Cardiovascular magnetic resonance features of caseous calcification of the mitral annulus
© Monti et al; licensee BioMed Central Ltd. 2008
Received: 03 April 2008
Accepted: 26 May 2008
Published: 26 May 2008
We present two cases of caseous calcification of the mitral annulus studied by Cardiovascular Magnetic Resonance; the diagnostic feature of this rare cardiac mass are described.
Cardiovascular Magnetic Resonance (CMR) is unrivalled as an imaging modality for the evaluation of cardiac and pericardial masses. Caseous calcification of the mitral annulus is a rare [1–4] form of degeneration of the fibrous skeleton of the mitral annulus that should be included in the differential diagnosis of myocardial masses. Usually found in elderly patients, it's typically located in the posterior mitral annulus. We studied with CMR two cases of caseous calcification of the mitral annulus; in both cases the diagnosis was confirmed with a CT scan.
Both patients were asymptomatic at the time of diagnosis and were treated conservatively.
The CMR findings of the two patients are similar. In T1-weighted (T1W) sequences (Panel A in Fig. 1 and 2) the masses are dark, and in fat suppressed T2-weighted (T2W) STIR sequences (Panel B in Fig. 1 and 2) they lack signal. The combination of dark T1W and T2W tissue signal is unusual for a cardiac mass  and suggests calcification. In balanced steady state free precession (bSSFP) images the regions of caseous calcification (* in Panel C in Fig. 1 and 2) appear only slightly darker than the normal myocardium, with a well-defined intramyocardial border. During first pass gadolinium contrast administration no enhancement can be observed (Panel E in Fig. 1 and 2). There was evidence of perfusion delay in the anterior mitral annulus (Fig. 1) and in the septal mitral annulus (Fig. 2), suggesting local extension of the disease process. Post-contrast T1-weighted sequence (Panel D in Fig. 1) is negative for enhancement of the mass, but fibrous tissue seems to surround and delimitate the caseous core. Delayed enhancement sequences were obtained only in patient 2 (Panel D in Fig. 2); an enhanced fibrous cap was found to surround a central core that showed no contrast enhancement.
CMR appearances found in the reported cases of caseous calcification of the mitral annulus
First pass perfusion
Slightly darker than myocardium
Enhanced border surrounding a non-enhanced core
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