Outcomes after transcatheter mitral valve implantation in valve-in-valve, valve-in-ring, and valve-in-mitral annular calcification.

AIMS: We aimed to evaluate transcatheter mitral valve implantation (TMVI) using predominantly balloon-expandable transcatheter heart valves (THV) in patients with a landing zone for a percutaneously delivered prosthesis. BACKGROUND: Patients with a degenerated mitral valve bioprosthesis, annuloplasty ring, and mitral annulus calcification (MAC) considered at high surgical risk currently represent a treatment challenge. TMVI is an alternative treatment option. METHODS: Retrospective analysis of patients with symptomatic degenerated mitral valve bioprosthesis, or annuloplasty ring, and MAC treated with TMVI between November 2011 and April 2021. Endpoints were defined according to Mitral Valve Academic Research Consortium (MVARC) criteria and included device and procedure success at 30 days as well as mortality at 30 days and 1 year after the procedure. RESULTS: A total of 77 patients underwent TMVI (valve in valve [ViV = 56], valve in ring [ViR = 11], and valve in MAC [ViMAC = 10]). There was a trend toward higher technical success (all = 93.5%, ViV = 96.4%, ViR = 90.9%, ViMAC = 80%, p = 0.06) and lower 30-day (all = 11.7%, ViV = 10.7%, ViR = 9.1%, ViMAC = 20%, p = 0.49) and 1-year mortality (all = 26%, ViV = 23.2%, ViR = 27.3%, ViMAC= 40%, p = 0.36) after ViV and ViR compared to ViMAC. CONCLUSION: TMVI represents a reasonable treatment option in selected patients with MAC or who are poor candidates for redo mitral valve surgery. Technical success and survival up to 1 year were not significantly dependent on the subgroup in which TMVI was performed.

Impact of mitral intervention on outcomes of patients with mitral valve dysfunction and annulus calcification.

OBJECTIVES: To compare all-cause mortality in patients with mitral annulus calcification (MAC) and severe mitral valve dysfunction (MVD) who received standard mitral intervention versus no intervention. BACKGROUND: Patients with MAC often have high surgical risk due to advanced age, comorbidities, and technical challenges related to calcium. The impact of a mitral intervention on outcomes of patients with MAC and severe MVD is not well known. METHODS: Retrospective review of patients with MAC by transthoracic echocardiography (TTE) in 2015 at a single institution. Patients with severe mitral stenosis (MS) or regurgitation (MR) were analyzed and stratified into two groups: surgical or transcatheter intervention performed <1 year after the index TTE, and no or later intervention. The primary endpoint was all-cause mortality. RESULTS: Of 5502 patients with MAC, 357 had severe MVD (MS = 27%, MR = 73%). Of those, 108 underwent mitral intervention (surgery = 87; transcatheter = 21). They were younger (73 ± 11 vs. 76 ± 11 years, p < 0.01) and less frequently had cardiovascular diseases compared with no-intervention. Frequency in women was similar (45% vs. 50%, p = 0.44). During median follow-up of 3.2 years, the intervention group had higher estimated survival than those without intervention (80% vs. 72% at 1 year and 55% vs. 35% at 4 year, p < 0.01). Adjusted for age, eGFR, LVEF < 50%, and pulmonary hypertension, mitral intervention was an independent predictor of lower mortality (hazard ratio = 0.66, 95% confidence interval 0.43-0.99, p = 0.046). CONCLUSION: Patients with MAC and severe MVD who underwent mitral intervention <1 year from index TTE had lower mortality than those without intervention. Mitral intervention was independently associated with lower mortality.

Causes and predictors of mortality after transcatheter mitral valve implantation in patients with severe mitral annulus calcification.

