Caseous calcification of the mitral annulus: a neglected lesion mimicking intracardiac mass

A 72-year-old woman with a medical history of hypertension, hyperuricemia, dyslipidemia and a transient ischemic attack was referred to our department due to a casual disclosure of an intracardiac mass during a transthoracic echocardiography. Transesophageal echocardiography con rmed the diagnosis, demonstrating a spheroid mass with echo-dense smooth borders with a heterogeneous echo density attached to the posterior mitral valve lea et (Figure 1). There was trivial mitral regurgitation with no functional stenosis, the left ventricle was hypertrophic with both normal dimensions and 60% ejection fraction. Computed tomography scan of the chest without enhancement showed the calci ed intracardiac mass, measuring 1.5 x 1.4 cm near the mitral commissure and the posterior lea et (Figure 2). A cardiac magnetic resonance imaging (CMRI) was requested to complete the diagnostic evaluation. CMRI showed in the T1 and T2 sequences a hypointense mass attached to the mitral annulus (Figure 3), whereas in the perfusion sequence, no contrast penetration was detected in the mass and in the late enhancement, only a certain grade of peripheral enhancement was found. Figure 1 Transesophageal echocardiography showing a round, echodense, calcified mass attached to the posterior mitral valve leaflet (white arrow). LA = Left atrium; LV = left ventricle.