E-page Original Images: Diagnosis of a caseous mitral annular calcification

A 75-year-old woman was presented with shortness of breath and palpitations. After initial evaluation, a transthoracic echocardiographic examination was planned and showed a large, round, echodense mass with central areas of echolucencies attached to the posterior mitral annulus (Fig.1, Video 1-3. See corresponding video/movie images at www.anakarder.com). Caseous calcification of the mitral annulus (CCMA) was suspected. A multidetector computed tomography (MDCT) scan without contrast agents (because of moderate chronic kidney disease) was performed to aid differential diagnosis and to establish the nature of the mass. The bone window and level settings showed a rim of peripheral calcification with central homogeneous hyperdense mass lesion (Fig. 2A). The mediastinal window and level settings showed homogeneous hyperdense mass lesion that cannot be differentiated from other calcific structures (Fig. 2B).