OBJECTIVES: To evaluate the causes and predictors of mortality after valve-in-mitral annulus calcification (MAC) transcatheter mitral valve implantation (TMVI). BACKGROUND: Conventional surgical mitral valve replacement is associated with a high risk in patients with mitral valve disease associated with severe MAC. In this population, TMVI may be an attractive alternative option. However, its prognostic factors are poorly understood. METHODS: All patients undergoing valve-in-MAC TMVI from 2013 to 2018 in our center were included. Indication for TMVI relied on the judgment of the local heart team. Patients were followed at 30 days and 1 year. RESULTS: A total of 34 patients underwent valve-in-MAC TMVI. The mean age was 79 ± 11 years and 73% of patients were women. Their mean EuroSCORE 2 was 8 ± 7%. The transseptal approach was used in 79% of patients and a hybrid transatrial in 29%. Balloon expandable transcatheter heart valves were used in all the patients. Technical success was achieved in 76% of the patients. Thirty-day and 1-year all-cause mortality rates were 14.7% and 32.4%, respectively. The main two causes of 1-year mortality were congestive heart failure (8.8%) and infective endocarditis (5.9%). In multivariate analysis, the only predictor of 1-year mortality was the presence of periprothetic mitral regurgitation grade 2 (HR, 5.69; 95%CI, 1.59-27.88, p = 0.032). CONCLUSION: Early and mid-term mortality remains high after valve-in-MAC TMVI and seems to be associated with the presence of paravalvular mitral regurgitation. However, whether the latter is a prognostic factor or marker remains to be determined to improve clinical outcomes in this high-risk population.

Transcatheter Mitral Valve Implantation Systematic Review: Focus on Transseptal Approach and Mitral Annulus Calcification.

INTRODUCTION: This systematic review was performed to evaluate the results of transcatheter mitral valve implantation (TMVI) in the native mitral valve. EVIDENCE ACQUISITION: Medline, EMBASE, and the Cochrane Central register were systematically searched for studies that reported results of TMVI in mitral valve regurgitation and/or stenosis and mitral annular calcification. To improve the sensitivity of the literature search, we performed citation chasing in Google Scholar, Scopus, and Web of Science. EVIDENCE SYNTHESIS: Twelve studies reporting results of TMVI in mitral regurgitation were retrieved and included 347 patients. The transseptal approach represented 28% of cases. Secondary mitral regurgitation was the predominant indication in 63% of cases. Thirty-day mortality was 11% and was lowered with the transseptal approach (7%). Technical success was 92%. Surgical conversion was needed in 5% of patients. Only one patient presented moderate to severe mitral regurgitation. These hemodynamic results were sustainable up to one year of follow-up. Three series focused on results of TMVI in mitral annulus calcification including 167 patients. Only nine patients were treated with TMVI dedicated prosthesis. Eighty-seven patients had their prosthesis delivered through a transseptal approach. Mitral stenosis was present in 63% of cases. Thirty-day mortality was 24%, and none with TMVI prosthesis. Technical success was achieved in 71% of cases and was improved by using TMVI prosthesis (89%). The main complication was left ventricular outflow tract obstruction (20%). Post procedural moderate to severe mitral regurgitation was observed in 4% of cases. CONCLUSION: TMVI seems to be feasible, achieving good technical success and predictable and durable MR reduction.

Advanced techniques in mitral annular calcification management.

BACKGROUND: The management of severe mitral annular calcification (MAC) with a conservative approach minimizes the risk of atrioventricular groove (AVG) disrupture. However, patients with a history of rheumatic valve disease may present with complex and mixed annular lesions requiring extensive debridement. Our technique for reconstructing the mitral annular plane after mechanical decalcification is presented. METHODS: This is a video of the surgical management of two cases of mitral valve rheumatic disease (one of which with superimposed native-valve-endocarditis) with severe MAC. After extensive mitral annulus debridement, the naked area of myocardium in the AVG is covered and reinforced using a patching technique. It is important to sew the patch of autologous pericardium with a double suture line: one line down in the ventricle, the other one inside the atrium. The valvular stitches have to be passed proximal to the patch, thus de facto atrializing the position of the prosthetic mitral valve. RESULTS: An optimal result was achieved in both cases. The double suture line avoids the risk of blood infiltrating behind the valve, into the AV groove, causing cardiac rupture. CONCLUSIONS: Reconstructing the posterior mitral valve annulus with a patch of autologous pericardium and related atrialization of the prosthetic mitral valve is a safe and feasible technique to manage severe MAC.

Concomitant mitral annular calcification and severe aortic stenosis: prevalence, characteristics and outcome following transcatheter aortic valve replacement.

