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Minga I, Appadurai V, Rigolin V. A Female in Her 50s With Caseating Mitral Annulus Calcification. JAMA Cardiol 2024; 9:406. [PMID: 38477890 DOI: 10.1001/jamacardio.2024.0074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
This case report describes a diagnosis of caseating mitral annulus calcification in a female patient with a history of peritoneal dialysis who presented with confusion and disorientation.
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Affiliation(s)
- Iva Minga
- Northshore University Health System, Evanston, Illinois
- University of Chicago Medical Center, Chicago, Illinois
| | - Vinesh Appadurai
- Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- School of Medicine, The University of Queensland, St Lucia, Queensland, Australia
| | - Vera Rigolin
- Bluhm Cardiovascular Institute, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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2
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Al-Kassou B, Weber M, Nickenig G, Zimmer S. Thrombotic ST-segment elevation myocardial infarction caused by a caseous mitral annular calcification. Clin Res Cardiol 2024; 113:644-646. [PMID: 36809351 PMCID: PMC10954851 DOI: 10.1007/s00392-023-02167-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 02/02/2023] [Indexed: 02/23/2023]
Affiliation(s)
- Baravan Al-Kassou
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Marcel Weber
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Georg Nickenig
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Sebastian Zimmer
- Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
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3
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Kucuk HO, Nan JZ, Larson KF, Sinak LJ, Eleid MF. Percutaneous Vacuum-Assisted Aspiration of Mobile Caseous Mitral Annulus Calcification. JACC Case Rep 2024; 29:102182. [PMID: 38361568 PMCID: PMC10865118 DOI: 10.1016/j.jaccas.2023.102182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 12/01/2023] [Indexed: 02/17/2024]
Abstract
A 68-year-old woman presented with an incidentally found intracardiac mass. Transesophageal echocardiography (TEE) showed a 26 × 8 mm mobile mass attached to a calcified posterolateral mitral annulus. The mass was removed with a commercially available percutaneous catheter system using cerebral embolic protection and TEE guidance. The pathologic examination showed caseous mitral annular calcification.
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Affiliation(s)
- Hilal Olgun Kucuk
- Cardiovascular Medicine Department, Mayo Clinic, Rochester, Minnesota, USA
| | - John Z. Nan
- Cardiovascular Medicine Department, Mayo Clinic, Rochester, Minnesota, USA
| | - Kathryn F. Larson
- Cardiovascular Medicine Department, Mayo Clinic, Rochester, Minnesota, USA
| | - Lawrence J. Sinak
- Cardiovascular Medicine Department, Mayo Clinic, Rochester, Minnesota, USA
| | - Mackram F. Eleid
- Cardiovascular Medicine Department, Mayo Clinic, Rochester, Minnesota, USA
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4
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Deng Y, Li G, Liu J, Wan X, Li L, Lv J, Li Q, Zhou F, Chang D. Case report: Catheter ablation for persistent atrial fibrillation in a patient with heart of stone. Front Cardiovasc Med 2023; 10:1207064. [PMID: 37849940 PMCID: PMC10577284 DOI: 10.3389/fcvm.2023.1207064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 09/19/2023] [Indexed: 10/19/2023] Open
Abstract
Myocardial calcification is a rare condition, with only a few reports in the literature. For the first time, we report a case of diffuse myocardial calcification who underwent successful catheter ablation for persistent atrial fibrillation (AF). In this case, catheter ablation was recommended due to repeated hospitalization for palpitation and heart failure, but preoperative computed tomography showed massive myocardial calcification. Electroanatomic mapping of the atrium was performed with a Pentaray catheter before ablation, which showed areas of low voltage in the calcified region. As the persistent AF was terminated after circumferential pulmonary vein isolation and posterior wall isolation, and no further ablation was performed. The patient recovered well, with no recurrence of palpitation or heart failure during the one-year follow-up.
