Mitral annulus calcification--a window to diffuse atherosclerosis of the vascular system

Multimodal Cardiac Imaging in the Assessment of Patients Who Have Suffered a Cardioembolic Stroke: A Review

Cardioembolic strokes account for 20-25% of all ischaemic strokes, with their incidence increasing with age. Cardiac imaging plays a crucial role in identifying cardioembolic causes of stroke, with early and accurate identification affecting treatment, preventing recurrence, and reducing stroke incidence. Echocardiography serves as the mainstay of cardiac evaluation. Transthoracic echocardiography (TTE) is the first line in the basic evaluation of structural heart disorders, valvular disease, vegetations, and intraventricular thrombus. It can be used to measure chamber size and systolic/diastolic function. Trans-oesophageal echocardiography (TOE) yields better results in identifying potential cardioembolic sources of stroke and should be strongly considered, especially if TTE does not yield adequate results. Cardiac computed tomography and cardiac magnetic resonance imaging provide better soft tissue characterisation, high-grade anatomical information, spatial and temporal visualisation, and image reconstruction in multiple planes, especially with contrast. These techniques are useful in cases of inconclusive echocardiograms and can be used to detect and characterise valvular lesions, thrombi, fibrosis, cardiomyopathies, and aortic plaques. Nuclear imaging is not routinely used, but it can be used to assess left-ventricular perfusion, function, and dimensions and may be useful in cases of infective endocarditis. Its use should be considered on a case-by-case basis. The accuracy of each imaging modality depends on the likely source of cardioembolism, and the choice of imaging approach should be tailored to individual patients.

Mitral Annular Calcification and Thromboembolic Risk

Thromboembolic (TE) risk scores used for atrial fibrillation (AF) patients do not include mitral annular calcification (MAC) as a potential indicator of vascular disease. This research evaluated the correlation between MAC and TE risk scores (CHADS₂ and CHA₂DS₂-VASc). We compared TE risk score values and clinical and echocardiographic data in patients with and without MAC. We included, prospectively, 103 patients: 40.8% with AF, 83.5% with hypertension, 30.1% with type II diabetes mellitus, 79.6% with chronic heart failure, and 7.8% with a history of stroke. We identified MAC in 50.5% of patients. The mean CHADS₂ and CHA₂DS₂-VASc scores were 2.56 ± 1.135 and 4.57 ± 1.61, respectively. In MAC patients, both scores tended to increase significantly compared with the control (2.88 ± 1.114 versus 2.24 ± 1.06, p = 0.005, and 5.21 ± 1.51 versus 3.92 ± 1.46, p < 0.001, respectively). The left ventricular ejection fraction negatively correlated with the presence of MAC (r = -0.254, p = 0.01). The presence of MAC was a risk factor for vascular disease (OR = 2.47, χ² = 34.32, p < 0001). Conclusions: The presence of MAC is associated with greater TE risk scores and a higher risk of vascular disease. It appears that adding MAC as a vascular disease parameter to TE risk scores may have benefits for patients by improving their predictive value.

[A case of caseous calcification of mitral annulus resulting in multiple cerebral infarctions]

The patient is a 73-year-old woman. She presented with dysarthria, and a head MRI revealed multiple acute cerebral infarctions in the bilateral cerebral hemisphere and cerebellar hemisphere. Transesophageal echocardiography after admission revealed a 16 mm large mobile calcification of the mitral annulus (caseous calcification of the mitral annulus; CCMA) on the posterior apex of the mitral valve annulus. Since the CCMA had a high risk of relapse, and a new infarction was detected on the 8th day, resection of the mass and mitral valve replacement surgery were performed. CCMA is a subtype of mitral annular calcification (MAC). When calcification progresses from the MAC state to form a mass, it is called a calcified amorphous tumor; CAT. Reports of embolic cerebral infarction caused by CAT are rare, but this is a rare report of an embolic cerebral infarction from CCMA presenting as CAT.

Novel Multi-Parametric Mitral Annular Calcification Score Predicts Outcomes in Mitral Valve Dysfunction

The objective of the study was to construct a multi-parametric mitral annular calcification (MAC) score using computed tomography (CT) features for prediction of outcomes in patients undergoing mitral valve surgery. We constructed a multi-parametric MAC score, which ranges between 2 and 12, and consists of Agatston calcium score (1 point: <1000 Agatston units (AU); 2 points: 1000-<3000 AU; 3 points: 3000-5000 AU; 4 points: >5000 AU), quantitative MAC circumferential angle (1 point: <90°; 2 points: 90-<180°; 3 points: 180-<270°; 4 points: 270-360°), involvement of trigones (1 point: 1 trigone; 2 points: both trigones), and 1 point each for myocardial infiltration and left ventricular outflow tract extension/involvement of aorto-mitral curtain. The association between MAC score and clinical outcomes was evaluated. The study cohort consisted of 334 patients undergoing mitral valve surgery (128 mitral valve repairs, 206 mitral valve replacements) between January 2011 and September 2019, who had both non-contrast gated CT scan and evidence of MAC. The mean age was 72 ± 11 years, with 58% of subjects being female. MAC score was a statistically significant predictor of total operation time (P<0.001), cross-clamp time (P = 0.001) and in-hospital complications (P = 0.003). Additionally, MAC score was a significant predictor of time to all-cause death (P = 0.046). A novel multi-parametric score based on CT features allowed systematic assessment of MAC, and predicted clinical outcomes in patients with mitral valve dysfunction undergoing mitral valve surgery.

