A 65-year-old female with recent anterior wall myocardial infarction presented with exertional angina. The examination found a pansystolic murmur at apex. Transthoracic echocardiography showed hypokinesia of the anteroseptal region and mitral annular calcification with severe mitral regurgitation.
Coronary angiography showed triple vessel disease. Fluoroscopy in the left anterior oblique (LAO) view demonstrated calcifications with a horizontal figure of eight appearance (Figure 1).
This image illustrates the importance of understanding fluoroscopic anatomy. Drawing an oblique line in the middle of the fluoroscopic LAO view helps to differentiate the right- and left-sided cardiac chambers1. The lower semicircle of the figure 8 was formed by annular calcification of the tricuspid valve and mitral valve annulus, while the upper half was completed by calcium along the right coronary artery and left circumflex artery on the right and left sides, respectively. The patient was referred for surgical mitral valve replacement with coronary artery bypass grafting.
Figure 1. Fluoroscopic LAO view. This figure shows calcium deposits in a figure of eight along the right coronary artery (A), the tricuspid annulus (B), the left circumflex artery (C) and the mitral annulus (D). LAO: left anterior oblique
Conflict of interest statement
The authors have no conflicts of interest to declare.