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Jang HY, Han SB, Jeong JH, Kwon HM, Kim KS, Kim JH, Kim SH, Jun IG, Song JG, Hwang GS. Prognostic Value of Mitral Annular Calcification in Liver Transplant Patients: Implication in Posttransplant Outcomes. Transplantation 2024; 108:1954-1961. [PMID: 38499508 DOI: 10.1097/tp.0000000000004981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
BACKGROUND With the rise of metabolic diseases and aging in liver transplant (LT) candidates, mitral annular calcification (MAC) is more recognizable. Despite cardiovascular risk becoming a leading cause of mortality in LT recipients, the influence of MAC remains unexamined. This study investigates the prevalence, related factors, and impact of MAC on LT outcomes. METHODS We explored 4148 consecutive LT patients who underwent routine pretransplant echocardiography from 2008 to 2019. Multivariate logistic analysis and the tree-based Shapley additive explanation scores in machine learning were used to evaluate the significant and important related factors. The primary outcome was 30-d major adverse cardiac events (MACE), and the secondary outcome was a median of 5-y cumulative all-cause mortality. RESULTS MAC was found in 123 (3.0%) patients. Significant and important related factors included age, alcoholic liver disease, chronic kidney disease, hyperuricemia, hypertension, and coronary artery disease. The MACE rate was higher in patients with MAC compared with those without MAC at 30 d ( P < 0.001, adjusted hazard ratio 1.67; 95% confidence interval, 1.08-2.57). Patients with MAC had poorer cumulative overall survival probability compared with those without MAC ( P = 0.0016; adjusted hazard ratio 1.47; 95% confidence interval, 1.01-2.15). Specifically, women with MAC had a poorer survival probability compared with men without MAC (65.0% versus 80.7%, P < 0.001) >10 y post-LT. CONCLUSIONS The presence of MAC before LT was linked to increased 30-d MACE and lower long-term survival rates, especially in women. Identification and management of MAC and potential risk factors are crucial for improving post-LT survival.
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Affiliation(s)
- Hwa-Young Jang
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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2
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Ntaios G, Baumgartner H, Doehner W, Donal E, Edvardsen T, Healey JS, Iung B, Kamel H, Kasner SE, Korompoki E, Navi BB, Pristipino C, Saba L, Schnabel RB, Svennberg E, Lip GYH. Embolic strokes of undetermined source: a clinical consensus statement of the ESC Council on Stroke, the European Association of Cardiovascular Imaging and the European Heart Rhythm Association of the ESC. Eur Heart J 2024; 45:1701-1715. [PMID: 38685132 PMCID: PMC11107123 DOI: 10.1093/eurheartj/ehae150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Abstract
One in six ischaemic stroke patients has an embolic stroke of undetermined source (ESUS), defined as a stroke with unclear aetiology despite recommended diagnostic evaluation. The overall cardiovascular risk of ESUS is high and it is important to optimize strategies to prevent recurrent stroke and other cardiovascular events. The aim of clinicians when confronted with a patient not only with ESUS but also with any other medical condition of unclear aetiology is to identify the actual cause amongst a list of potential differential diagnoses, in order to optimize secondary prevention. However, specifically in ESUS, this may be challenging as multiple potential thromboembolic sources frequently coexist. Also, it can be delusively reassuring because despite the implementation of specific treatments for the individual pathology presumed to be the actual thromboembolic source, patients can still be vulnerable to stroke and other cardiovascular events caused by other pathologies already identified during the index diagnostic evaluation but whose thromboembolic potential was underestimated. Therefore, rather than trying to presume which particular mechanism is the actual embolic source in an ESUS patient, it is important to assess the overall thromboembolic risk of the patient through synthesis of the individual risks linked to all pathologies present, regardless if presumed causally associated or not. In this paper, a multi-disciplinary panel of clinicians/researchers from various backgrounds of expertise and specialties (cardiology, internal medicine, neurology, radiology and vascular surgery) proposes a comprehensive multi-dimensional assessment of the overall thromboembolic risk in ESUS patients through the composition of individual risks associated with all prevalent pathologies.