AIMS: Calcified aortic stenosis (AS) and mitral annular calcification (MAC) have certain similar etiology and pathophysiological mechanisms. MAC is frequently encountered in pre-procedural computed tomography (CT) imaging of patients that undergo transcatheter aortic valve replacement (TAVR), but its prognostic implications for these patients have not been thoroughly investigated. This study sought to evaluate the prevalence of MAC among patients with severe AS and to assess the clinical implications of MAC on these patients during and following TAVR. METHODS AND RESULTS: Consecutive patients that underwent TAVR were compared according to the existence of MAC and its severity in pre-TAVR CT scans. From the entire cohort of 761 patients, 49.3% had MAC, and 50.7% did not have MAC. Mild MAC was present in 231 patients (30.4%), moderate MAC in 72 patients (9.5%), and severe MAC in 72 patients (9.5%). Thirty-day mortality and major complications were similar between patients with and without MAC. In a multivariable survival analysis, severe MAC was found to be an independent strong predictor of overall mortality following TAVR (all-cause mortality: hazards ratio [HR] 1.95, 95% confidence interval [CI] 1.24-3.07, P = 0.004; cardiovascular mortality: HR 2.35, 95% CI 1.19-4.66; P = 0.01). Severe MAC was also found to be an independent strong predictor of new permanent pacemaker implantation (PPI) after TAVR (OR 2.83, 95% CI 1.08-7.47; P = 0.03). CONCLUSION: Half of the patients with severe AS evaluated for TAVR were found to have MAC. Severe MAC is associated with increased all-cause and cardiovascular mortality and with conduction abnormalities following TAVR and should be included in future risk stratification models for TAVR.

Gender differences in clinical factors associated with coronary artery atherosclerosis severity in patients with aortic valve and/or mitral annulus calcification.

OBJECTIVE: Introduction: The previous studies of coronary atherosclerosis association with aortic valve calcification (AVC) and/or mitral annulus calcification (MAC) had contradictory results. The aim: To assess gender differences in clinical factors associated with coronary artery atherosclerosis severity. PATIENTS AND METHODS: Materials and methods: 362 patients (mean age 63.9 (8.8) years, 244 (67.4%) males) who underwent coronary angiography were included in the retrospective study. AVC and/or MAC presence was determined using transthoracic echocardioscopy. Coronary angiography results were assessed using coronary atherosclerosis severity index (CASI). RESULTS: Results: There were lower CASI in aortic stenosis (AS) subgroups (0 (0; 3.5) and (0; 9.5) in subgroups with severe and moderate AS respectively versus 12.0 (6.0; 20.5) in subgroup without AS, <0.005). Man with AVC and/or MAC (without AS and diabetes mellitus (DM)) had higher CASI compared to man without heart valve calcification and without DM (15.0 (7.0; 21.5) versus 7.0 (2.0; 12.0), p=0.0002), whereas in the similar woman subgroups CASI did not differ. In the male group without DM (without AS) CASI was associated with age (r=0.319, <0.0001), glomerular filtration rate (GFR) (r=(-0.164), p=0.049), cholesterol level (r=0.242, p=0.003) and the combined presence of AVC and MAC (r=0.229, p=0.006), whereas in the similar female group there were only CASI association with GFR (r=(-0.252), p=0.050) and with combined presence of AVC and MAC (r=0.219, p=0.080). CONCLUSION: Conclusions: CASI depended on AS severity. In subgroups without AS and DM CASI was associated with combined presence of AVC and MAC, GFR, and besides with age and cholesterol level in man.

Exposure to ambient air pollution and calcification of the mitral annulus and aortic valve: the multi-ethnic study of atherosclerosis (MESA).

BACKGROUND: Long-term exposure to high ambient air pollution has been associated with coronary artery calcium (CAC), a marker of cardiovascular disease (CVD). Calcifications of left-sided heart valves are also markers of CVD risk. We investigated whether air pollution was associated with valvular calcification and its progression. METHODS: We studied 6253 MESA participants aged 45-84 years who underwent two cardiac CT scans 2.5 years apart to quantify aortic valve calcium (AVC) and mitral annular calcium (MAC). CAC was included for the same timeframe for comparison with AVC/MAC. Ambient particulate matter <2.5 µm (PM2.5) and oxides of nitrogen (NOx) concentrations were predicted from residence-specific spatio-temporal models. RESULTS: The mean age (SD) of the study sample was 62 (10) years, 39% were white, 27% black, 22% Hispanic, and 12% Chinese. The prevalence of AVC and MAC at baseline were 13% and 9% respectively, compared to 50% prevalence of CAC. The adjusted prevalence ratios of AVC and MAC for each 5 µg/m3 higher PM2.5 was 1.19 (95% CI 0.87, 1.62) and 1.20 (0.81, 1.77) respectively, and for CAC was 1.14 (1.01, 1.27). Over 2.5 years, the mean change in Agatston units/year for each 5 µg/m3 higher PM2.5 concentration was 0.29 (-5.05, 5.63) for AVC and 4.38 (-9.13, 17.88) for MAC, compared to 8.66 (0.61, 16.71) for CAC. We found no significant associations of NOx with AVC and MAC. CONCLUSION: Our findings suggest a trend towards increased 2.5-year progression of MAC with exposure to outdoor PM2.5, although this association could not be confirmed. Additional well-powered studies with longer periods of follow-up are needed to further study associations of air pollution with valvular calcium. TRIAL REGISTRATION: Although MESA is not a clinical trial, this cohort is registered at ClinicalTrials.gov Identifier: NCT00005487; Date of registration May 25, 2000.

