Risk of Cerebral Embolization with Caseous Calcification of the Mitral Annulus: Review Article

Charles A. Dietl1, *, Christopher M. Hawthorn2, Veena Raizada3
1 Department of Surgery, Division of Cardiothoracic Surgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
2 School of Medicine Division of Cardiology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
3 Department of Internal Medicine, Division of Cardiology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA

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© Dietl et al.; Licensee Bentham Open

open-access license: This is an open access article licensed under the terms of the Creative Commons Attribution-Non-Commercial 4.0 International Public License (CC BY-NC 4.0) (, which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.

* Address correspondence to this author at the Division of Cardiothoracic Surgery, Department of Surgery, ACC-2, MSC 10 5610, University of New Mexico, Albuquerque, NM 87131-0001, USA; Tel: (+1) 505-272-6901; Fax: (+1) 505-272-6909; E-mails:,



Caseous calcification of the mitral annulus (CCMA) is believed to have a benign prognosis. Several authors have recommended conservative management in asymptomatic patients. However, the prevalence of cerebrovascular events (CVE) in patients with CCMA has never been evaluated before. The aims of this study are to investigate whether patients with CCMA are at increased risk of cerebral embolization, and to determine whether elective surgical resection of CCMA should be considered to prevent a cardioembolic stroke.


A comprehensive literature search was obtained from MEDLINE via,, and Google Scholar using the following search queries: caseous calcification of the mitral annulus, intracardiac pseudotumor, mitral annular calcification, and cardioembolic stroke.


From our initial search that yielded 1,502 articles, we identified a total of 130 patients with CCMA reported in 86 publications. Literature review revealed that the prevalence of CVE associated with CCMA is 19.2% (25 of 130) which is significantly higher than the prevalence of CVE reported with mitral annular calcification (MAC), 11.8% (214 of 1818) (range 4.8% to 24.1%) (P = 0.01796) (odds ratio = 1.78; 0.95 confidence interval = 1.1278 – 2.8239). Only four of 25 (16.0%) patients with CCMA who suffered a CVE had history of atrial fibrillation (AF).


Based on our review, it would be reasonable to consider elective surgical resection of CCMA in asymptomatic patients who are good surgical candidates, because patients with CCMA may be at increased risk of embolic strokes, which are unrelated to AF.

Keywords: Cardioembolic stroke, Caseous calcification, Caseous calcification of the mitral annulus, Cerebral embolism, Mitral annulus calcification, Stroke.