulus by 64-Detector-Row Computed Tomographic Coronary Angiography

A Rare Intracardiac Mass

Lev Lubarsky, DO; Vladimir Jelnin, MD; Nino Marino, MD; Harvey S. Hecht, MD

From Lenox Hill Hospital and Lenox Hill Heart and Vascular Institute, New York, NY.

Correspondence to Lev Lubarsky, DO, Lenox Hill Heart and Vascular Institute, 130 E 77th St, New York, NY 10021. E-mail Lev20000{at}aol.com

A 70-year-old diabetic, hypertensive woman underwent transesophageal echocardiography to evaluate a recent cerebrovascular accident. She was found to have mild mitral valve insufficiency with severe mitral annular calcification and a small patent foramen ovale. Because of complaints of chest pain, 64-detector-row computed tomographic coronary angiography was performed (Figures 1 and 2). A 2x1.8-cm heterogeneous mass consistent with caseous calcification of the mitral annulus was noted, without significant coronary artery disease. The patient was managed conservatively.

View larger version (108K): [in this window] [in a new window]   Figure 1. Volume-rendered image. Normal anterior mitral valve leaflet (black arrow) and caseous calcification of the mitral annulus (arrowheads) at posterior mitral valve leaflet are shown. Heterogeneity of the caseous calcification of the mitral annulus is confirmed by widely varying densities, including negative Hounsfield units (HU) consistent with fatty degeneration (straight arrow), as well as dense calcifications (curved arrow) and a broad range of intermediate densities. Ao indicates aortic root; LA, left atrium.

View larger version (123K): [in this window] [in a new window]   Figure 2. Maximum intensity projection. Computed tomographic angiography view of the caseous calcification of the mitral annulus, comparable to short-axis parasternal view on echocardiogram. Large areas of calcification (arrowheads) extending along posterior mitral annulus are noted; anterior mitral leaflet (large arrow) is normal. RV indicates right ventricle; R, right; P, posterior, and H, head.

Unlike mitral annular calcification, caseous calcification of the mitral annulus is rare, occurring in fewer than 0.07% of patients undergoing echocardiography, and it is without known clinical significance.¹ It is characterized echocardiographically as large, round, tumorlike calcifications, usually on the posterior mitral annulus. Histological analysis reveals a pasty, acellular substance that is culture-negative and free of cancerous or inflammatory cells.²

This is the first reported case of accidentally discovered caseous calcification of the mitral annulus by computed tomographic coronary angiography. Caseous calcification of the mitral annulus should be included in the differential diagnosis of intracardiac masses on computed tomographic imaging.

	Disclosures

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None.

	Footnotes

 
The online-only Data Supplement, consisting of movies, is available with this article at http://circ.ahajournals.org/cgi/content/full/116/5/e114/DC1.

	References

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1. Harpaz D, Auerbach I, Vered Z, Motro M, Tobar A, Rosenblatt S. Caseous calcification of the mitral annulus: a neglected, unrecognized diagnosis. J Am Soc Echocardiogr. 2001; 14: 825–831.[CrossRef][Medline] [Order article via Infotrieve]

2. Alkadhi H, Leschka S, Pretre, Perren A, Marincek B, Wildermuth S. Caseous calcification of the mitral annulus. J Thorac Cardiovasc Surg. 2005; 129: 1438–1440.[Free Full Text]

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This Article Extract Full Text (PDF) Data Supplement Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lubarsky, L. Articles by Hecht, H. S. Search for Related Content PubMed PubMed Citation Articles by Lubarsky, L. Articles by Hecht, H. S. Related Collections CT and MRI Related Article