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Affiliation(s)
| | | | | | | | | | | | | | - Faguang Zhou
- Department of Cardiology, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Dong Chang
- Department of Cardiology, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
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5
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Yoshihara S. Evaluation of causal heart diseases in cardioembolic stroke by cardiac computed tomography. World J Radiol 2023; 15:98-117. [PMID: 37181820 PMCID: PMC10167814 DOI: 10.4329/wjr.v15.i4.98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 03/08/2023] [Accepted: 03/30/2023] [Indexed: 04/26/2023] Open
Abstract
Cardioembolic stroke is a potentially devastating condition and tends to have a poor prognosis compared with other ischemic stroke subtypes. Therefore, it is important for proper therapeutic management to identify a cardiac source of embolism in stroke patients. Cardiac computed tomography (CCT) can detect the detailed visualization of various cardiac pathologies in the cardiac chambers, interatrial and interventricular septum, valves, and myocardium with few motion artifacts and few dead angles. Multiphase reconstruction images of the entire cardiac cycle make it possible to demonstrate cardiac structures in a dynamic manner. Consequently, CCT has the ability to provide high-quality information about causal heart disease in cardioembolic stroke. In addition, CCT can simultaneously evaluate obstructive coronary artery disease, which may be helpful in surgical planning in patients who need urgent surgery, such as cardiac tumors or infective endocarditis. This review will introduce the potential clinical applications of CCT in an ischemic stroke population, with a focus on diagnosing cardioembolic sources using CCT.
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Affiliation(s)
- Shu Yoshihara
- Department of Diagnostic Radiology, Iwata City Hospital, Iwata 438-8550, Shizuoka, Japan
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6
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Hishikawa T, Ohashi T, Kageyama S, Kojima A. Utility of cardiac magnetic resonance imaging for pre-operatively evaluating the degree of caseous calcification of the mitral annulus infiltration within the left ventricular myocardium: a case report. Eur Heart J Case Rep 2023; 7:ytad188. [PMID: 37123656 PMCID: PMC10141458 DOI: 10.1093/ehjcr/ytad188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 02/02/2023] [Accepted: 04/12/2023] [Indexed: 05/02/2023]
Abstract
Background Depending on the degree of infiltration of dry mitral annulus calcification (MAC) into the left ventricular myocardium, calcification removal may cause thinning of the left ventricular wall and increase the risk of post-operative left ventricular rupture. Therefore, the degree of pre-operative infiltration into the left ventricular myocardium should be assessed as accurately as possible. We report a case of caseous calcification of the mitral annulus (CCMA), a subtype of MAC, in an 84-year-old woman; cardiac magnetic resonance imaging (MRI) was useful in assessing the degree of left ventricular infiltration of calcification. Case summary The patient was referred to our hospital for surgery due to respiratory distress and severe mitral insufficiency. Echocardiography revealed a mass under the posterior mitral annulus adjacent to the mitral valve ring, suspected to be a CCMA. Cardiac MRI was performed to assess the risk of left ventricular rupture. Pre-operatively, no valve ring or left ventricular myocardium infiltration was confirmed. Surgical caseous calcification removal and artificial valve implantation within the preserved valve annulus were then performed. The patient had an uneventful post-operative course and was discharged without complications on the 21st post-operative day. Discussion In this CCMA case, a pre-operative cardiac MRI was useful for evaluating the degree of the valve annulus and left ventricular myocardial involvement and estimating the risk of left ventricular rupture.
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Affiliation(s)
| | - Takeki Ohashi
- Cardiovascular Surgery Department, Nagoya Tokushukai General Hospital, 2-52 Kozoji-cho kita, Kasugai City, Aichi 487-0016, Japan
| | - Soichiro Kageyama
- Cardiovascular Surgery Department, Nagoya Tokushukai General Hospital, 2-52 Kozoji-cho kita, Kasugai City, Aichi 487-0016, Japan
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7
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Ogasawara Y, Mano K, Henmi F, Uesaka Y, Takazawa Y. [A case of caseous calcification of mitral annulus resulting in multiple cerebral infarctions]. Rinsho Shinkeigaku 2023; 63:97-100. [PMID: 36725008 DOI: 10.5692/clinicalneurol.cn-001816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The patient is a 73-year-old woman. She presented with dysarthria, and a head MRI revealed multiple acute cerebral infarctions in the bilateral cerebral hemisphere and cerebellar hemisphere. Transesophageal echocardiography after admission revealed a 16 mm large mobile calcification of the mitral annulus (caseous calcification of the mitral annulus; CCMA) on the posterior apex of the mitral valve annulus. Since the CCMA had a high risk of relapse, and a new infarction was detected on the 8th day, resection of the mass and mitral valve replacement surgery were performed. CCMA is a subtype of mitral annular calcification (MAC). When calcification progresses from the MAC state to form a mass, it is called a calcified amorphous tumor; CAT. Reports of embolic cerebral infarction caused by CAT are rare, but this is a rare report of an embolic cerebral infarction from CCMA presenting as CAT.
