Mitral valve calcific embolization leading to myocardial infarction in a patient with end-stage renal disease.

While atherothrombosis accounts for the majority of acute coronary syndrome (ACS) cases, non-atherosclerotic mechanisms like coronary embolism are important considerations in end-stage renal disease (ESRD). A 52-year-old woman with ESRD and tertiary hyperparathyroidism presented with myocardial infarction. Echocardiography identified mobile mitral valve masses. Angiography showed a left anterior descending artery occlusion, but intravascular ultrasound revealed minimal plaque burden. Histopathological analysis of aspirated material confirmed calcified necrotic debris rather than thrombus. Despite concurrent COVID-19 infection, the rigid mechanical behavior of the masses during attempted percutaneous aspiration distinguished the pathology from infective endocarditis. This case highlights calcific coronary embolism as a rare ACS cause in ESRD patients. Multimodal imaging and histopathology are crucial for accurate diagnosis.