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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.

Myocarditis is an inflammatory disease of cardiac muscle with a variable clinical presentation, ranging from asymptomatic cases to different degrees of left ventricular systolic dysfunction up to heart failure and dilated heart disease. Ventricular arrhythmias (VA) can occur in patients with myocarditis and implantable cardioverter defibrillator (ICD) may be indicated in patients with life-threatening VA who are not in the acute phase of myocarditis and who are receiving optimal medical therapy. Reduced left ventricular ejection fraction (LVEF) below 35%, which is used as the main criterion for stratifying the risk of sudden cardiac death (SCD), has low sensitivity and low specificity for arrhythmic risk stratification in patients with myocarditis. Myocardial scar is the main determinant for VA in these patients. Cardiac magnetic resonance imaging (CMR), using late gadolinium enhancement(LGE), has an excellent ability to determinate the extension and characterization of myocardial scar, indeed CMR can potentially improve SCD risk stratification and indication for ICD implantation in patients with myocarditis. We present a case of a 36 years-old male presenting to the Emergency Department with a monomorphic sustained ventricular tachycardia in whom MRI revealed myocardial-pericardial recurrent inflammatory involvement and worsening disease progression. ICD was implanted in consideration of the high risk of life-threatening arrhythmias.