Aşil tendonu gerinim oranı ile mitral anulus kalsifikasyonu varlığı arasındaki ilişki

Amaç: Aşil tendonu (AT)- ultrasonografisi (US) ve gerinim elastografisi (SE) ile elde edilen AT- kalınlığı (T) ve AT- gerinim oranının (SR) mitral kapak kalsifikasyonlu (MAC) hastaları belirlemedeki önemini araştırmayı amaçladık. Gereç ve Yöntem: Çalışmaya ekokardiyografi sonrası MAC tanısı alan 100 hasta (65 kadın, 35 erkek ve ortalama yaş 64.7 ± 12.1) ve kardiyovasküler risk faktörü benzer olan 50 kontrol (32 kadın, 18 erkek ve ortalama yaş 63.2 ± 12.8) alındı. Laboratuvar incelemeler ve AT US yapıldı. AT-T ve AT-SR hesaplandı. Bulgular: MAC olan hastalarda AT-T ve AT-SR belirgin olarak yüksek olduğu bulundu. Logistic regresyon analizinde, AT-T ve AT-SR değerlerinin MAC olma riskini bağımsız olarak belirlediği bulundu. Bu analize göre AT-T (her 1 mm) ve AT-SR (her 0.1)’nin MAC olma riskini sırası ile %69.9 ve %12.7 oranlarında artırdığı saptandı. AT-T ve AT-SR değerlerinin MAC olan hastaları belirlemesi açısından ROC analizi yapıldığında, ROC eğri altında kalan alanın sırası ile 0.684 ve 0.819 belirlendi. Aynı analizde, AT-SR için sınır değer 1.25 olarak alındığında %94.1 sensitivite ve %76.2 spesivite ile MAC varlığını belirlediği tespit edildi. Sonuç: AT SE incelemesinde saptanan AT-SR, MAC olan hastaları önceden belirlemede kullanılabilecek basit, ucuz, tekrarlanabilir ve non-invaziv bir parametredir. Bu durum MAC ve AT-SR artışının benzer fizyopatolojik mekanizma ile meydana gelebilmesinin bir sonucu olabilir.

Association of Inflammatory and Metabolic Biomarkers with Mitral Annular Calcification in Type 2 Diabetes Patients

(1) Background: Type 2 diabetes mellitus (T2DM) contributes to cardiovascular disease and related mortality through the insidious effects of insulin resistance and chronic inflammation. Mitral annular calcification (MAC) is one such degenerative process promoted by T2DM. (2) Methods: This is a post hoc analysis of insulin resistance, inflammation, and hepatic steatosis markers in T2DM patients without atherosclerotic manifestations, but with incidental echocardiographic detection of mild MAC. (3) Results: 138 consenting patients were 49.3% men, 57.86 years old, with a history of T2DM of 6.16 years and HbA_1c 8.06%, of whom sixty had mild MAC (43.47%). The statistically significant differences between patients with/without MAC were higher HOMA C-peptide and C-peptide index for insulin resistance, higher TNF-α for inflammation, and lower estimated glomerular filtration rate. High-sensitive C-reactive protein (hsCRP) was significantly associated with insulin resistance and the strength of the relationship was higher in the MAC group. Predictive of MAC were TNF-α, HOMA C-peptide, and especially hepatic steatosis and hypertension. (4) Conclusions: MAC was more prevalent than reported in the literature. Insulin resistance and inflammation were predictive of MAC, but significant markers differ across studies. Widely available routine tests and echocardiographic assessments are useful in the early identification of mitral annular calcifications in diabetes patients.

Extra-coronary Calcification and Cardiovascular Events: What Do We Know and Where Are We Heading?

PURPOSE OF REVIEW

The coronary artery calcium score is a guideline-endorsed aid for further risk stratification in the primary prevention of atherosclerotic cardiovascular disease. The non-contrast scan performed for detection of coronary artery calcium also gives an opportunity to visualize calcifications in the thoracic aorta and in the heart valves, at no additional cost or radiation exposure. The purpose of this review was to discuss the potential clinical value of measuring thoracic aortic calcification, aortic valve calcification, and mitral annulus calcification.

RECENT FINDINGS

After two decades of active research, all three calcifications have been extensively evaluated, across various cohorts. We discuss classic and recent studies, current knowledge gaps, and future directions in this space. The added value of these measurements has traditionally been considered modest at best, and they are not currently discussed in relevant primary prevention guidelines in North America and Europe. However, recent studies evaluating high thoracic calcification thresholds and younger populations have further enriched this space. Specifically, some studies suggest that detection of severe thoracic aortic calcification may be helpful in further risk assessment and that detection of aortic valve calcifications may have important prognostic implications in younger individuals. Although more research is needed, particularly in larger young-to-middle-aged cohorts, future guidelines might consider including these features as risk-enhancing factors.

Risk Factors for Calcific Aortic Valve Disease in Afghan Population

Objective

Evidence from previous studies suggests that calcific aortic valve disease (CAVD) is not an unavoidable consequence of aging, and may be linked to explicit risk factors. However, little is known regarding the Afghan population in this context. The current study aimed to identify the clinical features of CAVD and determine independent risk factors for CAVD in the Afghan population.

Patients and Methods

A case-control study was conducted among 1072 Afghan participants (age >18 years) from January 2018 to December 2020. The study participants were divided into two groups based on echocardiographic findings: 536 individuals with CAVD and 536 age- and sex-matched controls. Data were collected using questionnaires from the medical records of all cases and controls. The independent predictors of CAVD were evaluated using multivariate logistic regression analysis.

Results

The mean age of study participants was 65.3 ± 13.5 years (range, 20–100 years). Of the 536 patients with CAVD, 77 (14.4%) had aortic valve stenosis, 415 (77.4%) had aortic valve calcification, and 44 (8.2%) had bicuspid aortic valve. Multivariate logistic regression analysis revealed that sedentary lifestyle (odds ratio [OR] = 2.517, p = 003), diabetes mellitus (DM) (OR = 1.902, p = 006), high body mass index (BMI ≥ 30 kg/m²) (OR = 1.776, p = 005), good socioeconomic status (OR = 1.724, p = 021), and hypertension (OR = 1.664, p ˂0.001) were independent risk factors for CAVD in the Afghan population.

Conclusion

It was observed that sedentary lifestyle, diabetes mellitus, high BMI (≥ 30 kg/m²), good socioeconomic status, and hypertension are independent risk factors for the development of CAVD compared to those with a normal aortic valve in the Afghan population.