Prenatal diagnosis of idiopathic infantile arterial calcification without fetal hydrops.

Idiopathic infantile arterial calcification (IIAC) is a rare autosomal recessive disease that is characterized by extensive calcification of the internal elastic lamina and intimal proliferation of large- and medium-sized arteries, including the aortic, coronary, pulmonary, and iliac arteries. Most reported cases of IIAC were diagnosed in the neonatal periods. Prenatal diagnosis of this condition is extremely rare and is usually made in the third trimester when fetuses had nonimmune hydrops together with aortic and pulmonary calcification. Early prenatal diagnosis can hardly be made without fetal hydrops in the second trimester. We report a case of IIAC referred to our center because of hyperechogenic tricuspid valve. The prenatal diagnosis was made by echocardiographic detection of diffuse hyperechogenicity of the cardiac valves, annuli, aorta, pulmonary artery, renal artery and common iliac artery without fetal hydrops. To the best of our knowledge, this was the first case of IIAC accurately diagnosed prenatally in the absence of fetal hydrops.

Left ventricular diverticulum mimicking cardiac tumor.

Left ventricular (LV) diverticulum represents a rare and frequently asymptomatic congenital anomaly, which is incidentally discovered during routine transthoracic echocardiography. We present a case of a 66-year-old female patient who was admitted to the cardiology department due to incidental finding of a tumor-like mass associated with the posterior mitral leaflet. Preliminary echocardiographic evaluation revealed a solid structure, suspected of mitral annulus calcification or LV malignancy. However, cardiac contrast-enhanced computed tomography confirmed the presence of LV diverticulum, partially filled with calcified thrombus. Conservative management was recommended. This case underscores the importance of multimodality imaging for differentiation of LV tumor-like structures.

Use of three-dimensional transesophageal echocardiography to evaluate mitral valve morphology for risk stratification prior to mitral valvuloplasty.

Mitral stenosis is often managed percutaneously with an interventional procedure such as balloon commissurotomy. Although this often results in an increased mitral valve area and improved clinical symptoms, this procedure is not benign and may have serious complications including the development of hemodynamically significant mitral valve regurgitation. Multiple scoring systems have been developed to attempt to risk stratify these patients prior to their procedure. CASE: A 64-year-old patient underwent an emergent mitral valve replacement after having percutaneous mitral balloon commissurotomy complicated by development of severe mitral regurgitation. Prior to valvuloplasty, her mitral valve was evaluated by traditional methods including calculation of a Wilkins score. Her mitral valve was evaluated after valvuloplasty and preoperatively with three-dimensional transesophageal echocardiography. This examination demonstrated heterogeneous distribution of calcification affecting the mitral valve commissures more than the leaflets, which is consistent with the noncommissural leaflet tearing that occurred during her procedure, causing severe mitral regurgitation. In the future, careful 3D evaluation of mitral valve morphology including leaflets, annular calcification, and subvalvular apparatus may help risk stratify patients prior to intervention.

Osteopontin is elevated in patients with mitral annulus calcification independent from classic cardiovascular risk factors.

BACKGROUND: Osteopontin (OPN) regulates the Ca(++)-deposition in bone and coronary arteries. Elevated OPN were also associated with (aortic) valve calcification in healthy individuals. This study aimed to investigate the association between OPN levels and mitral annulus calcification (MAC) in patients with coronary artery disease (CAD). METHODS: In this cross-sectional study OPN-levels were measured in 223 non-or ex-smoking patients (160 male, mean age: 61,09 ± 11,02 years; 63 female: mean age: 67,49 ± 7,87 years) with CAD. Plasma OPN levels were measured by ELISA and MAC was evaluated by echocardiography. RESULTS: Forward stepwise logistic regression analysis (likelihood quotient) showed significantly higher OPN-levels in patients with MAC compared to patient without calcified mitral annulus independent from the classic risk factors age and severity of coronary artery disease (CAD). In addition to age and the severity of CAD, the circulating OPN amount was a significant predictor for MAC. CONCLUSIONS: This is the first clinical trial which observed increased circulating OPN levels in MAC, suggesting a distinct role of OPN in the process of MAC. Considering the current knowledge about OPN it is more likely that OPN does not promote but counteracts valve calcification and therefore is elevated in course of a calcification processes.