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Affiliation(s)
| | - Kagari Mano
- Department of Neurology, Toranomon Hospital.,Department of Neurology, Yokohama Rosai Hospital
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Gower H, Hamilton M, Manghat N, Abubakr MOA. Caseous Mitral Annular Calcification Presenting as Retinal Artery Occlusion. EUROPEAN MEDICAL JOURNAL 2023. [DOI: 10.33590/emj/10305506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Caseous mitral annular calcification (CMAC), sometimes called liquefaction necrosis of mitral annular calcification (MAC), is a rare variant of MAC, a chronic degenerative process that progresses with age. It is a degenerative abnormality of the fibrous tissue and typically involves the posterior annulus, appearing as a smooth mass with no flow or acoustic shadow artefacts. It can be differentiated from other cardiac masses by CT and MRI. Whilst benign in nature, it is associated with a range of pathologies, such as mitral valve dysfunction, arrhythmias, and systemic embolisation. Given the risk of systemic embolisation, surgery may be appropriate, but there is no clear consensus in the literature in patients who are asymptomatic. This case highlights a case of CMAC presenting with a retinal artery occlusion, and was managed conservatively.
Background
The mitral annulus is a key component of the mitral valve, ensuring appropriate function by facilitating complete closure of the leaflets during systole. With age, MAC can occur, potentially resulting in mitral valve dysfunction, infective endocarditis, and arrhythmias. CMAC is a rare variant of MAC, typically involving the posterior annulus. Whilst benign, the risk of complications, such as systemic embolisation, may indicate a surgical approach to management, even in patients who are asymptomatic.
Case Presentation
A 60-year-old female, presenting with sudden loss of vision in the lower part of her left eye due to a branch retinal artery embolus, was admitted from ophthalmology services. An outpatient transthoracic echocardiogram showed an abnormal mass on the posterior annulus of the mitral valve. Transoesophageal echocardiography identified a calcified posterior aspect of the mitral annulus with normal leaflet mobility and trivial regurgitation, and an echogenic mass attached to the ventricular aspect of the mitral annulus (at the level of posteromedial commissure), 9x4 mm in size. A cardiac CT showed a caseous mitral valve with evidence of rupture of the calcified shell. Discussion with the surgical multidisciplinary team resulted in a conservative approach, with follow-up echo for monitoring.
Conclusion
Whilst a benign and rare variant of MAC, CMAC is associated with a range of pathologies, including mitral valve disease, arrhythmias, and systemic embolisation. Currently, there is no standardised management approach for CMAC. Surgery is currently recommended in the context of already known surgically indicated pathologies, such as severe mitral valve disease or systemic embolisation. However, this conservatively-managed patient has had no further complications with stable echocardiographic appearance on repeat echo 3 months following initial exam.
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Affiliation(s)
- Hannah Gower
- Department of Cardiology, Royal Cornwall Hospitals (Truro), UK
| | - Mark Hamilton
- Department of Radiology, Bristol Heart Institute, UK
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9
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Correia JL, Correia M. Bulky Mitral Annulus Caseous Calcification in an Atypical Location. Arq Bras Cardiol 2022; 119:1002-1005. [PMID: 36541999 DOI: 10.36660/abc.20210949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 06/15/2022] [Indexed: 11/27/2022] Open
Abstract
Mitral annular calcification (MAC) is a commonly observed chronic and degenerative fibrotic process of the base of the mitral valve, usually deemed as an incidental finding. Although initially, MAC was thought to be a consequence of an age-related degenerative process, recent findings suggest other independent contributive mechanisms, such as atherosclerosis and abnormal calcium-phosphorus metabolism. Caseous calcification of the mitral annulus (cMAC) is a rarely described variant of MAC, characterized by an ovoid, focal mass with internal caseous fluid-like calcifications and debris. Differentiating a cMAC from other cardiac masses attached to the mitral annulus may be challenging. A single imaging modality, such as transthoracic echocardiography, may not be sufficient for a clear diagnosis. Therefore, a multimodal imaging approach is necessary, including cardiac tomography computerized imaging and cardiac magnetic resonance (CMR). MAC and cMAC typically affect the posterior mitral annulus, with very few cases in the literature describing the involvement of the anterior annulus. We present a rare case of an anterior mitral annulus caseous calcification found in a CMR performed to evaluate a left atrial mass identified on a transthoracic echocardiogram.