Prevalence and Natural History of Mitral Annulus Calcification and Related Valve Dysfunction

OBJECTIVE

To evaluate the prevalence and natural history of mitral annulus calcification (MAC) and associated mitral valve dysfunction (MVD) in patients undergoing clinically indicated echocardiography.

METHODS

A retrospective review was conducted of all adults who underwent echocardiography in 2015. Mitral valve dysfunction was defined as mitral regurgitation or mitral stenosis (MS) of moderate or greater severity. All-cause mortality during 3.0 (0.4 to 4.2) years of follow-up was compared between groups stratified according to the presence of MAC or MVD.

RESULTS

Of 24,414 evaluated patients, 5502 (23%) had MAC. Patients with MAC were older (75±10 years vs 60±16 years; P<.001) and more frequently had MVD (MS: 6.6% vs 0.5% [P<.001]; mitral regurgitation without MS: 9.5% vs 6.1% [P<.001]). Associated with MS in patients with MAC were aortic valve dysfunction, female sex, chest irradiation, renal dysfunction, and coronary artery disease. Kaplan-Meier 1-year survival was 76% in MAC+/MVD+, 87% in MAC+/MVD-, 86% in MAC-/MVD+, and 92% in MAC-/MVD-. Adjusted for age, diabetes, renal dysfunction, cancer, chest irradiation, ejection fraction below 50%, aortic stenosis, tricuspid regurgitation, and pulmonary hypertension, MAC was associated with higher mortality during follow-up (adjusted hazard ratio, 1.40; 95% CI, 1.31 to 1.49; P<.001); MVD was associated with even higher mortality in patients with MAC (adjusted hazard ratio, 1.79; 95% CI, 1.58 to 2.01; P<.001). There was no significant interaction between MAC and MVD for mortality (P=.10).

CONCLUSION

In a large cohort of adults undergoing echocardiography, the prevalence of MAC was 23%. Mitral valve dysfunction was more than twice as prevalent in patients with MAC. Adjusted mortality was increased in patients with MAC and worse with both MAC and MVD.

Natural History of Mitral Annulus Calcification and Calcific Mitral Valve Disease

BACKGROUND

The natural history of mitral annular calcification (MAC) and risk for developing calcific mitral valve disease (CMVD) has been poorly defined. We sought to evaluate the progression rate of MAC and of the development of CMVD.

METHODS

Patients with MAC and paired echocardiograms at least one year apart between 2005 and 2019 were included. Progression rates from mild/moderate to severe MAC and to CMVD (defined as severe MAC and significant mitral stenosis and/or regurgitation) were assessed, along with potential association with sex.

RESULTS

A total of 11,605 patients (73±10years, 51%male) with MAC (78% mild, 17% moderate, 5% severe) were included and had a follow up echocardiogram at 4.2±2.7years. In patients with mild/moderate MAC, 33% presented with severe MAC at 10 years. The rate of severe MAC was higher in females than in males (41% vs. 24%, P<0.001, HR=1.3, P<0.001) and in patients with moderate vs. mild MAC (71% vs. 22%, P<0.001, HR=6.1, P<0.001). At 10 years 10% presented with CMVD (4%, 23% and 60% in patients with mild, moderate, and severe MAC respectively) and was predicted by female sex (15% vs. 5%, P<0.0001), even after adjustment for MAC severity (HR=1.9, P<0.001).

CONCLUSION

In this large cohort of patients with MAC, progression to severe MAC was common and frequently results in CMVD. Female sex was associated with higher progression rates. MAC and CMVD are expected to dramatically increase as the population ages highlighting the importance of a better understanding of the pathophysiology of MAC in order to develop effective preventive medical therapies.

Mitral Regurgitation in Patients Undergoing Noncardiac Surgery

Mitral regurgitation (MR) is one of the most frequently encountered types of valvular heart disease in the United States. Patients with significant MR (moderate-to-severe or severe) undergoing noncardiac surgery have an increased risk of perioperative cardiovascular complications. MR can arise from a diverse array of causes that fall into 2 broad categories: primary (diseases intrinsic to the valvular apparatus) and secondary (diseases that disrupt normal valve function via effects on the left ventricle or mitral annulus). This article highlights key guideline updates from the American College of Cardiologists (ACC) and the American Heart Association (AHA) that inform decision-making for the anesthesiologist caring for a patient with MR undergoing noncardiac surgery. The pathophysiology and natural history of acute and chronic MR, staging of chronic primary and secondary MR, and considerations for timing of valvular corrective surgery are reviewed. These topics are then applied to a discussion of anesthetic management, including preoperative risk evaluation, anesthetic selection, hemodynamic goals, and intraoperative monitoring of the noncardiac surgical patient with MR.

Current methods to assess mitral annular calcification and its risk factors

INTRODUCTION

Mitral annulus calcification (MAC) is a chronic, non-inflammatory, degenerative mechanism of the fibrous base of the mitral valve. While MAC was originally thought to be an age-related degenerative process, there is evidence that other mechanisms, such as atherosclerosis and abnormal calcium phosphorus metabolism, also contribute to the development of MAC.

AREAS COVERED

This paper summarizes, existing perception of clinically valid definition of MAC and the pathophysiological processes that lead to the development of MAC and the diagnostic implications of this disease entity.

EXPERT OPINION

Minimal evidence exists on the natural history and progression of MAC. Characterization of MAC progression and identification of predisposing risk factors can help to validate hypotheses. MAC is most commonly asymptomatic and incidental finding. Echocardiography is the primary imaging modality for identification and characterization of MAC and associated mitral valve (MV) disease. For patients with an indication for MV surgery, computed tomography (CT) is a complementary imaging modality for MAC. MAC is generally recognized by its characteristic density, location, and shape on echocardiography and CT, unusual variants are sometimes confused with other lesions.