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Affiliation(s)
- George Ntaios
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Larissa 41132, Greece
| | - Helmut Baumgartner
- Department of Cardiology III: Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Muenster, Germany
| | - Wolfram Doehner
- Department of Cardiology (Campus Virchow), Center of Stroke Research Berlin, German Centre for Cardiovascular Research (DZHK) partner site Berlin, Berlin Institute of Health-Center for Regenerative Therapies, Deutsches Herzzentrum der Charité, Charité, Berlin, Germany
| | - Erwan Donal
- Service de Cardiologie et CIC-IT 1414, CHU Rennes, Rennes, France
| | - Thor Edvardsen
- Department of Cardiology, Faculty of Medicine, Oslo University Hospital, Rikshospitalet, University of Oslo, Oslo, Norway
| | - Jeff S Healey
- Cardiology Division, McMaster University, Hamilton, Canada
| | - Bernard Iung
- Bichat Hospital, APHP and Université Paris-Cité, INSERM LVTS U1148, Paris, France
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Scott E Kasner
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Eleni Korompoki
- Department of Clinical Therapeutics, Alexandra Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, NY, USA
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Christian Pristipino
- Interventional and Intensive Cardiology Unit, San Filippo Neri Hospital, ASL Roma 1, Rome, Italy
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari—Polo di Monserrato, Cagliari, Italy
| | - Renate B Schnabel
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany
| | - Emma Svennberg
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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3
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Museedi AS, Le Jemtel TH. Mitral Annular Calcification-Related Valvular Disease: A Challenging Entity. J Clin Med 2024; 13:896. [PMID: 38337590 PMCID: PMC10856114 DOI: 10.3390/jcm13030896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 02/12/2024] Open
Abstract
Mitral valve annular calcification-related valvular disease is increasingly common due to the rising prevalence of age-related mitral annular calcifications. Mitral annular calcification alters the structure and function of the mitral valve annulus, which in turn causes mitral valve regurgitation, stenosis, or both. As it frequently coexists with comorbid conditions and overlapping symptoms, mitral annular calcification-related valvular disease poses significant diagnostic and therapeutic challenges. For instance, left ventricular diastolic dysfunction hinders the assessment of mitral valvular disease. Detection of mitral annular calcifications and assessment of related mitral valve disease hinge on two-dimensional echocardiography. Comprehensive assessment of mitral annular calcifications and related mitral valve disease may require multidetector computed tomography and three-dimensional echocardiography. Invasive hemodynamic testing with exercise helps identify the cause of symptoms in patients with comorbid conditions, and transcatheter interventions have emerged as a viable therapeutic option for older patients. After an outline of the normal mitral annulus, we examine how mitral annular calcifications lead to mitral valve disease and how to accurately assess mitral regurgitation and stenosis. Lastly, we review surgical and transcatheter approaches to the management of mitral annular calcification-related mitral valve regurgitation, stenosis, or both.
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Affiliation(s)
| | - Thierry H. Le Jemtel
- Section of Cardiology, John W. Deming Department of Medicine, Tulane University School of Medicine, Tulane University Heart and Vascular Institute, New Orleans, LA 70112, USA;
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4
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Demal TJ, Conradi L. Management of valve dysfunction in patients with mitral annular calcification. Heart 2023; 109:1639-1646. [PMID: 37137678 DOI: 10.1136/heartjnl-2022-321572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2023] Open
Affiliation(s)
- Till Joscha Demal
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lenard Conradi
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Boyraz B, Peker T. The Role of Advanced Glycation End-Product Levels Measured by Skin Autofluorescence in the Development of Mitral Annular Calcification. J Cardiovasc Dev Dis 2023; 10:406. [PMID: 37754835 PMCID: PMC10531500 DOI: 10.3390/jcdd10090406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 09/06/2023] [Accepted: 09/18/2023] [Indexed: 09/28/2023] Open
Abstract
As a person ages, mitral annular calcification develops in the mitral annulus with increasing frequency. Lipid deposition, inflammation, and aging-related degeneration have been cited as potential causes of this pathophysiology, though there is currently no conclusive evidence to support this. AGEs accumulate in tissues due to the glycation of proteins and lipids, increasing the release of proinflammatory cytokines secondary to oxidative stress through the AGE receptor. The AGE levels increase in diabetic microvascular complications and degenerative aortic valve disease. Our study was planned prospectively as a case-control study involving 94 MAC-positive patients and 94 MAC-negative patients. The demographics, echocardiographic data and AGE levels of the patients were measured and recorded using the skin autofluorescence method. AGE levels were significantly higher in the MAC-positive patient group (3.2 vs. 2.7; p < 0.001). The AGE levels were observed as an independent predictor of MAC development in a regression analysis (OR: 8.05, 95% CI: 3.74-17.33, p < 0.001). In a ROC-curve analysis, the AUC was 0.79 (95% CI: 0.72-0.85). At a cut-off value of 2.7, 79.7% sensitivity and 69.1% specificity were observed. AGE levels can be used to cheaply, easily and non-invasively identify patients at risk of developing MAC.
