Caseous calcification of the mitral annulus

Abstract

A 71-year-old woman with long-standing hypertension was referred for cardiological evaluation because of dyspnea on exertion, orthopnea, and orthostatic dizziness. On physical examination, a /6 systolic murmur was heard at the apex of the heart. She had no clinical signs of heart failure. There were no pulmonary rales. Transthoracic echocardiography showed pronounced concentric hypertrophy of the left ventricle with normal ejection fraction. Additionally, a large tumor attached to the posterior mitral annulus causing impairment of transmitral left ventricular inflow was visible. This tumor moved the mitral leaflet apparatus more anteriorly toward the left ventricular outflow tract resulting in systolic anterior motion (SAM) of the mitral valve leaflets with variable left ventricular outflow tract obstruction of up to 50 mm Hg. The diagnosis of caseous calcification of the mitral annulus was made (fig. 1). The patient underwent surgical resection of the tumor. The wall of the tumor was incised, a toothpaste-like mass was evacuated from a slightly calcified coat (fig. 2A), and the wall of the collapsed tumor was adapted with a running suture. The normal morphology and competence of the mitral valve could be preserved. Grossly, the lesion consisted of gray-white to yellow necrotic debris, resembling caseous