Series of myocardial FDG uptake requiring considerations of myocardial abnormalities in FDG-PET/CT

Distinct from cardiac PET performed with preparation to control physiological FDG uptake in the myocardium, standard FDG-PET/CT performed with 4-6 h of fasting will show variation in myocardial FDG uptake. For this reason, important signs of myocardial and pericardial abnormality revealed by myocardial FDG uptake tend to be overlooked. However, recognition of possible underlying disease will support further patient management to avoid complications due to the disease. This review demonstrates the mechanism of FDG uptake in the myocardium, discusses the factors affecting uptake, and provides notable image findings that may suggest underlying disease.

Assessment of Arterial Stiffness with Cardio-Ankle Vascular Index in Patients with Mitral Annular Calcification

Objective

Arterial stiffness is related to arteriolosclerotic diseases and is a marker of adverse cardiovascular events. Mitral annular calcification (MAC) is progressive calcium deposition on the posterior and inferior mitral annulus and is associated with atherosclerotic cardiovascular diseases. Cardio-ankle vascular index (CAVI) is a measurement technique used to estimate the degree of arterial stiffness without effect from blood pressure. The aim of this study is to research arterial stiffness using CAVI in patients with MAC.

Materials and Methods

The study was cross-sectional and observational and included 98 patients with MAC confirmed by echocardiography who referred to the cardiology clinics and met study inclusion criteria and 38 controls without MAC. CAVI measurements were obtained by using the Vascular Screening System VaSera VS-1000 (Fukuda Denshi, Tokyo, Japan) device.

Results

The two groups were similar in terms of demographic characteristics, including age, sex, hypertension, coronary artery disease, body surface area, and smoking (P > .05). Left atrial volume index was significantly higher in patients with MAC compared with the control group (P < .001). Right arm CAVI, left arm CAVI, and mean CAVI were significantly higher in the MAC group than the control group (P = .037, P = .005, and P = .014, respectively) and increased with MAC severity. There was a significant positive correlation between mean CAVI and MAC grade (r = 0.278, P = .001). Also, when ankle-brachial index (ABI) was measured with CAVI, left and right extremity ABI values were significantly lower in patients with MAC (P = .017 and P = .005, respectively).

Conclusion

CAVI increased in all patients with MAC and associated with increasing grade of calcification.

Mitral annular calcification and its severity predict high risk for cardio-embolic stroke in elderly patients with first diagnosed atrial fibrillation

BACKGROUND

Atrial fibrillation (AF) is the most common arrhythmia worldwide and a large proportion of patients with AF are older than 75 years of age. Mitral annular calcification (MAC), which is usually observed in advanced age, is associated with increased risk of AF and cardio-embolic stroke in the general population.

OBJECTIVES

This study was performed to assess whether presence of MAC and its severity predict cardio-embolic stroke in elderly patients with first diagnosed AF.

METHODS

In this cross-sectional study, 72 elderly patients suffering from acute cardio-embolic stroke with first diagnosed AF and 79 elderly control group patients with first diagnosed AF and without stroke were investigated. A parasternal short-axis view at the level of the mitral annulus was used for MAC measurements. The severity of MAC was measured from the anterior to posterior edge at its greatest width.

RESULTS

MAC thicknesses were significantly higher in the stroke group. ROC curve analysis showed that a cut point of 2.5 mm for the value of MAC thickness exhibited 68.1% sensitivity and 77.2% specificity for detecting cardio-embolic stroke in elderly patients with AF. In multivariate logistic regression analysis, MAC thickness (OR = 1.173, 95% CI 1.083-1.270; p < 0.001) was found to be independent predictor of cardio-embolic stroke in elderly patients with AF.

CONCLUSION

MAC thickness may provide useful information for the relevant risk evaluation of elderly patients with AF. Pre-stroke MAC presence and its severity appear to have better clinical value for predicting cardio-embolic stroke in elderly patients with AF, independent from traditional risk factors for stroke.

Predictors of Stroke Outcome Extracted from Multivariate Linear Discriminant Analysis or Neural Network Analysis

Aim: The prediction of functional outcome is essential in the management of acute ischemic stroke patients. We aimed to explore the various prognostic factors with multivariate linear discriminant analysis or neural network analysis and evaluate the associations between candidate factors, baseline characteristics, and outcome.

Methods: Acute ischemic stroke patients ( n =1,916) with premorbid modified Rankin Scale (mRS) scores of 0–2 were analyzed. The prediction models with multivariate linear discriminant analysis (quantification theory type II) and neural network analysis (log-linearized Gaussian mixture network) were used to predict poor functional outcome (mRS 3–6 at 3 months) with various prognostic factors added to age, sex, and initial neurological severity at admission.

Results: Both models revealed that several nutritional statuses and serum alkaline phosphatase (ALP) levels at admission improved the predictive ability. Of the 1,484 patients without missing data, 560 patients (37.7%) had poor outcomes. The patients with poor outcomes had higher ALP levels than those without (294.3±259.5 vs. 246.3±92.5 U/l, P ＜0.001). Multivariable logistic analyses revealed that higher ALP levels (1-SD increase) were independently associated with poor stroke outcomes after adjusting for several confounding factors, including the neurological severity, malnutrition status, and inflammation (odds ratio 1.21, 95% confidence interval 1.02–1.49). Several nutritional indicators extracted from prediction models were also associated with poor outcome.

Conclusion: Both the multivariate linear discriminant and neural network analyses identified the same indicators, such as nutritional status and serum ALP levels. These indicators were independently associated with functional stroke outcome.

Serum Alkaline Phosphatase Level is Associated with Angiographic Vasospasm, Delayed Cerebral Ischemia-Caused Clinical Deterioration, and Functional Outcome After Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Alkaline phosphatase (ALP) has been implicated to be associated with poor outcome in ischemic stroke patients, yet its role in aneurysmal subarachnoid hemorrhage (aSAH) patients is unknown. The current study aimed to investigate the on-admission and short-term variation trend of ALP levels in aSAH patients as well as its associations with vasospasm, delayed cerebral ischemia (DCI), and outcome after aSAH.

