Karan Abhinav, Feghaly Julien, Guo Hui Jun, Akinjogbin Temitope O, Sattiraju Srinivasan
Internal Medicine, University of Florida College of Medicine, Jacksonville, USA.
Cardiology, University of Florida College of Medicine, Jacksonville, USA.
Cureus. 2021 Oct 7;13(10):e18585. doi: 10.7759/cureus.18585. eCollection 2021 Oct.
Mitral annular calcification (MAC) commonly manifests as an incidental, asymptomatic finding that is associated with several cardiovascular risk factors, atherosclerosis, cardiovascular death, and all-cause mortality. Very rarely, patients with severe MAC can have extensive dystrophic calcification extending into the left atrial wall, termed porcelain left atrium. In this case report, we describe a patient who experienced multiple calcific acute embolic strokes in the setting of severe mitral annular calcification and porcelain left atrium. Our patient presented with multiple, small bilateral acute infarcts scattered throughout the cerebrum and cerebellum confirmed on magnetic resonance imaging (MRI). He was placed on continuous telemetry and underwent multimodal imaging with transthoracic and transesophageal echocardiography, carotid neck ultrasound (US), head and neck computed tomography angiogram (CTA), and cardiac MRI. There were no arrhythmic events detected on telemetry, and all imaging excluded left ventricular thrombi, aortic atheroma, carotid artery stenosis, intracardiac shunting, or large vessel stenosis. Noted on imaging, however, was severe mitral annular calcification with numerous, highly mobile calcific extensions and densely calcified plaque along the posterior left atrial wall, presumed to be the source of this patient's embolic stroke. Cardiac catheterization was significant for severe three-vessel disease requiring coronary artery bypass grafting, and our patient was subsequently discharged to outpatient follow-up on event monitoring and aspirin monotherapy. This case serves to highlight a previously unreported complication of calcific embolic stroke in severe MAC and porcelain left atrium, and highlight the need for further randomized controlled trials to determine the optimum management of these cases.
二尖瓣环钙化（MAC）通常表现为偶然发现的无症状体征，与多种心血管危险因素、动脉粥样硬化、心血管死亡及全因死亡率相关。极少数情况下，严重MAC患者可出现广泛的营养不良性钙化，延伸至左心房壁，称为“瓷性左心房”。在本病例报告中，我们描述了一名在严重二尖瓣环钙化和瓷性左心房背景下发生多次钙化性急性栓塞性卒中的患者。我们的患者经磁共振成像（MRI）证实，双侧大脑和小脑散在分布着多个小的急性梗死灶。他接受了持续的心电监测，并接受了经胸和经食管超声心动图、颈动脉超声（US）、头颈部计算机断层血管造影（CTA）及心脏MRI等多模态成像检查。心电监测未检测到心律失常事件，所有影像学检查均排除了左心室血栓、主动脉粥样硬化、颈动脉狭窄、心内分流或大血管狭窄。然而，影像学检查发现严重的二尖瓣环钙化，伴有大量高度活动的钙化延伸以及沿左心房后壁的致密钙化斑块，推测这是该患者栓塞性卒中的来源。心脏导管检查显示严重的三支血管病变，需要进行冠状动脉旁路移植术，随后我们的患者出院，接受门诊事件监测和阿司匹林单药治疗随访。本病例旨在突出严重MAC和瓷性左心房中钙化性栓塞性卒中一种此前未报道的并发症，并强调需要进一步开展随机对照试验以确定这些病例的最佳治疗方案。
