Association of mitral annulus calcification, aortic valve calcification with carotid intima media thickness

The Relationship of Mitral Annular Calcification and Aortic Valve Sclerosis to Endothelial Dysfunction

BACKGROUND

Calcific aortic valve disease (CAVD) and mitral annular calcification (MAC) are associated with various cardiovascular diseases and may influence systemic vascular pathologies. However, their relationship with endothelial dysfunction and carotid intima-media thickness (CIMT) remains poorly elucidated. This research aims to explore the associations between MAC, aortic valve sclerosis (AVS), and markers of vascular dysfunction, specifically CIMT and endothelial function.

METHODS

This prospective observational study included 200 patients undergoing routine echocardiographic evaluation at the National Heart Institute between May 2022 and April 2023. Patients were stratified into four groups namely isolated MAC (38 patients), isolated AVS (72 patients), combined MAC and AVS (50 patients), and a control group without MAC or AVS (40 patients). All participants underwent comprehensive cardiovascular evaluation, including transthoracic echocardiography (TTE) and carotid duplex ultrasonography. Endothelial function was determined by measuring reactive hyperemia-induced alterations in brachial artery diameter.

RESULTS

The mean age of participants was 60.6±8.4 years, with a predominance of male subjects (64%). No significant differences were noted in baseline demographic and clinical characteristics across the groups. Patients with isolated AVS, isolated MAC, and both conditions demonstrated increased CIMT compared to controls, with significant differences noted in the combined MAC and AVS group compared to controls (p-value=0.031). Endothelial dysfunction was observed in 14.8% of the AVS group and 21.1% in the combined group, but no significant differences existed when compared to controls. The study also revealed that patients with AVS are more likely to exhibit increased CIMT (p-value=0.008).

CONCLUSIONS

Both MAC and AVS are connected to increased CIMT, suggesting a link with systemic atherosclerotic processes. Although the existence of endothelial dysfunction was not significantly higher in patients with valvular calcifications, the findings support the need for further research into the cardiovascular implications of CAVD and MAC.

Factors predicting the occurrence of aortic valve calcification in patients with coronary artery calcification in China

OBJECTIVES

In patients with coronary artery calcification (CAC), a predictor of adverse cardiovascular events, coronary computed tomography angiography (CCTA) also shows valvular calcification. In this study, we evaluated common clinical indicators in CAC patients with aortic (AoVC) and mitral valve (MVC) calcification.

METHODS

CAC and valvular calcification were quantified using the Agatston score in 636 hospitalised patients with CAC who underwent CCTA.

RESULTS

Valvular calcification was found in 30.5% of patients, with 25.2% (160 patients) showing AoVC. Age was an independent predictor of AoVC in both men (odds ratio (OR), 1.086; 95% confidence interval (CI), [1.054-1.119]; p < 0.001) and women (OR, 1.109; CI, [1.066-1.154]; p < 0.001). In men, we also found that a history of cerebral infarction was an independent predictor of AoVC (OR, 2.402; CI, [1.177-4.902]; p < 0.05). The independent predictors of AoVC in the 60- to 69-years age group were BMI (OR, 1.181; CI, [1.061-1.316]; p < 0.01) and history of cerebral infarction (OR, 3.187; CI, [1.283-7.919]; p < 0.05).

CONCLUSIONS

Age is a key independent predictor of AoVC in CAC patients. History of cerebrovascular disease was also an independent predictor of AoVC, but only in men and patients aged 60-69 years. Our results indicate that a history of cerebral infarction may be used as a risk factor when identifying AoVC in patients with CAC.

Relation between carotid intimal medial thickness and left ventricular mass and left ventricular mass indices in maintenance hemodialysis patients

Left ventricular hypertrophy (LVH) is a risk factor of cardiovascular morbidity in dialysis patients. The association between LV mass and carotid intimal medial thickness (CIMT) could be due to increased hemodynamic load in dialysis patients. The relationship between CIMT and LVM indices in hemodialysis (HD) patients was investigated. This is a cross-sectional study including 65 HD patients, divided into two groups: Group 1 with CIMT ≤ 1 mm (N = 29), Group 2 with CIMT > 1 mm (N = 36). Echocardiographic evaluation of the LVM, CIMT measurement using B-mode ultrasonography, patients' basic clinical and biochemical data were recorded. Patients with CIMT > 1 mm (Group 2) showed significantly higher LVM, LVM/BSA (body surface area), and LVM/Ht^2.7 (height). Regarding linear regression, CIMT was found to be an independent predictor for LVM, LVM/BSA, and LVM/Ht^2.7 . LVM, LVMI, and LVM/Ht^2.7 are significantly elevated in HD patients with CIMT > 1 mm group. CIMT was found to be the independent predictor for LVH in maintenance HD patients.

