Multi-Modality Imaging in Caseous Calcification of the Mitral Annulus: Case Series and Clinical Implications

BACKGROUND Echogenic masses in the mitral annulus are often incidental findings during routine echocardiography examinations. Most represent the wide spectrum of underlying mitral annular calcifications and usually do not require further diagnostic workup. However, a rare variant called "caseous calcification of the mitral annulus" (CCMA) can be challenging to diagnose and often requires an extensive workup with the use of multiple imaging studies in order to accurately confirm the pathology. CASE REPORT The aim of this case series was to illustrate the range of challenges associated with CCMA in various clinical scenarios to highlight the importance of multi-modality imaging in the differential diagnosis. Patient 1 was a 78-year-old asymptomatic woman with a round echo-dense structure incidentally found during a routine echocardiographic examination. Patient 2 was a 79-year-old woman with a suspected mitral abscess. Patient 3 was a 73-year-old woman with an incidentaloma (lung mass), with a concomitant lesion of the mitral annulus. All 3 patients required a unique combination of confirmatory imaging studies to ultimately confirm their diagnosis. CONCLUSIONS The incidental detection of CCMA-like changes requires multi-modality imaging to differentiate from abscesses and proliferative changes in the mitral annulus. Transthoracic echocardiography, transesophageal echocardiography, computed tomography, and cardiac magnetic resonance imaging play a key role in this diagnostic workup. Using a combination of these imaging modalities can enhance diagnostic accuracy and strongly influence the subsequent treatment and management strategies.