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A 71-year-old man who had had rheumatic fever as a child presented with prosthetic-valve endocarditis. A mitral valvotomy had been performed 37 years before, and 21 years later, his mitral valve was replaced with a Starr–Edwards prosthesis. Lateral chest radiography showed complete calcification of the left atrial wall (Panel A, arrows). A transesophageal echocardiogram showed calcification of the interatrial septum (Panel B, arrow). This rare condition was first described in 1898, in association with chronic rheumatic mitral disease, and is more common in women, most of whom have symptoms for more than 20 years. The condition is assumed to be the end result of extensive rheumatic pancarditis. The calcification may be confined to the left atrial appendage or, rarely, to the posterior left atrial wall — owing to a regurgitant mitral jet — in which case the calcified patch is called the MacCallum's patch. Massive calcification usually spares the interatrial septum, but when the septum is affected (as in Panel B, arrow), any further surgery near the mitral valve is hazardous. Radiography of the left lateral side of the chest is recommended to assess long-standing rheumatic mitral-valve disease. Complete calcification has been described as a "coconut atrium" or "porcelain atrium."
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