Caseous calcification of the mitral annulus — A clinical case

Abstract

Introduction: The caseous calcification of the mitral annulus is a rare form of calcification not totally understood and which could point to an incorrect diagnosis of intracardiac tumor, leading to unnecessary surgeries. The typical picture in the echocardiogram is an hyperechogenic round mass in the outside and an hypoechogenic area inside. The course of the disease is benign,making the intervention dependent on themitral insufficiency that eventually will cause. Clinical case: Caucasian, 63 year old female, history of hypertension, venous insufficiency and nonspecific valvular disease, poli-medicated, admitted in the InternalMedicineWard with aggravation of chronic heart failure due to unknown cause. In the Ward, the full clinical history of the patientwas taken, and the symptoms were a lower respiratory infection with a week of evolution, which aggravated the chronic heart condition. The physical exam revealed: edemas in the lower limbs to the knee level, and crackles and rhonchi on the pulmonary auscultation. The patientwas treatedwith antibiotics for a respiratory infection acquired in the community and diuretics, while waiting to perform further exams. In the blood screen the Pro-BNP was increased, along with the inflammatory cells and CRP. Chest X-Ray was normal and the Echocardiogram revealed mitral e tricuspid insufficiency with calcification of the mitral valve due to a mass, which was suggested with the realization of a CT scan. Instead of a CT, a Cardiac MRI was performed revealing an intracardiac mass in the mitral valve, suspicious of a tumor or caseous calcification of the mitral valve. The case was discussed with the cardiothoracic surgery department, the patient recovered well with no need of surgery for now. Discussion: The presence of a caseous calcification of the mitral annulus is a common echocardiogram finding, especially in women in their 60's. The detection of intracardiac masses in the echocardiogram is an accidental finding or could be discovered on the follow-up of patients with chronic heart failure or thromboembolic conditions. The caseous calcification of the mitral annulus is a chronic and degenerative process, followed by the fibrosis of themitral valve withmain involvement of the posterior leaflet andmitral annulus. A Trans-thoracic Echocardiogram is an excellent noninvasive technique for the diagnosis of this disease and the images should be known. A Trans-esophageal Echocardiogram is superior for the evaluation of the etiology, the masses seen the in the echocardiogram look similar to those found in Cardiac CT orMRI.Conclusion: The caseous calcification of themitral annulus is a rare clinical situation, foundmainly in patients in the six decade of life or older, and should be integrated in the differential diagnosis upon the detection of an hyperechogenic mass in the posterior part of themitral valve annulus in echocardiogram. Upon the confirmation of the echocardiographic findings, the patients only have surgical indication if the hemodynamic state is compromised along with mitral valve function and not by the mass itself, which is totally benign.