A 78-year-old woman was admitted to our outpatient clinic with shortness of breath. Her medical history revealed hypertension, diabetes mellitus and hyperlipidaemia. Physical examination was unremarkable except for apical 2/6 systolic murmur. Two-dimensional transthoracic echocardiographic (2D TTE) apical four-chamber and two-chamber views showed a hyperechogenic mass around the region of the posterior mitral annulus and mild mitral regurgitation ( Fig. 1 A and B , arrow; Video 1A ). Full-volume three-dimensional transthoracic echocardiography (3D TTE) after cropping the left and right ventricle walls revealed a mass arising from the posterior mitral valve annulus ( Fig. 1 C). Full-volume 3D TTE after cropping the left and right atrium walls showed a mass extending into the left atrium ( Fig. 1 D). To clarify this pathology, we performed cardiac computed tomography (CT) and magnetic resonance imaging (MRI). A non-contrast axial CT image demonstrated a hyperdense mass at the base of the posterior mitral valve ( Fig. 1 E). Axial steady-state free-precession MRI showed a hypointense mass ( Fig. 1 F). T1 black-blood ( Fig. 1 G), T2 black-blood ( Fig. 1 H) and late gadolinium enhancement (LGE) MRI images ( Fig. 1 I) for mass characterization confirmed the diagnosis of caseous calcification. LGE is particularly interesting in the diagnosis as it shows very unique peripheral enhancement of the mass. Caseous calcification of mitral annulus (CCMA) is a rare form of mitral annular calcification that is most commonly seen in the posterior mitral annulus. CCMA is a benign lesion, so it is important to make a differential diagnosis from a tumour, thrombus, cyst or abscess, which would require very different management. For this reason, we should perform the full spectrum of non-invasive cardiac imaging modalities in the diagnosis of CCMA.