Calcified amorphous tumor of the heart in a hemodialysis patient.

We report a case of calcified amorphous tumor (CAT) of the heart in a 60-year-old Japanese man on hemodialysis. Because the masses in the mitral annulus developed during two-year echocardiographic follow-up, he underwent surgical resection with mitral valve replacement. Histological examination showed that the tumor contained multiple calcified nodules, which confirmed the diagnosis of CAT. This case report reinforces the need to deeply and periodically investigate for cardiac involvement of CAT in all patients on hemodialysis.

Mitral annular calcification and incident atrial fibrillation in the Multi-Ethnic Study of Atherosclerosis.

AIMS: The associations of mitral annular calcification (MAC) with atrial fibrillation (AF) risk factors and related outcomes suggest a possible association between MAC and AF. The aim of this study was to examine the association between MAC and AF in a racially and ethnically diverse population. METHODS AND RESULTS: This analysis included 6641 participants (mean age 62 ± 10 years; 53% women; 27% Blacks; 22% Hispanics; 12% Chinese-Americans) from the Multi-Ethnic Study of Atherosclerosis (MESA) who were free of clinical cardiovascular disease and AF at baseline. The presence of MAC was defined by cardiac computed tomography (CT) as an Agatston score >0. Atrial fibrillation was ascertained by hospital discharge records and from Medicare claims data until 31 December 2010. Cox regression was used to compute hazard ratios (HRs) and 95% confidence intervals (95% CIs) for the association between MAC and AF. At baseline, 619 (9.3%) participants had MAC. Over a median follow-up of 8.5 years, 308 (4.6%) participants developed AF. In a multivariable adjusted model, MAC was associated with an increased risk of AF (HR = 1.9, 95% CI = 1.5, 2.5). This association was consistent across subgroups of age, sex, race/ethnicity (Whites vs. non-Whites), hypertension, diabetes, and left atrial enlargement. The addition of MAC to the Framingham Heart Study and CHARGE AF risk scores for AF improved the C-statistics from 0.769 to 0.776 (P = 0.038) and 0.788 to 0.792 (P = 0.089), respectively. CONCLUSION: The presence of MAC was predictive of incident AF in MESA. Potentially, these findings suggest a usefulness of cardiac CT to identify individuals at risk for AF.

Caseous calcification of the mitral annulus associated with stroke: report of two cases.

OBJECTIVE: Caseous calcification of the mitral annulus (CCAM) is a rare complication of mitral annulus calcification (MAC). Whether CCAM should be considered as a cardiac source of stroke or a simple marker of atherosclerosis remains a matter of debate. METHOD: Herein, we report two patients with stroke and CCAM. RESULTS: The first one was associated with extensive aortic arch atheroma, while CCAM was the only potential cause in the second case. Transthoracic echocardiography was normal in both cases and CCAM was diagnosed on transesophageal echocardiography. CONCLUSION: These observations suggest that CCAM should be added to the list of minor cardioembolic sources of stroke but also requires a perfect control of vascular risk factors.

Mitral annulus caseous calcification mimicking cardiac mass in asymptomatic patient - multimodality imaging approach to incidental echocardiographic finding.

BACKGROUND: Caseous calcification of mitral annulus is rather rare echocardiographic finding with prevalence of 0.6% in pts. with proven mitral annular calcification and 0.06% to 0.07% in large series of subjects in all ages. Echocardiographic images of caseous calcification are often heterogenous due to calcium and lipid deposits, and the masses show hyperechogenic and hypoechogenic areas. However the appearance of caseous calcification can imitate that of abscess, tumors and cysts, surgical treatment may not be needed when there is no obstruction. CASE REPORT: 76-year old obese (BMI 32 kg/m(2)), female patient with history of hypertension, stable coronary artery disease, diabetes type 2 and hyperlipidemia presented with no symptoms of mitral valve dysfunction and had no abnormalities on physical exam. Transesophageal echocardiography identified well-organized, composite, immobile lesion (22×15 mm) localized in the posterior part of the mitral annulus, with markedly calcified margins, and no significant impact on the valve function. In computed tomography (CT) lesion was described as calcified (24×22×17.5 mm), connected with posterior leaflet and posterior part of the mitral annulus, reducing posterior leaflet mobility. CT brought the suggestion of caseous mitral annular calcification. Coming to a conclusion, bearing in mind no mitral valve dysfunction at that time, patient was offered conservative treatment. CONCLUSIONS: Although caseous mitral annular calcification is typically an incidental finding, accurate recognition is needed to avoid mistaking the lesion for a tumor or abscess, which may result in unnecessary cardiac surgery. However this entity is diagnosed on cardiac MRI, multi-modality imaging, especially non-contrast CT, allows for the confident, prospective diagnosis.