Association between Serum Dickkopf-1 (DKK-1) Glycoprotein and Calcific Deposits on Cardiac Valves and Carotid Intimal-Medial Thickness in Hemodialysis Patients

BACKGROUND

Cardiac valve calcification (CVC) is common in hemodialysis (HD) patients, and associated with cardiovascular and all-cause mortality. Once believed to be a passive process, it is now understood that the Wnt signaling pathway has a major role. The aim of the current study was to assess the relationship between circulating DKK-1, a negative regulator of the Wnt signaling pathway, and CVC, as well as carotid intimal-medial thickness (CIMT) in HD patients.

METHODS

We enrolled 74 consecutive adults on maintenance HD. Echocardiographic calcification of the mitral valve (MV) and aortic valve (AV) were detected according to Wilkins score (range 0-4), and the study of Tenenbaum et al. [Int J Cardiol. 2004 Mar;94(1):7-13] (range 0-4), respectively. CVC severity was calculated by a supposed score (range 0-8) that represents the sum of calcification grade of MV and AV. CVC severity was classified into absent (CVC score = 0), mild (CVC score = 1-2), moderate (CVC score = 3-4), and severe (CVC score ≥5). Demographic and biochemical data were collected in addition to serum DKK-1 levels and CIMT.

RESULTS

CVC was present in 67 patients (91.0%). There was a highly significant negative correlation between serum DKK-1 level and CVC score (r = -0.492; p ≤ 0.001), as well as CIMT (r = -0.611; p ≤ 0.001). Age and CIMT were independent determinants of CVC.

CONCLUSIONS

CVC is almost present in all HD patients. DKK-1 seems to have a direct relation with CVC and CIMT in HD patients. Age is the strongest independent determinant of CVC.

Serum fetuin-A is associated with the components of MIAC(malnutrition, inflammation, atherosclerosis, calcification) syndrome in different stages of chronic kidney disease

Background/aim

Fetuin-A, a circulating inhibitor of calcification, is a marker of inflammatory-nutritional state. We evaluated the association between serum fetuin-A levels and vascular calcification, intima-media thickness, and nutritional and inflammatory markers in different stages of chronic kidney disease (CKD).

Materials and methods

CKD patients were sampled for calcium-phosphate parameters and nutritional and inflammatory markers [highly sensitive C-reactive protein (hs-CRP)], and serum fetuin-A levels. Intima-media thicknesses of the common carotid arteries (CIMT) were measured. Peripheral artery calcification scores were obtained.

Results

A total of 238 patients were included in the study. Fetuin-A levels in patients with end-stage renal disease were significantly lower than those in patients with stage-3 and stage-4 CKD (stage-5 vs. stage-4, P < 0.001; stage-5 vs. stage-3, P < 0.001). Fetuin-A was negatively correlated with creatinine (P < 0.001), Ca × P product (P < 0.001), hs-CRP (P = 0.01), vascular calcification score (P < 0.001), and CIMT (P < 0.001), and positively correlated with BMI (P < 0.001, r = 0.30) and serum albumin (P < 0.001).

Conclusion

Lower levels of fetuin-A were associated with higher vascular calcification scores, CIMT, hs-CRP levels, and lower BMI and albumin. Fetuin-A deficiency may be a key element for MIAC syndrome.