METHODS

Between January 2014 and May 2018, all consecutive aSAH patients were prospectively enrolled. Blood samples from patients and 78 healthy individuals were obtained. Baseline information, clinical data, and radiologic data were collected, and serum ALP levels during hospitalization were measured. Patients were followed up for 6 months.

RESULTS

One hundred and ninety-six aSAH patients were included. The serum ALP levels in aSAH patients were significantly higher compared to controls (71 vs. 61 U/L, p = 0.0002), yet did not differ significantly between patients with severe (WFNS 4-5) and mild clinical condition (72 vs. 63 U/L, p = 0.3362). However, ALP was significantly higher in patients with severe radiologic status (modified Fisher 3-4) compared to those with mild radiologic status (77 vs. 61.5 U/L, p = 0.0005). A significant correlation emerged between modified Fisher score and ALP level (r = 0.246, p = 0.001). Multivariable analysis found that higher ALP level was associated with angiographic vasospasm (OR 1.019, 95% CI 1.002-1.036, p = 0.026) and DCI-caused clinical deterioration (OR 1.019, 95% CI 1.001-1.037, p = 0.037), while higher WFNS score, modified Fisher score, and ALP level were independently associated with unfavorable outcome (serum ALP level, OR 1.083, 95% CI 1.041-1.127, p < 0.001). Trend analysis of ALP level based on 103 patients' data revealed a significant decrease in ALP level on post-admission day 7-9 (median; on-admission day vs. post-admission day 7-9, 72 vs. 60 U/L, p = 0.0012; post-admission day 3-5 vs. day 7-9, 70 vs. 60 U/L, p = 0.0052) and subsequent increase in ALP level on post-admission day 12-14 (median, 84 U/L, p < 0.0001). Higher ALP levels were observed in patients with unfavorable outcome on on-admission day, post-admission day 3-5, and 12-14 (median; unfavorable vs. favorable; on-admission day, 86 vs. 67 U/L, p = 0.0122; post-admission day 3-5, 80 vs. 64 U/L, p = 0.0044; post-admission day 7-9, 75 vs. 53.5 U/L, p < 0.0001) but not on post-admission day 12-14.

CONCLUSIONS

Elevated serum ALP level is associated with vasospasm, DCI-caused clinical deterioration, and functional outcome after aSAH. Further studies are required to examine the potential role of serum ALP as an outcome predictor for aSAH patients.

Presentation and management of calcific mitral valve disease

Little is known about the prevalence, presentation and management of calcific mitral valve disease (CMVD). We identified 167 patients (80 ± 10 years; 79% women) with significant CMVD undergoing transthoracic echocardiography at our institution in 2016. Patients presented with significant co-morbidities, 47% had moderate/severe mitral stenosis, 38% had 3+/4+ mitral regurgitation and 15% had a combination of both. Fifty-eight percent were symptomatic. Most symptomatic patients were managed conservatively and incurred higher mortality and mortality/heart failure admission rates than those managed surgically. These data highlight the importance of gaining mechanistic insights into CMVD to prevent its occurrence and avoid the need for high-risk surgery, which is seldom performed in contemporary practice.

TAVI in Patients with Mitral Annular Calcification and/or Mitral Stenosis

BACKGROUND

 We herein aimed for analysis of influence of mitral annular calcification (MAC) and mitral stenosis (MS) on outcomes in transcatheter aortic valve implantation (TAVI).

METHODS

 Between 11/2009 and 06/2017, 1,058 patients underwent TAVI in the presence of concomitant MAC or MS at our center. Subgroups were built and multivariate logistic regression, COX regression, Kaplan-Meier survival analyses, and receiver operating characteristics method were performed.

RESULTS

 Thirty-day mortality was 7.5% (79/1,058) with highest mortality in patients severe MS (MAC: 3.4% vs. mild MS: 5.9% vs. moderate MS: 15.0% vs. severe MS: 72.7%; p < 0.001). Moderate-to-severe MS (odds ratio [OR]: 7.75, confidence interval [CI]: 3.94-16.26, p < 0.001), impaired left ventricular ejection fraction (OR: 1.38, CI: 1.10-1.72, p < 0.01), and coronary artery disease (OR: 1.36, CI: 1.11-1.67, p < 0.01) were predictive of 30-day survival. Left ventricular systolic/end-diastolic pressure drop of <59.5 mm Hg / <19.5 mm Hg was associated with increased mortality.

CONCLUSIONS

 TAVI in the presence of MAC and mild MS is associated with acceptable acute outcomes but should be considered high-risk procedures in patients with moderate and especially those with severe MS. Our results suggest adverse hemodynamics after TAVI with concomitant MS, which may be caused by underfilling of the left ventricle leading to low-cardiac output.

Mitral Annular Calcification: Association with Atherosclerosis and Clinical Implications

PURPOSE OF REVIEW

This review summarizes the pathophysiology of mitral annular calcification (MAC) with recent findings and current strategies for diagnosis and treatment.

RECENT FINDINGS

Major factors in MAC development seem to be shear stress of the flow past the mitral valve, local inflammation, and dysregulation in regulators of mineral metabolism. MAC itself poses daunting technical challenges. Implanting a valve on top of the calcium bar might lead to paravalvular leak (PVL) that is less likely to heal. Annular decalcification allows for better valve seating and potentially better healing and less PVL. This, however, comes with the risk for catastrophic atrioventricular groove disruption. MAC can be sharply dissected with the scalpel; the annulus can be reconstructed with the autologous pericardium. Transcatheter mitral valve replacement is a promising approach in the treatment of patients who are deemed high-risk surgical candidates with severe MAC. MAC is a multifactorial disease that has some commonalities with atherosclerosis, mainly regarding lipid accumulation and calcium deposition. It is of great clinical importance, being a risk marker of cardiovascular events (including sudden death) and, with its progression, can have a negative impact on patients' lives.

