Caseous calcification of the mitral annulus: a case report
Caseous calcification of the mitral annulus (CCMA) is a very rare variant of mitral annular calcification, which is typically asymptomatic but can manifest as a cardiac tumour, abscess, or in the form of mitral valve dysfunction.

Published in the European Heart Journal Case Reports, the authors present a case of a patient who developed shortness of breath and was initially thought to have an intracardiac tumour, but ultimately was recognized as massive calcification of the mitral valve by computed tomography angiogram.

This finding was unfortunately made only shortly before the patient’s clinical deterioration, and the specific diagnosis of CCMA was made on post-mortem findings, precluding any directed treatment for this entity.

The case involves a 77-year-old man with a history of severe coronary artery disease requiring stenting of the proximal left anterior descending coronary artery (LAD) 6 years prior, left cerebral stroke with subsequent patent foramen ovale closure 2 years prior, chronic obstructive pulmonary disease requiring 2 L of oxygen support, and chronic kidney disease (CKD) who was admitted for shortness of breath, chest pain, and elevated troponin levels at 3.16 ng/mL (normal <0.03 ng/mL).

On initial physical examination, the patient had a temperature of 36.6° Celsius, heart rate of 72 b.p.m., blood pressure of 132/57 mmHg, oxygen saturation of 95%, and respiratory rate of 18 b.p.m.. At the time of admission, no specific abnormalities were heard on cardiac or pulmonary auscultation.

Learning points
• Rare forms of mitral annular calcification (MAC) such as caseous calcification of the mitral annulus are often overlooked and initially misdiagnosed.

• Caseous calcification of the mitral annulus appears to share an aetiology with the classic form of MAC, with an added component of atherosclerotic cardiovascular disease leading to caseous necrosis.

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