Big mitral annular calcification: a case report of a dynamic liquefaction necrosis as a potential source of embolism

Figures

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  Figure 1. Initial echocardiography. Initial transthoracic echocardiography at first presentation. The parasternal long axis is shown on the left, whereas the basal short axis is shown on the right. Transthoracic echocardiogram reveals an echo-lucent, sclerotic structure of 28 mm × 24 mm × 21 mm at the posterior mitral annulus with a posterior echo shadow. There were no signs of mitral valve regurgitation or stenosis and normal biventricular function.

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  Figure 2. Native cardiac magnetic resonance of the dynamic changes of the caseous calcification of the posterior mitral annulus. Dynamic changes in native cardiac magnetic resonance in caseous calcification of the posterior mitral annulus in a 71-year-old woman. (A) Cine balanced steady-state free precession sequences demonstrated an 18 mm × 23 mm × 31 mm non-invasive heterogeneous mass in the left atrium in proximity to the posterior mitral valve annulus. (B) First follow-up cardiac magnetic resonance after 6 months. Cine balanced steady-state free precession showed an enlarging, centrally hyperintense mass (42 mm × 22 mm × 32 mm) (red arrow), further protruding into the lateral wall of the myocardium and new evidence of mitral regurgitation. In T1 Turbo Spin Echo dark blood (TSEdb) and Turbo Inversion Recovery Magnitude (TIRM), the central part of the mass presented as hyperintense with elevated values of 1138 ms (1.5 T) in quantitative tissue characterization by native T1 mapping and 225 ms by T2 mapping (blue arrow). The elevated T1 values implicate a dyshomogeneous content (liquid, calcification, and cell infiltrates) with values lower than blood pool (1551 ms). T1 relaxation time was…

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  Figure 3. Post-contrast cardiac magnetic resonance of the dynamic changes of the caseous calcification of the posterior mitral annulus. Dynamic changes in post-contrast cardiac magnetic resonance of the caseous calcification of the posterior mitral annulus. (A) Initial cardiac magnetic resonance showing a non-invasive nodular mass in the left atrium in proximity to the posterior mitral valve annulus. First pass perfusion (FFP) revealed no perfusion of the mass (red arrow) and late gadolinium enhancement showed enhancement along the periphery of cMAC with only minimal peripheral contrast-uptake of the mass (blue arrow). (B) Cardiac magnetic resonance 6 months later showed again no perfusion of the grown mass. Similarly to the initial scan, late gadolinium enhancement revealed enhancement along with the periphery of cMAC (yellow arrow) with only minimal contrast-uptake of the mass [lower post-contrast T1 values compared to native T1 values (green arrow)]. (C) Follow-up cardiac magnetic resonance 12 months after diagnosis showed a residual mass at the lateral mitral valve still without perfusion in the FFPs and no contrast-uptake in the late gadolinium enhancement.

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