Multimodality Cardiac Imaging in the Evaluation of Mitral Annular Caseous Calcification

A 77-year-old man with severe aortic stenosis was referred for consideration of aortic valve replacement. He admitted to mild exertional dyspnea and was systemically well. His past medical history was remarkable for hypertension, hypercholesterolemia, and a previous transient ischemic attack. A transthoracic echocardiogram confirmed severe calcific aortic stenosis (peak gradient 95mm Hg, estimated orifice area 0.5 cm2) with normal left ventricular ejection fraction (70%). In addition, a well-circumscribed, echodense mass (25 mm in diameter) was observed in the posterolateral basal wall attached to the posterior mitral valve leaflet (Figures 1A and 1B). Although highly echogenic, the mass also contained central echolucent areas. The mitral valve was competent, with no functional stenosis. There was no pericardial effusion. Three-dimensional transesophageal echocardiography confirmed an encapsulated, heterogenous mass arising from the posterior mitral valve annulus, adherent to the posterior mitral valve leaflet P2 scallop, in close proximity to the left atrioventricular groove and circumflex artery (Figures 1C …