Caseous Calcification of the Mitral Annulus by 64-Detector-Row Computed Tomographic Coronary Angiography
A Rare Intracardiac Mass
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 2×1.8-cm heterogeneous mass consistent with caseous calcification of the mitral annulus was noted, without significant coronary artery disease. The patient was managed conservatively.
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.
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.