The Relationship Between Mitral Annular Calcification, Metabolic Syndrome and Thromboembolic Risk

INTRODUCTION

Metabolic syndrome (MetS) is defined as an association between diabetes, hypertension, obesity and dyslipidemia and an increased risk of cardiovascular disease. Mitral annular calcification (MAC) is associated with several cardiovascular disorders, including coronary artery disease, atrial fibrillation (AF), heart failure, ischemic stroke and increased mortality. The CHA2DS2-VASc score is used to estimate thromboembolic risk in AF. However, the association among MAC, MetS and thromboembolic risk is unknown and was evaluated in the current study.

METHODS

The study group consisted of 94 patients with MAC and 86 patients with MetS. Patients were divided into two groups: those with and those without MAC.

RESULTS

Patients with MAC had a higher MetS rate (P<0.001). In patients with MAC, the CHA2DS2-VASc scores and the rate of cerebrovascular accident and AF were significantly higher compared to those without MAC (P<0.001, for both parameters). The results of the multivariate regression analysis showed that history of smoking, presence of MetS and high CHA2DS2-VASc scores were associated with the development of MAC. ROC curve analyses showed that CHA2DS2-VASc scores were significant predictors for MAC (C-statistic: 0.78; 95% CI: 0.706-0.855, P<0.001). Correlation analysis indicated that MAC was positively correlated with the presence of MetS and CHA2DS2-VASc score (P=0.001, r=0.264; P<0.001, r=0.490).

CONCLUSION

We have shown that CHA2DS2-VASc score and presence of MetS rates were significantly higher in patients with MAC compared without MAC. Presence of MAC was correlated with CHA2DS2-VASc score, presence of MetS, AF and left atrial diameter and negatively correlated with left ventricular ejection fraction.

Caseous Calcification of the Mitral Annulus

Soft-tissue masses or mass-like lesions involving the mitral valve include a wide range of diseases such as tumors, abscesses, vegetations, thrombus and, rarely, caseous calcifications of the mitral annulus. Caseous calcifications of the mitral annulus is a rare variant of mitral annular calcification that is usually asymptomatic and diagnosed incidentally. Echocardiography is the first-choice imaging modality. Cardiac computed tomography is an ideal tool to confirm the presence of calcifications and caseous necrosis. In cases where there is doubt, cardiac magnetic resonance imaging may be used. We present the case of a 62-year-old patient with an intra-cardiac mass diagnosed by echocardiography. Imaging modalities to achieve a correct diagnosis and avoid unnecessary surgical intervention are discussed.

Mitral annulus calcification: current management and future challenges

Mitral annulus calcification is a chronic degenerative process in the fibrous base of the mitral valve. Assessment and treatment of mitral valve disease in patients with severe mitral annulus calcification is challenging, and a multimodal approach is helpful to delineate its severity and anatomic features, and to guide the therapeutic strategy. This article reviews the current literature to provide a clinically relevant description of mitral annulus calcification, analyze the diagnostic pathway of a patient with mitral annulus calcification, and summarize the therapeutic options.

Mitral Annular Calcification and Calcific Mitral Stenosis: Therapeutic Challenges and Considerations

PURPOSE OF REVIEW

Mitral annular calcification (MAC) and associated calcific mitral stenosis (MS) are frequent in the aging population, although optimal management remains debated and outcomes are poor. This article summarizes challenges in the diagnosis and therapy of calcific MS, the indications for valve intervention, procedural concerns, and emerging treatment options.

RECENT FINDINGS

Surgical mitral valve replacement is the procedure of choice in symptomatic patients at acceptable surgical risk, with transcatheter mitral valve replacement (TMVR) being evaluated in clinical trials as an alternative for patients at prohibitive surgical risk. Significant challenges exist with the currently available technology and outcomes have been suboptimal. Optimizing the patient-selection process by using multimodality imaging tools has proven to be essential. MAC and calcific MS is an increasingly prevalent, challenging issue with poor outcomes. While surgical valve replacement can be performed in patients with acceptable surgical risk, TMVR can be considered for patients at higher risk. Clinical trials are underway to optimize outcomes. Dedicated device designs and techniques to minimize risk of left ventricular outflow tract obstruction, paravalvular leakage, and device embolization are to be awaited.

The relation between echocardiographic epicardial fat thickness and mitral annular calcification

Background

Mitral annular calcification (MAC) is associated with several cardiovascular disorders including coronary artery disease (CAD), atrial fibrillation, heart failure, ischemic stroke and increased mortality. Epicardial fat thickness (EFT) has strong correlation with obesity, CAD, insulin resistance, metabolic syndrome, hypertension, diabetes mellitus, and atherosclerosis. There are strong similarities between EFT and MAC from the aspect of risk factors and pathogenesis.

Objective

In this study we aimed to investigate the EFT in patients with MAC.

Methods

The study group consisted of 78 patients with MAC. An age, gender and body mass index matched control group consisted of 47 subjects who admitted to echocardiography laboratory due to suspicion of organic heart disease and eventually found to be free of MAC. We measured EFT in patients with MAC and control subjects.

Results

EFT was significantly higher in patients with MAC than in control subjects (5.7±0.9 vs. 4.4±0.6 mm respectively; P< 0.001). Correlation analysis indicated that EFT was positively correlated with presence of MAC (p<0.001, r=0.597).

Conclusion

We showed that EFT was significantly elevated in patients with MAC and it was positively correlated with MAC.

The Role of Arterial Hypertension in Mitral Valve Regurgitation

PURPOSE OF REVIEW

To review medical literature for evidence of association between hypertension and mitral regurgitation (MR) and summarize potential favorable effects of antihypertensive drugs on MR natural history and treatment.

