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 [
5] 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.
Apart from citations in two CT-based case reports [
1,
2] we are not aware of previous descriptions of the CMR features of caseous calcification of the mitral annulus. We believe the hallmarks of this condition to be low signal in both T1-W and T2-W sequences, both before and after contrast, associated with a slightly-darker-than-myocardium signal in SSFP sequences. Further examples need to be studied, but it may prove feasible to diagnose caseous calcification of the mitral annulus by CMR without the need for further CT examination.
Table 1
CMR appearances found in the reported cases of caseous calcification of the mitral annulus
DARK | BLACK | Slightly darker than myocardium | Not perfused | Enhanced border surrounding a non-enhanced core |