Aortic stenosis: insights on pathogenesis and clinical implications

Aortic stenosis (AS) is a common valvular heart disease in the Western populations, with an estimated overall prevalence of 3% in adults over 75 years. To understand its patho-biological processes represents a priority. In elderly patients, AS usually involves trileaflet valves and is referred to as degenerative calcific processes. Scientific evidence suggests the involvement of an active "atherosclerosis-like" pathogenesis in the initiation phase of degenerative AS. To the contrary, the progression could be driven by different forces (such as mechanical stress, genetic factors and interaction between inflammation and calcification). The improved understanding presents potentially new therapeutic targets for preventing and inhibiting the development and progression of the disease. Furthermore, in clinical practice the management of AS patients implies the evaluation of generalized atherosclerotic manifestations (i.e., in the coronary and carotid arteries) even for prognostic reasons. In counselling elderly patients, the risk stratification should address individual frailty beyond the generic risk scores. In these regard, the co-morbidities, and in particular those linked to the global atherosclerotic burden, should be carefully investigated in order to define the risk/benefit ratio for invasive treatment strategies. We present a detailed overview of insights in pathogenesis of AS with possible practical implications.

The Forgotten Variable of Shear Stress in Mitral Annular Calcification: Whole Blood Viscosity

OBJECTIVE

The aim of this research was to assess the relationship between mitral annular calcification (MAC) and whole blood viscosity (WBV).

SUBJECTS AND METHODS

A total of 184 patients with MAC and 133 patients without MAC were enrolled in the study. The WBV was calculated with a confirmed formulation using the hematocrit and total plasma protein at a low shear rate (LSR) and high shear rate (HSR). Early diastolic mitral annular velocity (Ea) and late diastolic mitral annular velocity (Aa) were measured using pulse Doppler tissue echocardiography. Pearson's correlation analysis was performed to assess the relationship between WBV and mitral annular motion velocities. The effects of different variables on the occurrence of MAC were assessed in univariate and multivariate logistic regression analysis.

RESULTS

In patients with MAC, WBV values were significantly higher at HSR (18.04 ± 0.84 vs. 17.25 ± 0.96 208 s(-1), p < 0.001) and at LSR (78.0 ± 14.2 vs. 61.9 ± 17.1 0.5 s(-1), p < 0.001). The WBV at HSR and LSR were significantly correlated with Ea (r = -0.477, p < 0.001; r = -0.385, p < 0.001, respectively) and Aa (r = -0.544, p < 0.001; r = -0.323, p < 0.001, respectively). Multivariate analysis showed that WBV of both shear rates was an independent predictor of MAC. Using the ROC curve, a cut-off value of 70.1 for WBV at LSR had a sensitivity of 83.7% and a specificity of 73.7% (AUC 0.785, p < 0.001) and a WBV cut-off value of 17.5 at HSR had a sensitivity of 79.6% and a specificity of 71.4% (AUC 0.761, p < 0.001) for the prediction of MAC.

CONCLUSION

Patients with MAC had significantly higher WBV, which independently predicted the presence of MAC. WBV had an inverse correlation with mitral annular motion velocities, indicating that a higher WBV may lead to greater limitation in annular motion and, thus, more calcification.

Is Mitral Annular Calcification Associated With Atherosclerotic Risk Factors and Severity and Complexity of Coronary Artery Disease?

We assessed the association of mitral annular calcification (MAC) with atherosclerotic risk factors and severity and complexity of coronary artery disease (CAD). Cardiac catheterization reports and electronic medical records from 2010 to 2011 were retrospectively reviewed. A total of 481 patients were divided into 2 groups: MAC present (209) and MAC absent (272). All major cardiovascular risk factors, comorbidities, and coronary lesion characteristics were included. On linear regression analysis, age ( P = .001, β 1.12) and female gender ( P = .031, β 0.50) were the independent predictors of MAC. Mitral annular calcification was not independently associated with the presence of lesions with >70% stenosis ( P = .283), number of obstructive vessels ( P = .469), lesions with 50% to 70% stenosis ( P = .458), and Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery score ( P = .479). Mitral annular calcification is probably a benign marker of age-related degenerative changes in the heart independent of the severity and complexity of CAD.

Real-time imaging required for optimal echocardiographic assessment of aortic valve calcification

Introduction

Aortic valve calcification (AVC), even without haemodynamic significance, may be prognostically import as an expression of generalized atherosclerosis, but techniques for echocardiographic assessment are essentially unexplored.

