A 76-year-old woman with a history of mixed connective tissue disease presented with sudden dysarthria. Brain magnetic resonance imaging indicated multiple infarctions, suggesting cardioembolic stroke. An electrocardiogram showed sinus rhythm. Transthoracic echocardiography showed severe aortic-valve stenosis (AS) and heavy mitral annular calcification (MAC) (Panel A, arrows). A 5-mm calcified amorphous tumour (CAT, Panel B, Supplementary data online, Video S1Supplementary data online, Video S1, arrow) with high mobility was localized at the left ventricular outflow tract (LVOT) below the aortic valve. Transoesophageal echocardiography (TOE) showed no evidence of intracardiac thrombus or significant aortic atheroma. Real-time 3D TOE demonstrated multiple calcified cardiac masses surrounding the mitral annulus with heavy MAC (Panel C, arrows). On cardiac computed tomography, this appeared as oval hyperdense masses with external calcification and without internal contrast enhancement (Panels D-1 and D-2, arrows). We diagnosed these masses as multiple caseous calcifications of the mitral annulus (CCMAs). Fluorine-18 fluorodeoxyglucose positron emission tomography showed no abnormally increased uptake in the severely calcified mitral annulus with multiple CCMAs (Panel E, dashed circle).

中文翻译：

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二尖瓣环多处干酪样钙化伴钙化无定形肿瘤

一名有混合性结缔组织病病史的 76 岁女性因突发构音障碍就诊。脑磁共振成像显示多处梗死，提示心源性卒中。心电图显示窦性心律。经胸超声心动图显示严重的主动脉瓣狭窄 (AS) 和严重的二尖瓣环钙化 (MAC)（图A，箭头）。5 毫米钙化无定形肿瘤（CAT，图B，在线补充数据，视频 S1 在线补充数据，视频 S1，箭头）具有高流动性位于主动脉瓣下方的左心室流出道（LVOT）。经食道超声心动图 (TOE) 未显示心内血栓或明显主动脉粥样硬化的证据。实时 3D TOE 显示二尖瓣环周围有多个钙化心脏肿块，MAC 重（图C，箭头）。在心脏计算机断层扫描上，这表现为椭圆形高密度肿块，外部钙化，内部没有对比增强（图 D-1和D-2，箭头）。我们将这些肿块诊断为二尖瓣环 (CCMA) 的多个干酪样钙化。Fluorine-18 氟脱氧葡萄糖正电子发射断层扫描显示在具有多个 CCMA 的严重钙化二尖瓣环中摄取没有异常增加（图E，虚线圆圈）。