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No communication with any cardiac chamber could be detected (Fig. 2). Otherwise, there was no cardiac source of systemic embolism on this TEE study. Despite the high ESR, valvular endocarditis was unlikely in the absence of vegetation on any of the heart valves, valve dysfunction, fever or positive blood cultures. The specific echocardiographic features favored the diagnosis of CMAC. http://www.selleck.co.jp/products/Bleomycin-sulfate.html Although some authors advise operative intervention in case of CMAC with evidence of embolic phenomena [6], surgical removal of CMAC was not considered in our case due to the absence of mitral valve dysfunction and the lack of randomized trials to support the operative intervention. The echocardiographic prevalence of CMAC is 0.64% of patients with MAC and 0.068% of all studies in large series of patients of all ages [7]. However, the prevalence selleck chemicals llc in necropsy series has been reported to be 2.7% [14], which indicates that this condition is yet under-recognized. The prevalence tends to be higher in elderly women, hypertensive patients and patients with chronic renal failure or altered calcium-phosphate metabolism. The CMAC is defined echocardiographically as a round or semilunar bright echogenic mass in the peri-annular region of the mitral valve, typically in the posterior mitral annulus [9]. Characteristically, it contains a central echo-lucent area resembling liquefaction, but with no acoustic shadowing artifacts unlike the mitral annular calcification that presents with a posterior echo shadow. Transthoracic echocardiography provides a good diagnostic tool for detection of CMAC. However, in some patients, Mephenoxalone limited acoustic viewing restricts its diagnostic accuracy. The trans-esophageal approach has additional value since it improves visualization of cardiac structures and in assessing its consistency, mobility and intra-cardiac origin, particularly if posteriorly located. The best visualization of the mass and its characteristic central area of echoluency is obtained by trans-esophageal echocardiography (TEE) in the mid-esophageal 4-chamber, the mid-esophageal 2-chamber and the mid-esophageal long axis views. The true pathogenesis of caseous calcification is unknown; it might be an atheroma-like lesion. MAC, in general, might be a part of multiple atherosclerotic lesions, since recent reports note that calcification of the mitral annulus is related to atherosclerosis in other vascular beds including atherosclerotic coronary artery disease [1]?and?[3]. However, the higher prevalence of CMAC in patients with end-stage renal disease particularly those on hemodialysis and the observed association with hypercalcemic states suggest a relationship to altered calcium-phosphate metabolism. CMAC may represent a reversible stage of MAC.