Intra-pericardial rupture of a caseous calcified mass of the mitral annulus

A 64-year-old female with a medical history of hypertension, dyslipidemia, and a family history of coronary artery disease, was referred to an external institution for persistent retro-sternal chest pain. Her ECG showed a significant ST depression and the patient's blood troponin level was normal. A coronary angiography showed only mild stenosis of the posterior interventricular artery that did not required an angioplasty. Transthoracic Echocardiogram (TTE) showed an irregular calcified mass of the posterior mitral annulus with mitral regurgitation due to a reduction in posterior leaflet motion. A CT scan showed that the mass was centered at the posterior mitral annulus, bulging along the lateral wall of the left atrium, with peripheral calcifications and an intrinsically dense core. Delayed venous contrast acquisitions (70 seconds) did not show any enhancement of the mass, nor peri-valvular aneurysm or pericardial effusion. The patient was referred to our institution for the medical work up of the persistent thoracic pain and for the management of the mitral mass.