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Affiliation(s)
| | - Miguel Correia
- Centro Hospitalar Tondela -Viseu, Viseu - Portugal.,Hospital Cuf Viseu, Viseu - Portugal
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10
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Three Cases of Caseous Calcification of the Mitral Annulus Resulting in Spontaneous Fistulation. CASE 2022; 6:355-360. [PMID: 36247370 PMCID: PMC9556935 DOI: 10.1016/j.case.2022.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
CCMA is a rare disease. CCMA is diagnosed incidentally on echocardiography. CCMA can result in fistula formation, valve disease, and systemic embolization. CCMA should be observed regularly. CCMA should be operated on before complications arise.
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11
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Gać P, Cheładze P, Poręba R. The Importance of Cardiac Computed Tomography in the Diagnosis of Caseous Calcification of the Mitral Annulus—Case Reports. Diagnostics (Basel) 2022; 12:diagnostics12030667. [PMID: 35328220 PMCID: PMC8947161 DOI: 10.3390/diagnostics12030667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 03/02/2022] [Accepted: 03/07/2022] [Indexed: 12/01/2022] Open
Abstract
Mitral annular calcification (MAC) is a common pathology of the mitral valve. In rare cases, calcifications occur in the mitral annulus degenerate serous; the caseous calcification of the mitral annulus (CCMA) then develops. Detection of CCMA is often random and requires differentiation from heart tumors or an abscess. The paper presents two cases of patients with ambiguous focal lesions of the mitral valve in echocardiography. In the first case, the cardiac computed tomography (CCT) showed a spherical, slightly irregular structure measuring approximately 33 × 22 mm, which was in contact with the posterior mitral valve leaflet from the lumen of the left ventricle. The lesion was heterogeneously intense, with an average density of about 500 HU and up to 975 HU on the periphery; it was not enhanced after the administration of a contrast agent. In the second case, the CCT revealed a heterogeneous, highly calcified structure in the peripheral zone and intermediate density in the central zone in the topography of the posterior mitral valve leaf, with dimensions up to about 41 × 31 mm in the plane of the valve leaflet, passing into the lumen of the left ventricle along its inferolateral wall to a depth of about 3.5 cm. In both cases, CCT enabled the diagnosis of CCMA. In conclusion, cardiac computed tomography may be decisive in the case of suspected caseous calcification of the mitral annulus where there is ambiguous echocardiography.
