Caseous Calcification of the Mitral Annulus

Abstract

Soft-tissue masses or mass-like lesions involving the mitral valve include a wide range of diseases such as tumors, abscesses, vegetations, thrombus and, rarely, caseous calcifications of the mitral annulus. Caseous calcifications of the mitral annulus is a rare variant of mitral annular calcification that is usually asymptomatic and diagnosed incidentally. Echocardiography is the first-choice imaging modality. Cardiac computed tomography is an ideal tool to confirm the presence of calcifications and caseous necrosis. In cases where there is doubt, cardiac magnetic resonance imaging may be used. We present the case of a 62-year-old patient with an intra-cardiac mass diagnosed by echocardiography. Imaging modalities to achieve a correct diagnosis and avoid unnecessary surgical intervention are discussed.

Keywords: Cardiac Calcifications; Cardiac MRI; Cardiac masses; Caseoma; Caseous calcification of the mitral annulus.

Figure 1

62 y/o female with caseous calcification of the mitral annulus. Technique: Transthoracic echocardiography (cardiac transducer, 2-dimensional (2D) scanning, sector phased 7–12 MHz). Findings: Large, echodense mass (arrows) at the level of the mitral valve. Echocolordoppler analysis revealed mild mitral regurgitation with reduced posterior mitral leaflet motion, with no outflow tract obstruction. a: Parasternal long-axis view b: Parasternal short-axis view c: Apical 4-chamber view d: Echocolordoppler analysis

Figure 2

62 y/o female with caseous calcification of the mitral annulus. Technique: Cardiac MRI, Ingenia 1.5 T (Philips Healthcare, Best, The Netherlands) scanner with a SENSE torso phased-array coil. Pre and post intra-venous contrast administration (Prohance 0.15 mmol/kg, Bayer HealthCare, Germany) infused as bolus at a rate of 5 ml/s pushed by a 40 ml saline at 5 ml/s. Findings: (a) Cine balanced turbo field echo bTFE (TR 2.5 ms, TE 1.2 ms, flip angle 60, slice thickness 6 mm) sequence in four chamber view (4Ch) and (b) Cine bTFE (TR 1.6 ms, TE 3.3 ms, flip angle 50, slice thickness 6 mm) post-contrast sequence in two chamber view (2Ch) shows a large solid mass (white arrows) extending along the posterior mitral annulus, with low signal intensity.

Figure 3

62 y/o female with caseous calcification of the mitral annulus. Technique: Cardiac MRI, Ingenia 1.5 T (Philips Healthcare, Best, The Netherlands) scanner with a SENSE torso phased-array coil. Post intra-venous contrast administration (Prohance 0.1 mmol/kg, Bayer HealthCare, Germany) infused as bolus at a rate of 5 ml/s pushed by a 40 ml saline at 5 ml/s. Findings: First-pass perfusion (TE 1.1, TR 2.5) sequence in short axis view shows a mitral valve mass (arrow) with no contrast enhancement.

Figure 4

62 y/o female with caseous calcification of the mitral annulus. Technique: Cardiac MRI, Ingenia 1.5 T (Philips Healthcare, Best, The Netherlands) scanner with a SENSE torso phased-array coil. Approximately 10–15 min post-contrast, a whole heart high spatial resolution 3D gradient echo (T1 fast field echo) PSIR (phase sensitive inversion recovery) sequence was acquired after intra-venous contrast administration (Prohance 0.15 mmol/kg, Bayer HealthCare, Germany) infused as bolus at a rate of 5 ml/s pushed by a 40 ml saline at 5 ml/s. Findings: Myocardial LGE PSIR sequence in 4Ch (a) and 2Ch (b) shows a large solid mass extending along the posterior mitral annulus with a peripheral ring of enhancement (red arrows).

Figure 5

62 y/o female with caseous calcification of the mitral annulus. Technique: chest computed tomography angiography (CTA) performed with Somatom Definition Flash (Siemens Healthcare, Erlangen, Germany) with ECG-gating. Pre and post-contrast agent administration (Iomeron 400 mg iodine/ml, Bracco, 100 ml at 6 ml/s); slice thickness of 0.6 mm, 100 kV, 236 mAs. Findings: (a) axial contrast-enhanced CT in arterial phase and (b) axial non-contrast CT images show a hyperdense mass (arrows) at the level of the mitral valve annulus with peripheral calcifications and no enhancement after contrast agent administration.

Figure 6

62 y/o female with caseous calcification of the mitral annulus. Technique: Chest computed tomography angiography (CTA) performed with Somatom Definition Flash (Siemens Healthcare, Erlangen, Germany) with ECG-gating. Pre and post-contrast agent administration (Iomeron 400 mg iodine/ml, Bracco, 100 ml at 6 ml/s); slice thickness of 0.6 mm, 100 kV, 236 mAs. Findings: En face view of the mitral valve (a) multiplanar reconstruction (MPR) and (b) maximum intensity projection (MIP) images show a large hyperdense mass located at the posterior mitral valve annulus with peripheral calcifications (arrows).

Figure 7

62 y/o female with caseous calcification of the mitral annulus. Technique: Transthoracic echocardiography (cardiac transducer, 2-dimensional (2D) scanning, sector phased 7–12 MHz). Findings: Follow-up transthoracic echocardiography after 8 months confirmed the presence of a large, echodense mass (red arrows) at the level of the mitral valve; no morphological or dimensional changes were observed. a: Apical 4-chamber view b: Parasternal short-axis view