Caseous calcification of the mitral annulus: A multi-modality imaging perspective

Abstract

Mitral annulus calcification is a common echocardiographic finding, particularly in the elderly and in end-stage renal disease patients under chronic dialysis. Caseous calcification or liquefaction necrosis of mitral annulus calcification is a rare evolution of mitral annular calcification. Early recognition of this entity avoids an invasive diagnostic approach, since it is benign and, unlike intracardiac tumors and abscesses, has a favorable prognosis. The authors present the case of an 84-year-old woman with a suspicious large, echodense mass at the level of the posterior mitral leaflet with associated severe mitral regurgitation. Cardiac magnetic resonance imaging demonstrated a hypoperfused mass with strong peripheral enhancement 10 minutes after gadolinium administration. Multislice computed tomography showed the calcified nature of the mass. A multi-modality imaging approach confirmed the diagnosis of caseous calcification of the posterior mitral annulus. The patient refused surgical treatment. © 2011 Sociedade Portuguesa de Cardiologia. Published by Elsevier España, S.L. All rights reserved. Degenerescência caseosa da calcificação do anel mitral: uma perspectiva multi-imagem Resumo A calcificação do anel mitral é um achado ecocardiográfico comum, particularmente em idosos e doentes com insuficiência renal terminal em diálise. A degenerescêncica caseosa, ou necrose liquefeita, da calcificação do anel mitral é uma forma rara de calcificação do anel mitral. O reconhecimento precoce desta entidade evita procedimentos diagnósticos invasivos na medida em que é uma patologia benigna e, ao contrário de tumores e abcesso cardíacos, tem um bom prognóstico. Os autores apresentam o caso clínico de uma doente de 84 anos de idade com uma massa hiperecogénica ao nível do folheto posterior da válvula mitral, associada * Corresponding author. E-mail address: silviamartinsribeiro@gmail.com (S. Ribeiro). Ressonância magnética cardíaca a insuficiência mitral severa. A ressonância magnética cardíaca demonstrou uma massa hipoperfundida, com realce tardio, após administração de gadolíneo. A tomografia computadorizada cardíaca evidenciou a natureza calcificada da lesão. Uma abordagem multi-imagem permitiu o diagnóstico de calcificação caseosa do anel mitral posterior. A doente recusou cirurgia cardíaca. PALAVRAS-CHAVE

Caseous Calcification of the Mitral Annulus: A Review

“…In fact, most cases of CCMA are diagnosed as a part of the workup for an intracardiac mass. Multimodality imaging, including 3‐dimensional (3D) transesophageal echocardiography (TEE), cardiac magnetic resonance imaging (MRI), and computed tomography (CT) can be used in suspicious cases to avoid unnecessary surgery …”

“…On 3D TTE or 3D TEE, CCMA appears as a large area of liquefaction necrosis, with an irregular surface on the posterior mitral annulus, that extends to the most basal area at the region of the P1‐P2 scallops. The mass may distort the shape of the annulus …”

Caseous Necrosis of the Mitral Valve: Imaging Methods Allow the Diagnosis and Prevent Surgery

“…6 The differential diagnoses include intracardiac tumors, especially atrial myxoma, thrombosis of the coronary sinus, circumflex artery anomalies, and vegetations and abscesses of the mitral annulus. 1,9,10 Multiple modalities of cardiovascular imaging should be used to differentiate between the various lesions and, in these cases, are capable of establishing a definitive diagnosis without requiring pathological analysis of the mass, eliminating invasive surgical procedures. 9,10 Follow-up after diagnostic definition may be performed only with echocardiography at the discretion of the attending physician.…”

“…1,9,10 Multiple modalities of cardiovascular imaging should be used to differentiate between the various lesions and, in these cases, are capable of establishing a definitive diagnosis without requiring pathological analysis of the mass, eliminating invasive surgical procedures. 9,10 Follow-up after diagnostic definition may be performed only with echocardiography at the discretion of the attending physician. 10 CNMV is a dynamic process that, in some cases, may resolve spontaneously and even recur after surgically excised, depending on the valvular degeneration.…”

“…9,10 Follow-up after diagnostic definition may be performed only with echocardiography at the discretion of the attending physician. 10 CNMV is a dynamic process that, in some cases, may resolve spontaneously and even recur after surgically excised, depending on the valvular degeneration. Surgery is recommended upon dysfunction of the mitral valve with important stenosis or insufficiency, embolic events or when other types of tumors cannot be excluded regardless of the imaging method used.…”