An 87-year-old female was transferred to the emergency department due to fever for three days. She has been treated for hypertension and diabetes mellitus. Physical examination revealed a clear breathing sound and regular heart sound without murmur. Chest X-ray demonstrated mild cardiomegaly and calcification in the position of the heart (Figure 1). Laboratory findings showed leukocytosis, high hs-C-reactive protein (3.65 mg/dL), and elevated erythrocyte sedimentation rate (32 mm) suggestive of infection. Computed tomography of chest and abdomen showed non-specific findings except prominent mitral annular calcification (MAC) (Figure 2). Transthoracic echocardiography (TTE) revealed a mobile, echogenic mass attached to MAC (Figure 3, Supplementary Video 1). Transesophageal echocardiography showed a 1.2×1.1 cm-sized, stippled cystic mass containing multiple sparkling dots suggestive of focal calcifications (Figure 4A-C, Supplementary Video 2). Based on the peculiar echocardiographic finding, we made a diagnosis of infective endocarditis on MAC and began empirical antibiotics therapy for the most common organism, staphylococci.1)2) Considering the large size of vegetation and the site of endocarditis despite very old age, minimally invasive mitral surgery was undergone to remove vegetation and repair posterior mitral annulus with bovine pericardium after partial removal of MAC (Figure 5). Postoperative TTE found normal mitral function and no evidence of newly developed echogenic mass on MAC (Figure 6). After 6 weeks of antibiotic treatment using ceftriaxone and vancomycin, the patient was discharged without a neurologic deficit. This case highlights typical findings of MAC endocarditis represented by large, stippled vegetation in the elderly.