Multimodality cardiac imaging in the evaluation of mitral annular caseous calcification.

A77-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 cm) 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. Threedimensional 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 and 1D; online-only Data Supplement, Movie 1). The mass did not appear to be pedunculated or vascular in nature. The patient was referred for cardiac magnetic resonance imaging to further characterize the cardiac mass. Cine imaging with a balanced steady state free-precession sequence showed an immobile, low-signal mass with a smooth contour located at the posterior mitral valve annulus (Figure 2A; online-only Data Supplement, Movie 2). There was no restriction of the posterior mitral valve leaflet motion or associated mitral regurgitation. On both multicontrast T1-weighted turbo spin-echo (Figure 2B) and short-tau inversion recovery T2-weighted images (Figure 2C), the mass was hypointense. After intravenous gadolinium contrast administration, first-pass perfusion images revealed no