Huge Mitral Annular Caseoma: Complementary Role of Multimodality Imaging Metin Cagdas, M.D.,* Hasan Sahan, M.D.,† Yalcin Velibey, M.D.,* Nazmi Calik, M.D.,* and Sinan Sahin, M.D.† *Department of Cardiology, Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey; and †Department of Radiology, Siyami Ersek Thoracic and Cardiovascular Surgery Center, Training and Research Hospital, Istanbul, Turkey (Echocardiography 2013;30:E138-E140) Key words: transthoracic echocardiography, caseoma, mitral annulus Case Report: A 70-year-old, hypertensive woman presented to the emergency department with palpitation. Electrocardiography (ECG) (Nihon Kohden ECG 1500-K, Tokyo, Japan) showed atrial fibrillation with a high ventricular response. Transthoracic echocardiography (TTE) (Vivid 3 3S 1.5-3.6 Mhz, GE Healthcare, Milwaukee, WI, USA) revealed a discrete calcified mass with smooth borders in the posterior periannular region of the mitral valve and posterior myocardial wall (Fig. 1, movie clips S1–S3). There was moderate mitral and tricuspid regurgitation without stenosis (movie clip S4). A cardiac magnetic resonance imaging (MRI) (Siemens Avanto 1.5 Tesla, Erlangen, Germany) was performed and demonstrated a hypointense mass in the pos- terior wall of the left ventricle between the coro- nary sinus and posterior mitral valve leaflet (Fig. 2). Contrast-enhanced ECG-gated 64-slice Figure 1. Two dimensional transthoracic echocardiogram. A. Parasternal long-axis view. B. Parasternal short-axis view. C, D. Modified apical two-chamber view. Note the discrete calcified mass (arrow) with smooth borders in the posterior periannular region of the mitral valve and posterior myocardial wall. RA = right atrium; RV = right ventricle; LA = left atrium; LV = left ventri- cle; Ao = aorta. Address for correspondence and reprint requests: Yalc ßın Veli- bey, M.D., Siyami Ersek Hospital, Tıbbiye Str. No:25, Uskudar/ Istanbul, Turkey. Fax: +902163379719; E-mail: dr_yalchin_dr@yahoo.com.tr E138 © 2013, Wiley Periodicals, Inc. DOI: 10.1111/echo.12109 Echocardiography