Asymptomatic Caseous Calcification of the Mitral Annulus in a 66-Year-Old Woman with 3-Year Imaging Follow-Up

Objective: Rare disease Background: Caseous calcification of the mitral annulus (CCMA) is an uncommon form of mitral annular calcification and can be misdiagnosed as heart abscess, neoplasm, or other lesions occupying the atrioventricular groove. Data regarding imaging follow-up of patients with CCMA are limited. This report presents a case of CCMA with a 3-year imaging follow-up. Case Report: A 66-year-old asymptomatic woman was referred to our cardiology department for further evaluation of a rapidly expanding intracardiac mass observed using transthoracic echocardiography (TTE) in an outpatient setting. A neoplasm was suspected. Echocardiographic examination was normal 5 years ago, and 2 years later, TTE revealed an echodense structure (10x10 mm) occupying the atrioventricular groove. Three years later, TTE revealed an increase in the size of the lesion (21x18 mm) and a mild acoustic shadow. Cardiac magnetic resonance imaging revealed a pathological mass (20x20x37 mm) in the posterior portion of the mitral annulus that extended into the left ventricle. Using computed tomography, a round mass (20x19x39 mm) with a demarcated area of calcification was revealed in the posterior portion of the mitral annulus. Thus, the intracardiac mass was diagnosed as CCMA. Although there was a considerable increase in lesion size (doubling of lesion size within 3 years), normal intracardiac flow and asymptomatic course of the disease remained. Therefore, this patient underwent conservative management with imaging follow-up. Conclusions: In cases of atypical presentation of CCMA, multimodal imaging may provide an accurate diagnosis and important information regarding the course of the disease.