Caseous Mitral Annular Calcification Causing Left Ventricular Outflow Tract Obstruction and Embolic Stroke in Hypertrophic Cardiomyopathy

Background: Caseous mitral annular calcification is a variant of annular calcification that may alter mitral valve geometry and represent a potential embolic source. Case Summary: A 50-year-old woman with exertional dyspnea was diagnosed with hypertrophic cardiomyopathy with left ventricular outflow tract obstruction. Transesophageal echocardiography revealed caseous calcifications of the posterior mitral annulus, causing leaflet displacement, promoting systolic anterior motion. Despite optimized medical therapy, she developed ischemic stroke, with imaging suggesting liquefactive degeneration of the masses as a potential embolic source. Discussion: This case highlights a mechanistic link between mitral annular calcification and left ventricular outflow tract obstruction. Caseous mitral annular calcification may act as an embolic source following liquefactive degeneration. Take-Home Messages: Caseous mitral annular calcification may contribute to left ventricular outflow tract obstruction. Liquefactive degeneration of caseous mitral annular calcification may represent an embolic source. Persistent symptoms or embolic complications require recognition of structural mechanisms.