RECENT FINDINGS

Hypertension and MR are common diseases affecting a large proportion of the general population. Contemporary evidence suggests that hypertension may worsen the progression and prognosis of MR through augmented mechanical stress and increased regurgitation volume. Renin-angiotensin axis inhibitors, beta-blockers, and vasodilators have been tested in order to prevent or decrease primary or secondary MR. Although antihypertensive agents may improve hemodynamic parameters and left ventricular remodeling in primary MR, there is no strong evidence of benefit on clinical outcomes. On the other hand, a beneficial effect of these drugs on secondary MR is better established. Moreover, there are no studies evaluating a possible benefit of lower blood pressure targets in MR. Randomized controlled trials are warranted to elucidate the precise role of antihypertensive therapy on treatment of MR.

Impact of Mitral Annular Calcium on Outcomes after Transcatheter Aortic Valve Implantation

A high prevalence of mitral annular calcium (MAC) is expected in patients undergoing transcatheter aortic valve implantation (TAVI); however, data regarding the prevalence of MAC and impact on risk of cardiovascular events are lacking. To determine the prevalence of MAC and its association with clinical outcomes in patients undergoing TAVI, we retrospectively analyzed 424 patients who underwent transfemoral TAVI from 2007 to 2015 and whose preoperative computed tomography images were available for assessment of MAC. Severe circumferential MAC (SC-MAC) was defined as calcification involving at least the whole posterior annulus alone or with the attachment of the anterior leaflet. Clinical outcomes were examined according to Valve Academic Research Consortium-2 criteria up to 2 years. SC-MAC was found in 17.7% of patients. Patients with SC-MAC were more likely to be female, with a higher prevalence of atrial fibrillation and peripheral artery disease. There were no differences between the groups regarding age, functional class, prevalence of diabetes, kidney disease, and operative risk. Female gender and peripheral artery disease were independent predictors of SC-MAC. SC-MAC did not appear to be associated with periprocedural and 30-day outcomes. At 2 years' follow-up, patients with SC-MAC had significantly higher cardiovascular and all-cause mortality rates. SC-MAC was an independent predictor of cardiovascular mortality during follow-up. In conclusion, SC-MAC is a frequent finding in the TAVI population and appears to be an independent predictor of cardiovascular mortality at 2 years' follow-up.

Conflicting relationship between age-dependent disorders, valvular heart disease and coronary artery disease by covariance structure analysis: Possible contribution of natriuretic peptide

Background

It is conceivable that contemporary valvular heart disease (VHD) is affected largely by an age-dependent atherosclerotic process, which is similar to that observed in coronary artery disease (CAD). However, a comorbid condition of VHD and CAD has not been precisely examined. The first objective of this study was to examine a possible comorbid condition. Provided that there is no comorbidity, the second objective was to search for the possible reasons by using conventional risk factors and plasma B-type natriuretic peptide (BNP) because BNP has a potentiality to suppress atherosclerotic development.

Methods

The study population consisted of 3,457 patients consecutively admitted to our institution. The possible comorbid condition of VHD and CAD and the factors that influence the comorbidity were examined by covariance structure analysis and multivariate analysis.

Results

The distribution of the patients with VHD and those with CAD in the histograms showed that the incidence of VHD and the severity of CAD rose with seniority in appearance. The real statistical analysis was planned by covariance structure analysis. The current path model revealed that aging was associated with VHD and CAD severity (P < 0.001 for each); however, as a notable result, there was an inverse association regarding the comorbid condition between VHD and CAD (Correlation coefficient [β]: -0.121, P < 0.001). As the second objective, to clarify the factors leading to this inverse association, the contribution of conventional risk factors, such as age, gender, hypertension, smoking, diabetes, obesity and dyslipidemia, to VHD and CAD were examined by multivariate analysis. However, these factors did not exert an opposing effect on VHD and CAD, and the inverse association defied explanation. Since different pathological mechanisms may contribute to the formation of VHD and CAD, a differentially proposed path model using plasma BNP revealed that an increase in plasma BNP being drawn by VHD suppressed the progression of CAD (β: -0.465, P < 0.001).

Conclusions

The incidence of VHD and CAD showed a significant conflicting relationship. This result supported the likely presence of unknown diverse mechanisms on top of the common cascade of atherosclerosis. Among them, the continuous elevation of plasma BNP due to VHD might be one of the explicable factors suppressing the progression of CAD.

The Role of Valvular and Thoracic Aortic Calcifications in Distinction Between Ischemic and Nonischemic Cardiomyopathy

Determination of underlying etiology in patients with dilated and globally hypokinetic left ventricles may sometimes be difficult even after detailed history and complete clinical evaluation. Cardiac valvular and thoracic aortic calcifications have previously been reported to be used as a window to diffuse atherosclerosis of the vascular system. The authors prospectively examined the predictive value of mitral annular calcification (MAC), aortic valve calcification (AVC), and thoracic aortic calcification (TAC) in diagnosis of coronary artery disease as the underlying cause of diffuse left ventricular dilatation and systolic dysfunction. The study included 98 consecutive patients (male/female = 76/22, mean age = 58.9 ±10.7 years, range: 33 to 75 years) over the age of 30 years admitted to their clinics between October 1999 and December 2001 with signs and symptoms of congestive heart failure associated with documented cardiomegaly. Transthoracic echocardiography and coronary angiography were performed in all patients for the evaluation of valvular calcifications and coronary status. Although there was no significant difference between the groups with and without coronary artery stenosis (CAS), with regard to presence of MAC, patients with CAS tended to have MAC more frequently (12/61, 20% vs 4/37, 11%, p>0.05). AVC and TAC were found to be significantly more frequent in patients with CAS compared to those without CAS (AVC, 35/61, 57% vs 4/37, 11%, p<0.001 and TAC, 28/61, 46% vs 2/37, 5%, p<0.001). While all 3 calcifications had sensitivity under 60%, and specificity and positive predictive value over 75% individually, the presence of any of them had a sensitivity of 80%, specificity of 86%, positive predictive value of 91%, and negative predictive value of 73%. Thus the presence of any of these calcifications distinguished patients with coronary artery disease with a sensitivity of 80% and specificity of 86%. The presence of aortic valvular valve and thoracic aortic calcifications seems to be associated with significant coronary arterial stenosis; however, with relatively low negative predictive values these cannot be used in clinical practice for diagnosis of underlying coronary artery disease in patients with dilatated left ventricles and impaired systolic functions.

