Live/Real Time Three‐Dimensional Transesophageal Echocardiographic Findings in Caseous Mitral Annular Calcification

Abstract

We describe a 77-year-old female with hypertrophic cardiomyopathy in whom live/real time three-dimensional transesophageal echocardiography (3DTEE) provided incremental value over two-dimensional transthoracic and transesophageal echocardiography (2DTTE, 2DTEE) and three-dimensional transthoracic echocardiography (3DTTE) in making a more comprehensive assessment and a more confident diagnosis of caseous mitral annular calcification. 3DTEE revealed a portion of the mass to consist of small, multiple, highly echogenic discrete band-like and punctate areas within a relatively much less echogenic stroma and surrounded by a well defined highly echogenic border. This appearance correlated with the pathological findings of calcific granules/strands located in a liquefied or semiliquefied interior providing a typical toothpaste like appearance. The highly echogenic outer border represented the residual outer portion or rim of the calcific mass which did not undergo liquefaction. These findings on 3DTEE which correlated with the toothpaste like appearance seen at surgery were not visualized on 2DTTE, 2DTEE, and 3DTTE.

Real Time Three‐Dimensional Echocardiography Evaluation of Intracardiac Masses

“…RT3DE has been used to aid with this differentiation and thus avoid unnecessary surgical procedures. A case of caseous mitral annular calcification was described by Assudani et al 49 RT3DE demonstrated similar characteristics to the pathological specimen which was surgically excised (Fig. 11).…”

“…These characteristics included echogenic band like areas surrounded by a well-defined highly echogenic border (from Assudani et al49 ) (reproduced with permission from Wiley Blackwell). At the time of surgical removal of the annulus, the characteristics of the material removed from the annulus was closely described the preoperative RT3DTTE.…”

Intrinsic and Extrinsic Cardiac Pseudotumors: Echocardiographic Evaluation and Review of the Literature

“…Mitral annular calcification (MAC) should always be in the differential diagnosis of a left-sided cardiac mass. 45 The presentation of MAC might be associated with concomitant coronary artery disease, peripheral arterial disease, or DM. 46 In most cases, MAC is a degenerative process of the posterior annulus of the mitral valve fibrous ring.…”

Images in Cardiovascular Medicine: Caseous Calcification of the Mitral Annulus

“…4,5 Three-dimensional TEE, allowing a detailed imaging of morphological aspects of CCMA, has been shown to provide an incremental value over 2D TEE and TTE, as well as 3D TTE in the identification of CCMA. 6 Similarly, cardiac MRI proved to be very accurate in the diagnosis of CCMA as a peculiar imaging pattern, characterized by hypointensive signal in T1 and T2 sequences without early penetration of contrast inside the mass and late enhancement, has been observed. 7 Furthermore, cardiac CT, particularly 64-slice multidetector CT, providing a better visualization of calcifications and a precise anatomical localization of the mass can offer useful additional information in the diagnosis of CCMA.…”

“…In this respect, a multimodality imaging by use of three‐dimensional transesophageal echocardiography (3D TEE), cardiac magnetic resonance imaging (MRI), and CT, providing a better spatial and tissue characterization, has been proved to be useful, especially, in the cases of inconclusive diagnosis after two‐dimensional echocardiography (2D) . Three‐dimensional TEE, allowing a detailed imaging of morphological aspects of CCMA, has been shown to provide an incremental value over 2D TEE and TTE, as well as 3D TTE in the identification of CCMA . Similarly, cardiac MRI proved to be very accurate in the diagnosis of CCMA as a peculiar imaging pattern, characterized by hypointensive signal in T1 and T2 sequences without early penetration of contrast inside the mass and late enhancement, has been observed .…”