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Affiliation(s)
- Paweł Gać
- Centre for Diagnostic Imaging, 4th Military Hospital, Weigla 5, PL 50-981 Wroclaw, Poland;
- Department of Population Health, Division of Environmental Health and Occupational Medicine, Wroclaw Medical University, Mikulicza-Radeckiego 7, PL 50-368 Wroclaw, Poland
- Correspondence: or
| | - Przemysław Cheładze
- Centre for Diagnostic Imaging, 4th Military Hospital, Weigla 5, PL 50-981 Wroclaw, Poland;
| | - Rafał Poręba
- Department of Internal and Occupational Diseases, Hypertension and Clinical Oncology, Wroclaw Medical University, Borowska 213, PL 50-556 Wroclaw, Poland;
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12
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Sveric KM, Platzek I, Golgor E, Hoffmann RT, Linke A, Jellinghaus S. Purposeful use of multimodality imaging in the diagnosis of caseous mitral annular calcification: a case series report. BMC Med Imaging 2022; 22:7. [PMID: 34991503 PMCID: PMC8734157 DOI: 10.1186/s12880-021-00725-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 12/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Caseous mitral annular calcification (CMAC) is a rare liquefactive variant of mitral annular calcification (MAC) and superficially mimics a cardiac vegetation or abscess. CMAC is viewed as a benign condition of MAC, while MAC has clinical implications for patients' lives. Correctly diagnosing CMAC is essential in order to avoid unnecessary interventions, cardiac surgery or even psychological suffering for the patient. CASE PRESENTATION We report on 6 patients with suspected intra-cardiac masses of the mitral annulus that were referred to our institution for further clarification. A definitive diagnosis of CMAC was achieved by combining echocardiography (Echo), cardiac magnetic resonance imaging (MRI) and cardiac computed tomography (CT) for these patients. Echo assessed the mass itself and possible interactions with the mitral valve. MRI was useful in differentiating the tissue from other benign or malign neoplasms. CT revealed the typical structure of CMAC with a "soft" liquefied centre and an outer capsule with calcification. CONCLUSION CMAC is a rare condition, and most clinicians and even radiologists are not familiar with it. CMAC can be mistaken for an intra-cardiac tumour, thombus, vegetation, or abscess. Non-invasive multimodality imaging (i.e. Echo, MRI, and CT) helps to establish a definitive diagnosis of CMAC and avoid unnecessary interventions especially in uncertain cases.
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Affiliation(s)
- Krunoslav Michael Sveric
- Department of Internal Medicine and Cardiology, Herzzentrum Dresden, Technische Universität Dresden, Fetscherstr. 76, 01307, Dresden, Germany.
| | - Ivan Platzek
- Insitute and Polyclinic for Diagnostic and Interventional Radiology, Dresden University Hospital, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Elena Golgor
- Insitute and Polyclinic for Diagnostic and Interventional Radiology, Dresden University Hospital, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Ralf-Thorsten Hoffmann
- Insitute and Polyclinic for Diagnostic and Interventional Radiology, Dresden University Hospital, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Axel Linke
- Department of Internal Medicine and Cardiology, Herzzentrum Dresden, Technische Universität Dresden, Fetscherstr. 76, 01307, Dresden, Germany
| | - Stefanie Jellinghaus
- Department of Internal Medicine and Cardiology, Herzzentrum Dresden, Technische Universität Dresden, Fetscherstr. 76, 01307, Dresden, Germany
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Singh N, Shah AP, Torregrossa G, Blair JE. Recurrent ST-elevation myocardial infarction: a case report of a rare complication of caseous mitral annular calcification. Eur Heart J Case Rep 2022; 6:ytab502. [PMID: 35047746 PMCID: PMC8759494 DOI: 10.1093/ehjcr/ytab502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/12/2021] [Accepted: 11/30/2021] [Indexed: 11/14/2022]
Abstract
Background Caseous mitral annular calcification (MAC) is an under-diagnosed division of calcific mitral valve disease that has recently been reported to have increased propensity for embolic disease. Early recognition of this entity as a cause of embolic disease can lead to prevention of occlusive vascular disease and long-standing complications. Case summary We present the case of a patient with end-stage renal disease who presented for evaluation of chest pain and was found to have ST-segment myocardial infarction. Despite thrombectomy and stenting, he had multiple recurrent events, and imaging evaluation demonstrated caseous MAC with mobile components. He was taken for surgical replacement of the mitral valve, with pathology confirming diagnosis. Discussion Caseous MAC may represent an increased risk of embolic disease. Better understanding of this pathology and it’s propensity for embolic disease will be important to best determine treatment plans and timing of operative intervention.