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Affiliation(s)
- Bedrettin Boyraz
- Cardiology Department, Medicalpark Hospital, Health Science Faculty, Mudanya University, Bursa 16950, Turkey;
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Lee HJ, Seo J, Gwak S, Kim K, Cho I, Hong G, Ha J, Shim CY. Risk Factors and Outcomes With Progressive Mitral Annular Calcification. J Am Heart Assoc 2023; 12:e030620. [PMID: 37702056 PMCID: PMC10547289 DOI: 10.1161/jaha.123.030620] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 08/11/2023] [Indexed: 09/14/2023]
Abstract
Background Mitral annular calcification (MAC) is a chronic degenerative process that may progress. This study aimed to investigate associating factors and clinical implications of MAC progression. Methods and Results Among 560 patients with MAC identified by transthoracic echocardiography between January 2012 and June 2016, 138 patients (mean±SD age 72.7±10.2 years, 73 women) with mild or moderate MAC who received follow-up examination within 18 to 36 months were retrospectively analyzed. Progressive MAC was defined as hemodynamic or structural profiles that had worsened by more than 1 grade. Hemodynamic features were assessed by the transmitral mean diastolic pressure gradient (MDPG), and structural features were assessed by the MAC angle in the parasternal short-axis view. The clinical outcome was defined as a composite of all-cause mortality, hospitalization for heart failure, and occurrence of ischemic stroke. Forty-three patients (31.2%) showed progressive MAC. Patients with progressive MAC had higher systolic blood pressure, pulse pressure, MAC angle, and MDPG than those with stable MAC. Patients with progressive MAC had smaller left ventricular (LV) end-systolic dimensions and higher LV ejection fractions compared with those with stable MAC. In multivariate analysis, pulse pressure, LV ejection fraction, MAC angle, and MDPG at baseline were significantly associated with MAC progression. During a median of 39.2 months' follow-up, patients with progressive MAC showed poorer clinical outcomes than those with stable MAC (log-rank P=0.015). Conclusions MAC progression is not rare and is associated with structural substrate and hemodynamic loads that result in mechanical stress. Patients with progressive MAC have poor outcomes.
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Affiliation(s)
- Hee Jeong Lee
- Division of Cardiology, Department of Internal Medicine, Keimyung University Dongsan HospitalKeimyung University School of MedicineDaeguSouth Korea
| | - Jiwon Seo
- Division of Cardiology, Department of Internal Medicine, Gangnam Severance HospitalYonsei University College of MedicineSeoulSouth Korea
| | - Seo‐Yeon Gwak
- Division of Cardiology, Severance Cardiovascular HospitalYonsei University College of MedicineSeoulSouth Korea
| | - Kyu Kim
- Division of Cardiology, Severance Cardiovascular HospitalYonsei University College of MedicineSeoulSouth Korea
| | - Iksung Cho
- Division of Cardiology, Severance Cardiovascular HospitalYonsei University College of MedicineSeoulSouth Korea
| | - Geu‐Ru Hong
- Division of Cardiology, Severance Cardiovascular HospitalYonsei University College of MedicineSeoulSouth Korea
| | - Jong‐Won Ha
- Division of Cardiology, Severance Cardiovascular HospitalYonsei University College of MedicineSeoulSouth Korea
| | - Chi Young Shim
- Division of Cardiology, Severance Cardiovascular HospitalYonsei University College of MedicineSeoulSouth Korea
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Yao Y, Zhang Z, Xue J, Chen Z, Zhou Y, Luo W, Ye F, Wang J, Long D. Echocardiographic Mitral Annular Calcification is Associated With Atrial Fibrillation Recurrence After Catheter Ablation. Am J Cardiol 2023; 193:55-60. [PMID: 36871530 DOI: 10.1016/j.amjcard.2023.01.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 01/24/2023] [Accepted: 01/27/2023] [Indexed: 03/06/2023]
Abstract
There is a significant relation between mitral annular calcification (MAC) and the development of atrial fibrillation (AF) and major adverse cardiovascular events. However, the influence of MAC on the outcome of AF ablation remains unknown. The study cohort included 785 consecutive patients who underwent successful ablation. AF recurrence was monitored 3 months after ablation. Cox proportional hazards models were used to assess the association between MAC and AF recurrence. Kaplan-Meier analysis was performed to calculate the incidence of AF recurrence. Over a follow-up period of 16 ± 10 months, 190 patients (24.2%) experienced AF recurrence after ablation. MAC by echocardiography was identified in 42 patients (22%) with AF recurrence but only 60 without (10%, p <0.001). Patients with MAC were older (p <0.001), more often women (p <0.001), with a higher prevalence of hypertension (p <0.001) and diabetes mellitus (p<0.001), moderate/severe mitral regurgitation (p <0.001), larger left atrial dimension (p <0.001), and higher CHA2DS2-VASc score (p <0.001). Patients with MAC were more likely to develop AF recurrence than those without (36% vs 22%, respectively, p = 0.002). MAC was significantly associated with AF recurrence in the unadjusted analysis (hazard ratio 1.77, 95% confidence interval 1.26 to 2.58, p <0.001) and remained statistically significant after the multivariate adjustment (hazard ratio 1.48, 95% confidence interval 1.13 to 1.95, p = 0.001). In conclusion, echocardiographic MAC is significantly associated with an increased risk of AF recurrence after successful ablation, demonstrating an independent predictive value other than the established risk factors.
