Ruptured caseous calcification of the mitral annulus

Mitral annular calcification (MAC) is considered a chronic and degenerative process involving the fibrous annulus of the mitral valve. The prevalence of MAC has been reported between 8% and 15%. It significantly increases with age, often seen in females, individuals with hypertension, chronic kidney disease and those with multiple cardiovascular risk factors. Caseous calcification of the mitral annulus (CCMA) (also known as caseoma) is a rare variant of MAC and should be considered in the differential diagnosis with other cardiac masses of the mitral valve. An 85-year-old female presented for a transthoracic echocardiogram with a history of hypertension and a systolic murmur. The echocardiogram demonstrated a possible rare variant of MAC, with independent mobile echodensities identified. Further testing using transoesophageal echocardiography was used to confirm diagnosis and ensure appropriate clinical management was arranged. This case demonstrated CCMA, a benign condition that can be mistaken for cardiac tumours, thrombus, vegetations or abscesses. A low prevalence has been reported between 0.06% and 0.07% and 0.6% of patients with MAC using echocardiography. Echocardiography can provide the initial diagnosis for identification and characterisation of MAC. CCMA appears as a calcified mass with an echolucent, liquid-like inner part, located on the posterior mitral valve annulus. Acoustic shadowing is usually absent. Multi-modality imaging can lead to an accurate diagnosis of CCMA without unnecessary interventions. Transoesophageal echocardiography provides further information on the site and composition of the internal material. Computed tomography (CT) and cardiac magnetic resonance imaging (MRI) can also be used, to confirm the diagnosis and to exclude other differential diagnoses.