Massive mitral annular calcification with valvular involvement: Multimodality and longitudinal imaging correlation

Mitral annular calcification is a chronic and progressive process involving the fibrous support of the mitral valve and is commonly encountered as an incidental finding in elderly patients. In rare cases, it may evolve into a massive form with relevant diagnostic and clinical implications. We report the case of a 76-year-old woman with a history of transient ischemic attacks and prior syncopal episodes who presented with progressive exertional dyspnea. Serial imaging over 8 years demonstrated progressive calcification of the mitral annulus, initially visible as a subtle curvilinear density on chest radiography and later becoming a prominent annular structure. Transthoracic echocardiography revealed preserved left ventricular systolic function, mild mitral and tricuspid regurgitation, and moderate-to-severe aortic regurgitation, with extensive calcification of both the mitral and aortic valve apparatus. Cardiac computed tomography provided definitive characterization, demonstrating massive, confluent, high-attenuation calcification of the mitral annulus with bulky crescentic morphology and mild extension toward the left ventricular inflow tract, without an associated soft-tissue component. This case highlights the value of longitudinal and multimodality imaging in recognizing massive mitral annular calcification and underscores its association with systemic cardiovascular risk factors.