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Affiliation(s)
- Nikhil Singh
- Section of Cardiology, Department of Medicine, University of Chicago Medicine, 5841 South Maryland Avenue, MC 5076, Chicago, IL 60637, USA
| | - Atman P Shah
- Section of Cardiology, Department of Medicine, University of Chicago Medicine, 5841 South Maryland Avenue, MC 5076, Chicago, IL 60637, USA
| | - Gianluca Torregrossa
- Section of Cardiothoracic Surgery, Department of Cardiothoracic Surgery, University of Chicago Medicine, 5841 South Maryland Avenue, MC 5076, Chicago, IL 60637, USA
| | - John E Blair
- Section of Cardiology, Department of Medicine, University of Chicago Medicine, 5841 South Maryland Avenue, MC 5076, Chicago, IL 60637, USA
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14
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Allwood RP, Bonacci EL, McKinnon E. Ruptured caseous calcification of the mitral annulus. Australas J Ultrasound Med 2021; 24:106-111. [PMID: 34765419 DOI: 10.1002/ajum.12238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Richard P Allwood
- Cardiology Department St Vincent's Hospital Melbourne 41 Victoria Parade Fitzroy 3065 Australia
| | - Emma L Bonacci
- Cardiology Department St Vincent's Hospital Melbourne 41 Victoria Parade Fitzroy 3065 Australia
| | - Erin McKinnon
- Cardiology Department St Vincent's Hospital Melbourne 41 Victoria Parade Fitzroy 3065 Australia
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15
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Li TYW, Yeo LLL, Ho JSY, Leow AS, Chan MY, Dalakoti M, Chan BPL, Seow SC, Kojodjojo P, Sharma VK, Tan BYQ, Sia CH. Association of Global Cardiac Calcification with Atrial Fibrillation and Recurrent Stroke in Patients with Embolic Stroke of Undetermined Source. J Am Soc Echocardiogr 2021; 34:1056-1066. [PMID: 33872703 DOI: 10.1016/j.echo.2021.04.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 04/06/2021] [Accepted: 04/07/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Calcium deposits in the heart have been associated with cardiovascular events, mortality, stroke, and atrial fibrillation (AF). However, there is no accepted standard method for scoring cardiac calcifications. Existing methods have also not been validated for the assessment of patients with embolic stroke of undetermined source (ESUS). The aim of this study was to evaluate the association of various cardiac calcification scores with new-onset AF and stroke recurrence in a cohort of patients with ESUS. METHODS In this study, 181 consecutive patients with stroke diagnosed with ESUS were identified and evaluated. They were followed for new-onset AF and ischemic stroke recurrence for a median duration of 2.1 years. Various echocardiographic cardiac calcification scores were assessed on transthoracic echocardiography performed during the evaluation of ESUS and subsequently assessed for their relation to AF detection and recurrent stroke. The echocardiographic calcium scores assessed were the (1) global cardiac calcium score (GCCS), (2) echocardiographic calcium score (eCS), (3) echocardiographic calcification score, (4) echocardiographic composite cardiac calcium score, and (5) total heart calcification score. Only two of these scoring schemes, GCCS and eCS, quantified the cardiac calcium burden. RESULTS Higher calcium scores as measured by GCCS and eCS were found to be significantly associated with subsequent AF detection as well as recurrent ischemic stroke in patients with ESUS. The association with recurrent stroke remained significant even after adjustment for comorbidities and AF. CONCLUSIONS Higher cardiac calcification measured using the GCCS and eCS is independently associated with AF detection and recurrent ischemic stroke in patients with ESUS, and these scores can be useful markers for further risk stratification in patients with ESUS.
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Affiliation(s)
- Tony Y W Li
- Internal Medicine Residency, National University Health System, Singapore
| | - Leonard L L Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, Department of Medicine, National University Health System, Singapore.