Mitral valve disease--current management and future challenges

The field of mitral valve disease diagnosis and management is rapidly changing. New understanding of disease pathology and progression, with improvements in and increased use of sophisticated imaging modalities, have led to early diagnosis and complex treatment. In primary mitral regurgitation, surgical repair is the standard of care. Treatment of asymptomatic patients with severe mitral regurgitation in valve reference centres, in which successful repair is more than 95% and surgical mortality is less than 1%, should be the expectation for the next 5 years. Transcatheter mitral valve repair with a MitraClip device is also producing good outcomes in patients with primary mitral regurgitation who are at high surgical risk. Findings from clinical trials of MitraClip versus surgery in patients of intermediate surgical risk are expected to be initiated in the next few years. In patients with secondary mitral regurgitation, mainly a disease of the left ventricle, the vision for the next 5 years is not nearly as clear. Outcomes from ongoing clinical trials will greatly inform this field. Use of transcatheter techniques, both repair and replacement, is expected to substantially expand. Mitral annular calcification is an increasing problem in elderly people, causing both mitral stenosis and regurgitation which are difficult to treat. There is anecdotal experience with use of transcatheter valves by either a catheter-based approach or as a hybrid technique with open surgery, which is being studied in early feasibility trials.

Effect of Mitral Annular Calcium on Left Ventricular Diastolic Parameters

Assessment of left ventricular (LV) diastolic function by Doppler flow imaging and tissue Doppler is an integral part of the echocardiographic examination. Mitral annular calcium (MAC) is frequently encountered on echocardiography. The aim of this study was to assess the impact of MAC, quantitatively measured by computed tomography scan, on echocardiographic LV diastolic parameters. We included 155 patients aged ≥65 years. Computed tomography reconstructions of the mitral annulus were created, and calcium identified and quantified by Agatston technique. Calcium locations were assigned using an overlaid template depicting the annular segments in relation to surrounding anatomic structures. Echocardiographic assessment of diastolic function was performed in standard fashion. Mean age was 77 years; 49% were men; and 43% were black. Patients with MAC had lower septal e' (p = 0.003), lateral e' (p = 0.04), and average e' (p = 0.01) compared with those without MAC. They also had a higher E-wave velocity (p = 0.01) and E/e' ratio (p <0.001). When evaluated by severity of MAC, and after adjustment for multiple clinical factors, there was a graded (inverse) relation between MAC severity and septal e' (p = 0.01), lateral e' (p = 0.01), and average e' (p = 0.01). In conclusion, LV diastolic parameters, as measured by Doppler echocardiography, are altered in the presence of MAC. This could be due to direct effects of MAC on annular function or might reflect truly reduced diastolic function. Interpretation of diastolic parameters in patients with MAC should be performed with caution.

Clinical and Echocardiographic Features of Mitral Annular Calcium in Patients Aged ≤50 Years

Data regarding characteristics of young patients with mitral annular calcification (MAC) and its associations with other cardiovascular risk factors are scarce. Hence, we sought to characterize patients aged <50 years with MAC and to examine whether in these patients, MAC is also associated with cardiovascular risk factors. Consecutive patients who underwent an echocardiographic study were prospectively entered into a database. The database included clinical, laboratory, and echocardiographic parameters. The present study included 56 patients aged <50 years with a diagnosis of MAC. The mean age was 44.2 ± 6.9 years with a male-to-female ratio of 2.5:1. The prevalence of cardiovascular risk factors (30 patients [53%] hypertension, 17 patients [30%] diabetes mellitus, 24 patients [43%] dyslipidemia, 22 patients [39%] smoking) and established cardiovascular disease (22 patients [39%] coronary artery disease, 11 patients [19%] previous stroke) was substantially higher than expected for this age group. Twenty-nine patients (52%) had chronic kidney disease. Of these, 18 patients (62%) had end-stage kidney disease and 7 patients (24%) underwent renal transplantation. Fourteen patients (25%) and 3 patients (5%) had moderate or severe mitral regurgitation and mitral stenosis, respectively. Aortic valve disease was present in 37 patients (66%). Moderate or severe left ventricular dysfunction and left ventricular hypertrophy were identified in 9 patients (16%) and 31 patients (56%), respectively. In conclusion, the detection of MAC in a young patient should be regarded as a marker of atherosclerotic disease, chronic kidney disease, and aortic valve disease.

Association Between Mitral Annular Calcium and Flail Mitral Leaflet in Degenerative Mitral Valve Disease

The aim of this study was to assess the association between mitral annular calcium (MAC) and flail mitral leaflets in a cohort of patients with degenerative mitral valve disease. A retrospective study was conducted of consecutive patients with degenerative mitral valve disease who underwent echocardiography at Rabin Medical Center from 2003 to 2012. Special focus was attended to the presence and grade of MAC and characterization of valve pathology (myxomatous vs nonmyxomatous, prolapse vs flail). Patients were excluded if they had undergone previous mitral valve surgery and/or had infective endocarditis. Multivariate logistic regressions were used to control for confounders. The study included 1,912 patients (60.8% men, mean age 63.8 ± 17.4 years) divided into 3 groups: 1,627 (86%) without MAC, 183 (10%) with either mild or moderate MAC, and 94 (5%) with severe MAC. The presence of flail leaflet was 27%, 30%, and 46% in these groups, respectively (p <0.001). After adjustment for age, gender, and co-morbidities, the odd ratio for flail mitral leaflet with severe MAC versus no MAC was 1.76 (95% confidence interval 1.10 to 2.83, p = 0.019). In conclusion, this study demonstrates that degenerative mitral valve disease with severe MAC is significantly associated with flail mitral leaflet.