The caseous calcification of the mitral annulus (CCMA) is a rare variant of the mitral annulus calcification (MAC), with prevalence of 0.067% in general population. It is usually an asymptomatic condition but rarely it can cause severe mitral valve dysfunction, embolization, and conduction abnormalities. Transthoracic echocardiography (TTE) is a useful diagnostic tool. However, it can be necessary a multi-modality imaging approach for a differential diagnosis among other intra-cardiac masses. We are presenting a case of CCMA in an 88-year-old woman admitted to our department for acute decompensation of chronic heart failure. TTE has shown pathognomonic findings of CCMA. Tridimensional trans-esophageal echocardiography (3D TEE) gave a better characterization of the CCMA, avoiding further diagnostic procedures.
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