| | - Jamie S Y Ho
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Aloysius S Leow
- Internal Medicine Residency, National University Health System, Singapore
| | - Mark Y Chan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Mayank Dalakoti
- Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Bernard P L Chan
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Swee-Chong Seow
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Pipin Kojodjojo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore
| | - Vijay K Sharma
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Benjamin Yong-Qiang Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore
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Ullah W, Haas D, Almas T, Al-Mukhtar A, Inayat A. Caseous mitral valve calcification and concurrent hypertrophic obstructive cardiomyopathy: A rare cause of stroke. IJC HEART & VASCULATURE 2020; 30:100647. [PMID: 33015316 PMCID: PMC7524529 DOI: 10.1016/j.ijcha.2020.100647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 09/12/2020] [Accepted: 09/16/2020] [Indexed: 12/01/2022]
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17
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Calcified amorphous tumor with caseous calcification of mitral annulus in hemodialysis patients. Gen Thorac Cardiovasc Surg 2020; 68:1513-1516. [PMID: 32314150 DOI: 10.1007/s11748-020-01363-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 04/07/2020] [Indexed: 10/24/2022]
Abstract
Mitral annular calcification (MAC) is a common finding, especially among the elderly. Caseous calcification of the mitral annulus (CCMA) is a rare variant of MAC. Calcified amorphous tumor (CAT) is an extremely rare non-neoplastic cardiac tumor accompanied by calcification and is often associated with MAC. We encountered two patients with end-stage renal failure in whom a cardiac CAT developed on the mitral annulus. In both patients, preoperative examination showed MAC of the posterior mitral annulus and a mobile mass attached to the MAC. CAT and CCMA were considered, and surgical resection was performed because of a high risk of systemic embolization. Intraoperatively, the mobile mass was associated with the CCMA. The CCMA with the mass was entirely removed, and the diagnosis of CAT was histologically confirmed. We herein report these two cases of CAT arising from CCMA in patients undergoing hemodialysis and propose the characteristic imaging features and operative findings.
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Cavalcanti LRP, Sá MPBO, Perazzo ÁM, Escorel Neto AC, Gomes RAF, Weymann A, Zhigalov K, Ruhparwar A, Lima RC. Mitral Annular Calcification: Association with Atherosclerosis and Clinical Implications. Curr Atheroscler Rep 2020; 22:9. [PMID: 32034516 DOI: 10.1007/s11883-020-0825-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW This review summarizes the pathophysiology of mitral annular calcification (MAC) with recent findings and current strategies for diagnosis and treatment. RECENT FINDINGS Major factors in MAC development seem to be shear stress of the flow past the mitral valve, local inflammation, and dysregulation in regulators of mineral metabolism. MAC itself poses daunting technical challenges. Implanting a valve on top of the calcium bar might lead to paravalvular leak (PVL) that is less likely to heal. Annular decalcification allows for better valve seating and potentially better healing and less PVL. This, however, comes with the risk for catastrophic atrioventricular groove disruption. MAC can be sharply dissected with the scalpel; the annulus can be reconstructed with the autologous pericardium. Transcatheter mitral valve replacement is a promising approach in the treatment of patients who are deemed high-risk surgical candidates with severe MAC. MAC is a multifactorial disease that has some commonalities with atherosclerosis, mainly regarding lipid accumulation and calcium deposition. It is of great clinical importance, being a risk marker of cardiovascular events (including sudden death) and, with its progression, can have a negative impact on patients' lives.
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Affiliation(s)
- Luiz Rafael P Cavalcanti
- Division of Cardiovascular Surgery, Pronto Socorro Cardiológico de Pernambuco - PROCAPE, Recife, Brazil. .,University of Pernambuco - UPE, Recife, Brazil. .,, Recife, Brazil.
| | - Michel Pompeu B O Sá
- Division of Cardiovascular Surgery, Pronto Socorro Cardiológico de Pernambuco - PROCAPE, Recife, Brazil.,University of Pernambuco - UPE, Recife, Brazil.,Nucleus of Postgraduate and Research in Health Sciences of Faculty of Medical Sciences and Biological Sciences Institute - FCM/ICB, Recife, Brazil
| | - Álvaro M Perazzo
- Division of Cardiovascular Surgery, Pronto Socorro Cardiológico de Pernambuco - PROCAPE, Recife, Brazil.,University of Pernambuco - UPE, Recife, Brazil
| | - Antonio C Escorel Neto
- Division of Cardiovascular Surgery, Pronto Socorro Cardiológico de Pernambuco - PROCAPE, Recife, Brazil.,University of Pernambuco - UPE, Recife, Brazil
| | - Rafael A F Gomes
- Division of Cardiovascular Surgery, Pronto Socorro Cardiológico de Pernambuco - PROCAPE, Recife, Brazil.,University of Pernambuco - UPE, Recife, Brazil.,Nucleus of Postgraduate and Research in Health Sciences of Faculty of Medical Sciences and Biological Sciences Institute - FCM/ICB, Recife, Brazil
| | - Alexander Weymann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital of Essen, University Duisburg-Essen, Essen, Germany
| | - Konstantin Zhigalov
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital of Essen, University Duisburg-Essen, Essen, Germany
| | - Arjang Ruhparwar
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital of Essen, University Duisburg-Essen, Essen, Germany
| | - Ricardo C Lima
- Division of Cardiovascular Surgery, Pronto Socorro Cardiológico de Pernambuco - PROCAPE, Recife, Brazil.,University of Pernambuco - UPE, Recife, Brazil
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19
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Caseous Intracardiac Calcification: A Diagnostic Enigma. Case Rep Cardiol 2019; 2019:6707690. [PMID: 31110822 PMCID: PMC6487139 DOI: 10.1155/2019/6707690] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 02/19/2019] [Indexed: 11/23/2022] Open
Abstract
Intramyocardial calcification is a rare phenomenon often only discovered on postmortem. We describe the case of a healthy 69-year-old lady diagnosed with idiopathic caseous intracardiac calcification extending from the mitral valve annulus. We present high-quality images and propose an investigatory template for future cases.