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Affiliation(s)
- Yan Yao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
| | - Zhihui Zhang
- Department of Cardiology, the Third Xiangya Hospital, Central South University, Changsha, China
| | - Jia Xue
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhuo Chen
- Echocardiography Medical Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yuan Zhou
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Wenzhi Luo
- Department of Cardiology, the Third Xiangya Hospital, Central South University, Changsha, China
| | - Fei Ye
- Department of Cardiology, the Third Xiangya Hospital, Central South University, Changsha, China
| | - Jiangang Wang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Deyong Long
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Welker CC, Huang J, Khromava M, Boswell MR, Gil IJN, Ramakrishna H. Analysis of the 2021 European Society of Cardiology/European Association for Cardio-Thoracic Surgery Guidelines for the Management of Valvular Heart Disease. J Cardiothorac Vasc Anesth 2023; 37:803-811. [PMID: 36775745 DOI: 10.1053/j.jvca.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 01/05/2023] [Indexed: 01/11/2023]
Affiliation(s)
- Carson C Welker
- Division of Anesthesia and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Jeffrey Huang
- Division of Critical Care Medicine, Mayo Clinic, Rochester, MN
| | | | | | - Iván J Núñez Gil
- Interventional Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain; Biomedical Science Faculty, Universidad Europea de Madrid, Madrid, Spain
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic, Rochester, MN; Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Muncan B, Amabile A, Kalogeropoulos AP, Geirsson A, Krane M. Midterm outcomes of mitral valve repair versus replacement in elderly patients: A propensity score-matched analysis. J Card Surg 2022; 37:4391-4396. [PMID: 36168792 DOI: 10.1111/jocs.16972] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 09/03/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Current literature reports better short-term mortality rates in mitral valve repair over replacement in elderly patients. However, valve durability, postoperative complications, and reintervention rates in these cohorts remain understudied. As such, we aimed to investigate 5-year rates of mortality and reoperation after initial mitral repair or replacement in elderly patients. METHODS Using the TriNetX Research Network database, we identified patients aged ≥70 who underwent mitral valve repair or replacement for nonrheumatic mitral insufficiency between January 2010 and December 2020. We 1:1 propensity score-matched cohorts for 33 covariates including demographics, comorbidities, and surgical history. After matching, we compared 5-year mortality and reoperation rates between cohorts using Kaplan-Meier estimates and multivariable Cox proportional hazards models. RESULTS We compared 823 mitral valve repair patients to a propensity score-matched cohort of 823 mitral valve replacement patients over a 5-year follow-up period. All variables of interest were adequately matched. Cumulative 5-year mortality rate was significantly lower among mitral valve repair patients (17.0% vs. 24.9%; hazard ratio [HR]: 0.66, 95% confidence interval [95% CI]: 0.51-0.87, p < 0.0025). Reoperation rates at 5-year did not differ (2.6% vs. 2,1%; HR: 1.34, 95% CI: 0.67-2.68, p = 0.401). CONCLUSIONS We observed lower 5-year mortality rates and nonsignificantly different reoperation rates among elderly patients with mitral regurgitation undergoing mitral valve repair compared to replacement. Our data support the current understanding that mitral valve repair should be considered as the first treatment line whenever possible, even in elderly patients.
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Affiliation(s)
- Brandon Muncan
- Division of Cardiology, Department of Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York, USA
| | - Andrea Amabile
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Andreas P Kalogeropoulos
- Division of Cardiology, Department of Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York, USA
| | - Arnar Geirsson
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Markus Krane
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
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Postalian A, Krajcer Z. Mitral annular calcification-A marker of risk, and a harbinger of technical challenges during intervention. Catheter Cardiovasc Interv 2022; 99:1817-1818. [PMID: 35568978 DOI: 10.1002/ccd.30216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 04/15/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Alexander Postalian
- Department of Cardiology, Texas Heart Institute, Houston, Texas, USA.,Division of Cardiology, Department of Internal Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Zvonimir Krajcer
- Department of Cardiology, Texas Heart Institute, Houston, Texas, USA.,Division of Cardiology, Department of Internal Medicine, Baylor College of Medicine, Houston, Texas, USA
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