Caseous Mitral Valve Calcification (C-MAC) and Stroke: Overview and Management

Caseous Mitral Valve Calcification (C-MAC) is a rare condition characterized by spectrum liquefaction necrosis of the mitral annular calcification (MAC), potentially leading to cardiovascular complications like strokes and emboli. This article discusses the features, diagnostic aspects, and treatment options related to C-MAC, emphasizing the risks of emboli and strokes associated with the condition.

• Mitral Valve Calcification
• C-MAC
• Stroke
• Spectrum Liquefaction Necrosis
• Cardiovascular Complications

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1. Caseous Mitral Valve Calcification (C-MAC) and Stroke

2. Brief review of patient Small mobile mass in mitral valve noted on prior imaging, prior ?subclinical stroke, on DOAC, now with new recurrent migraines with aura c/f recurrent cardioembolism TEE: There is a small 6-7 mm long filamentous echogenic mobile mitral valve density present on the atrial aspect of the posterior mitral annulus. This may represent thrombus, denuded MAC, or caseation.

3. Caseous MAC (CMAC) Caseous MAC (CMAC) Spectrum liquefaction necrosis of MAC 0.6% of patients with MAC But 2.7% of all MAC in autopsy studies Close to AV node = arrhythmias Also related to MR/HF More common in women, older patients, ESRD No reports of stroke in younger patients that I found

4. Features Features CMAC <-> MAC Calcium + fat + cholesterol = toothpaste-like Can look like a tumor or abscess= Posterior, echodense with central lucence TEE -> Cardiac MRI

5. Stroke Emboli from calcium, thrombus, fistulization Stroke, ACS > ?systemic emboli Biggest case series published in 2001 19 patients, 5 had strokes, 1 referred to surgery for emboli, 2 had surgery for MV dysfunction Replacement > Repair (highly technically difficult)

6. Our patient Operative note documents caseous appearance of valve = Caseous MAC CTC = CMAC

7. References Akram M, Hasanin AM. Caseous mitral annular calcification: Is it a benign condition? J Saudi Heart Assoc. 2012 Jul;24(3):205-8. doi: 10.1016/j.jsha.2012.02.003. Epub 2012 Feb 14. PMID: 23960697; PMCID: PMC3727444. Davidson MJ, Cohn LH. Surgical treatment of caseous mitral valve annulus calcification. J Thorac Cardiovasc Surg. 2006 Mar;131(3):738-9. doi: 10.1016/j.jtcvs.2005.11.025. PMID: 16515935. Rosenblatt S. Caseous calcification of the mitral annulus. J Am Soc Echocardiogr. 2001; 14: 825-831 Chevalier B, Reant P, Laffite S, Barandon L. Spontaneous fistulization of a caseous calcification of the mitral annulus: an exceptional cause of stroke. Eur J Cardiothorac Surg. 2011 Jun;39(6):e184- 5. doi: 10.1016/j.ejcts.2011.01.038. Epub 2011 Mar 3. PMID: 21376613.