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A 65 year-old woman with an echodense mitral annular mass. Caseous calcification of the mitral annulus (CCMA) is a rare variant of mitral annular calcification which usually represents an incidental finding during cardiac imaging. Differential diagnosis from significant lesions such as myocardial abscesses or tumours may be problematic. Herein, we present the case of a 65 year-old woman with CCMA who was managed conservatively. Besides providing useful diagnostic clues, we briefly discuss management issues for this under-recognised clinical entity.