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Matsou A, Symeonidis C, Dermenoudi M, Sachpekidis V. Caseous calcification of the mitral valve annulus: a rare cause of bilateral cerebral and ocular embolisation. BMJ Case Rep 2018; 2018:bcr-2018-224322. [PMID: 30021732 DOI: 10.1136/bcr-2018-224322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 65-year-old woman presented with sudden bilateral visual loss of recent onset. She was recently diagnosed with multiple acute stroke syndrome for which she was commenced on antiplatelet therapy. Funduscopic examination revealed bilateral inferotemporal retinal artery occlusions. The recent history of multiple cerebral infarcts combined with the current ocular findings prompted a transoesophageal echocardiogram which successfully revealed caseous calcification of the mitral valve annulus as the source of the numerous sequential emboli, a finding which the conventional transthoracic echocardiogram had failed to disclose as a result of suboptimal image quality. Transoesophageal echocardiography should always be considered as part of the diagnostic workup of retinal arterial occlusive disease, particularly in bilateral lesions, due to its higher yield in identifying posteriorly located cardiac valvular and aortic lesions.
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Affiliation(s)
- Artemis Matsou
- 2nd Department of Ophthalmology, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Chrysanthos Symeonidis
- 2nd Department of Ophthalmology, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria Dermenoudi
- 2nd Department of Ophthalmology, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Ono M, Mizuno A, Masuda K, Suzuki K, Abe K, Kawazoe K, Komiyama N. Infective Endocarditis on Caseous Calcification of the Mitral Annulus Involving Both the Anterior and Posterior Annulus: A Rare Case Report. Intern Med 2018; 57:965-969. [PMID: 29269657 PMCID: PMC5919854 DOI: 10.2169/internalmedicine.9520-17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
A 72-year-old man with end-stage renal disease and who was on dialysis was admitted with fever and chills. Two years previously, he had been diagnosed with caseous calcification of the mitral annulus (CCMA). Blood cultures revealed Staphylococcus aureus, and echocardiography revealed vegetation attached to the CCMA lesion, progressing to both the anterior and posterior annulus. Infective endocarditis (IE) was diagnosed and antibiotic (ampicillin) treatment was initiated. Emergent mitral valve replacement was performed after the occurrence of multiple cerebral infarctions. During surgery, we identified vegetation attached to the CCMA lesion. After surgery, the patient showed a good recovery and was discharged. This case demonstrates that IE can be complicated with CCMA.
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Affiliation(s)
- Masafumi Ono
- Cardiovascular Center, St. Luke's International Hospital, Japan
| | - Atsushi Mizuno
- Cardiovascular Center, St. Luke's International Hospital, Japan
| | - Keita Masuda
- Cardiovascular Center, St. Luke's International Hospital, Japan
| | - Koyu Suzuki
- Department of Pathology, St. Luke's International Hospital, Japan
| | - Kohei Abe
- Cardiovascular Center, St. Luke's International Hospital, Japan
| | - Kohei Kawazoe
- Cardiovascular Center, St. Luke's International Hospital, Japan
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