Caseous calcification of the mitral annulus presenting with symptomatic complete heart block

Figures

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  Figure 1. A: Electrocardiogram (ECG) of the patient upon presentation to the hospital shows complete atrioventricular dissociation. The sinus rate is 100 beats/min (bpm) and ventricular rate of 36 bpm. B: Intracardiac electrogram done prior to pacemaker insertion, which shows complete heart block owing to an infrahisian block. Signals labeled as follows: A = atrium; H = His bundle potential. C: Twelve-lead ECG post pacemaker insertion. The first complex shows myocardial capture, and the second complex shows a nonselective His-bundle capture.

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  Figure 2. A: Transthoracic echocardiogram (apical 2-chamber view). Bright echogenic lesion measuring 3.1 × 3.0 cm across the entire mitral annulus extending into the basal septum. B: Transesophageal echocardiogram (mid-esophageal 4-chamber long-axis view) showing well-circumscribed intramyocardial mass in the basal posterior medial aspect of the left ventricle measuring 2.5 × 2 cm in diameter. It did not appear caseous and was echodense compared to the adjacent tissue. C: Computed tomography of the chest at the level of the heart. Dense thick caseous calcification of the mitral annulus with basal septal extension. Moderate bilateral pleural effusion noted.

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  Figure 3. Two-chamber long-axis view demonstrating a hypointense lesion on the posterior and inferior portion of the mitral annulus with septal extension.