Percutaneous Vacuum-Assisted Aspiration of Mobile Caseous Mitral Annulus Calcification.

A 68-year-old woman presented with an incidentally found intracardiac mass. Transesophageal echocardiography (TEE) showed a 26 × 8 mm mobile mass attached to a calcified posterolateral mitral annulus. The mass was removed with a commercially available percutaneous catheter system using cerebral embolic protection and TEE guidance. The pathologic examination showed caseous mitral annular calcification.

Progression of Mild Mitral Annulus Calcification to Mitral Valve Dysfunction and Impact on Mortality.

BACKGROUND: Mitral annulus calcification (MAC) represents a degenerative process resulting in calcium deposition in the mitral valve apparatus. Mitral annulus calcification is associated with adverse clinical outcomes. We sought to examine the long-term significance of mild MAC and its relationship to subsequent mitral valve dysfunction (MVD) and mortality in patients without MVD on the initial echocardiogram. METHODS: A total of 1,420 patients with mild MAC and no MVD at baseline and 1 or more follow-up echocardiograms at least 1 year after the baseline echocardiogram were included in the analysis. For patients with >1 echocardiogram during follow-up, the last echocardiogram was used. The same criteria were used to identify 6,496 patients without MAC. Mitral valve dysfunction was defined as mitral regurgitation (MR) and/or mitral stenosis (MS) of moderate or greater severity. Mixed disease was defined as the concurrent presence of both moderate or greater MS and MR. The primary end point was development of MVD, and the secondary end point was all-cause mortality. RESULTS: For patients with mild MAC, age was 74 ± 10 years and 528 (37%) were female. Over a median follow-up of 4.7 (interquartile range, 2.7-6.9) years, 215 patients with mild MAC developed MVD, including MR in 170 (79%), MS in 37 (17%), and mixed disease in 8 (4%). In a multivariable regression model compared to patients without MAC, the presence of mild MAC was independently associated with increased mortality (hazard ratio = 1.43; 95% CI 1.24, 1.66; P < .001). Kaplan-Meier 4-year survival rates were 80% and 90% for patients with mild MAC and no MAC, respectively. CONCLUSIONS: Mild MAC observed on transthoracic echocardiography is an important clinical finding with prognostic implications for both valvular function and mortality.

Transaortic TAVR and Mitral Repair Under Deep Hypothermic Circulatory Arrest in a Porcelain Aorta Patient.

Vascular and valvular calcifications, commonly seen in renal patients, increase operative mortality and can preclude conventional valvular management. We show a novel approach to treat aortic stenosis and degenerative mitral regurgitation under hypothermic circulatory arrest in a hemodialysis patient with aortic, mitral disease and porcelain aorta with surgical and transcatheter contraindications.

A Case of Transient Hypercalcemia Following Fistulization of a Calcified Mitral Annulus.

We report a case of severe symptomatic hypercalcemia that resolved after a short course of therapy of exclusively fluids and furosemide. An extensive workup for metabolic, neoplastic, and drug-induced causes did not provide a possible etiology of the hypercalcemia. After calcium level returned to baseline, the patient was discharged, only to return a week later with multiple embolic strokes of unknown source. The comparison of cardiac imaging obtained during the hospitalization periods established a possible mechanism for both phenomena; the interior caseous cavity of a calcified mitral annulus (CMAC), which was demonstrated on echocardiography during the first hospitalization, disappeared in a subsequent study in the second hospitalization, probably reflecting a fistulization of the structure into the left ventricle. The spill of contents into the bloodstream, over several days presumably, explains the transient increase in calcium, and the embolic events that followed. We hereby demonstrate a clear relationship between the fistulization of a CMAC and hypercalcemia, emphasizing the risks of this valvular pathology, and introducing a rare mechanism for transient and potentially severe hypercalcemia.