Severe mitral stenosis secondary to massive calcification of the mitral annulus with unusual echocardiographic manifestations

In mitral annular calcifications, hemodynamic documentation of a significant diastolic gradient across the mitral valve has been rarely demonstrated, and then only with the associated finding of a small left ventricular cavity with hypertrophic left ventricular wall. We present a patient with severe mitral annular calcification, with a significant diastolic gradient and unusual echocardiographic manifestations which include a densely calcified mitral valve annulus with anterior mitral valve leaflets consistent with what is seen in patients with mitral stenosis. When recordings were made immediately below the mitral valve annulus at the free edge of the mitral valve, its leaflets were seen departing in opposite directions, certainly not suggestive of outflow obstruction of the left atrium. Although in previous studies it has been suggested that mitral stenosis does not exist in the presence of mitral annulus calcification, our present report indicates that significant diastolic gradients can be found in patients with mitral annular calcifications. Because of the predominance of this condition in the elderly population, it is suggested that a more aggressive approach be taken in those patients in whom it is warranted by clinical circumstance.