Three Cases of Caseous Calcification of the Mitral Annulus Resulting in Spontaneous Fistulation

Figures

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  Figure 1. (A) TTE parasternal long-axis view shows a mass in the posterior mitral annulus (white arrow). The center of the mass appears echolucent and is encircled by an echogenic rim creating a string-of-pearls appearance. There is also increased thickening and calcification of a band extending from the mitral valve toward the papillary muscle (yellow arrow). (B) TTE parasternal short-axis view at the level of the papillary muscles shows an echogenic mass near the posteromedial papillary muscle (arrow). (C) TEE midesophageal 4-chamber image focusing on the mitral valve shows a mass in the posterior mitral annulus. The mass has an echogenic rim creating a string-of-pearls appearance. (D) On the three-dimensional TEE short-axis image, a lump in the P2 region of the mitral valve is seen (arrow). (E) Photo taken during cardiac surgery with the left atrium opened and the mitral valve exposed shows a white, milky, toothpaste-like discharge. (F) Photo of the mobile string-like structure, which was a calcified structure entwined within, but separate from, the chordae tendineae attached to the papillary muscle. (G) Histology with hematoxylin and eosin staining demonstrates calcifications (black…

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  Figure 2. (A) Initial apical 2-chamber view shows a mass within the posterior mitral annulus measuring 11 mm (arrow). (B) Apical 2-chamber view acquired 12 months after the initial presentation showed an increase in the size of the mass to 18 mm (arrow). (C) Apical 2-chamber view acquired 1 year later shows a further increase in the size of the mass to 20 mm (white arrow) along with an additional structure distal to the mass (yellow arrow).

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  Figure 3. (A) TEE midesophageal 2-chamber view focusing on the mitral valve shows a globular mass at the posterior mitral valve (arrow). (B) On the three-dimensional TEE short-axis image, a mass in the P2 region of the mitral valve is seen (arrow). (C) TEE midesophageal 2-chamber view with color Doppler compare shows the perforation of the posterior mitral leaflet with associated mitral regurgitation (arrows).

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  Figure 4. (A) TTE zoomed apical long-axis views show an echogenic mass in the region between the posterior aortic root and the anterior mitral leaflet (arrow). The mass measures 16 × 9 mm. (B) TTE zoomed apical long-axis views show an echogenic mass in the region between the posterior aortic root and the anterior mitral leaflet (arrow). The mass measures 29 × 14 mm. (C) TEE midesophageal 5-chamber view revealed a mass on the anterior mitral valve. (D) On the three-dimensional TEE short-axis image, a mass superior and anterior to the anterior mitral valve is seen (arrow).

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  Figure 5. Contrast-enhanced CT in the coronal (A) and axial (B) planes revealed that the mass was located outside the aortic valve (arrows).