Methods

Two-dimensional (2D) echocardiographic recordings (Philips IE33) of the aortic valve in short-axis and long-axis views were performed in 185 consecutive patients within 1 week before surgery for aortic stenosis (n = 109, AS), aortic regurgitation (n = 61, AR), their combination (n = 8) or dilation of the ascending aorta (n = 7). The grey scale mean (GSMn) of the aortic valve in an end-diastolic short-axis still frame was measured. The same frame was scored visually 1–5 as indicating that the aortic valve was normal, thick, or had mild, moderate or severe calcification. The visual echodensity of each leaflet was determined real time applying the same 5-grade scoring system for each leaflet, and the average for the whole valve was calculated. Finally, a similar calcification score for the whole valve based on inspection and palpation by the surgeon was noted.

Results

Visual assessment of real-time images using the proposed scoring system showed better correlation with the surgical evaluation of the degree of valve calcification (r = 0·83, P<0·001) compared to evaluation of stop frames by visual assessment (r = 0·66, P<0·001) or the GSMn score (r = 0·64, P<0·001). High inter- and intra-observer correlations were observed for real-time visual score (both intraclass correlation coefficient = 0·93).

Conclusion

Real-time evaluation of the level of AVC is superior to using stop frames assessed either visually or by dedicated computer grey scale measurement software.

Association between asymptomatic carotid atherosclerosis and degenerative aortic stenosis

OBJECTIVE

Degenerative aortic stenosis shows similarities with atherosclerosis. To confirm the hypothesis that aortic stenosis is an "atherosclerosis-like" disease, we investigated the association between degenerative aortic stenosis and atherosclerosis of carotid arteries.

METHODS

We studied 270 consecutive patients, 135 with degenerative aortic stenosis (trans-aortic peak velocity ≥ 2 m/sec) and other 135 subjects without aortic valve disease. All patients underwent echocardiography and ultrasound scan of the supra-aortic trunks to assess the presence of plaque and/or intima-media thickening (IMT).

RESULTS

Atherosclerosis of carotid arteries (IMT and plaque) was significantly more frequent in patients with aortic stenosis than in controls (95.5% vs. 66.6%, p < 0.0001). The same result was confirmed as concerns carotid plaques (69.6% vs. 42.2%, p < 0.0001). In addition, there was a significant association between aortic stenosis and degenerative carotid plaque (OR = 3.13; 95% C.I. = 1.90-5.17). Thus the presence of a linear correlation between the trans-aortic peak velocity of the cases and the thickness of the plaques and IMT was evaluated by calculating the coefficient of correlation (R = 0.15 for plaque and R = 0.53 for IMT).

CONCLUSIONS

The presence of carotid atherosclerosis is associated with degenerative aortic stenosis and the severity of aortic stenosis corresponds to an increase of the thickness of plaque and IMT. This relationship is quite new. Our result strengthens the pathogenetic hypothesis "atherosclerosis-like" of degenerative aortic stenosis and suggest the ultrasound scan as a non invasive method for risk stratification in patient with aortic stenosis, with therapeutic implications especially for higher risk subgroups.

Asymptomatic Carotid Artery Disease in Valvular Heart Surgery

We evaluated the prevalence of asymptomatic carotid artery disease in patients scheduled for valvular cardiac surgery. Preoperative screening of the carotid arteries was performed. Among 1012 patients scheduled for valvular cardiac surgery, 267 (26.4%) had carotid stenosis graded >50%; 37 had carotid stenosis >70% and underwent combined valvular surgery and carotid endarterectomy (CEA); and 230 (86%) had carotid stenosis >50% to ≤69% and received valvular cardiac surgery under hypothermic cardiopulmonary bypass. Operative mortality and the rate of perioperative adverse neurological events were comparable among the groups. During 6.8 years of follow-up, patients with carotid stenosis not exceeding 69% at the time of surgery had CEA more frequently ( P < .05) and stroke/transient ischemic attack ([TIA] P < .05) versus patients treated with combined surgery. The prevalence of asymptomatic carotid stenosis is not negligible in patients undergoing isolated valvular surgery. Combined valvular and carotid surgery is safe and reduces the incidence of CEA and stroke/TIA during follow-up.