Echographic-quantified severity of mitral anulus calcification: prognostic correlation to related hemodynamic, valvular, rhythm, and conduction abnormalities

Mitral Annulus Calcification and Cardiac Conduction Disturbances: a DANCAVAS Sub-study

BACKGROUND

Due to its location very close to the bundle of His, mitral annulus calcification (MAC) might be associated with the development of atrioventricular (AV) conduction disturbances. This study assessed the association between MAC and AV conduction disturbances identified by cardiac implantable electronic device (CIED) use and electrocardiographic parameters. The association between MAC and traditional cardiovascular risk factors was also assessed.

METHODS

This cross-sectional study analyzed 14,771 participants, predominantly men aged 60–75 years, from the population-based Danish Cardiovascular Screening trial. Traditional cardiovascular risk factors were obtained. Using cardiac non-contrast computed tomography imaging, MAC scores were measured using the Agatston method and divided into absent versus present and score categories. CIED implantation data were obtained from the Danish Pacemaker and Implantable Cardioverter Defibrillator Register. A 12-lead electrocardiogram was available for 2,107 participants. Associations between MAC scores and AV conduction disturbances were assessed using multivariate regression analyses.

RESULTS

MAC was present in 22.4% of the study subjects. Participants with pacemakers for an AV conduction disturbance had significantly higher MAC scores (odds ratio [OR], 1.11; 95% confidence interval [CI], 1.01–1.23) than participants without a CIED, whereas participants with a CIED for other reasons did not. Prolonged QRS-interval was significantly associated with the presence of MAC (OR, 1.45; 95% CI, 1.04–2.04), whereas prolonged PQ-interval was not. Female sex and most traditional cardiovascular risk factors were significantly associated with high MAC scores.

CONCLUSIONS

MAC was associated with AV conduction disturbances, which could improve our understanding of the development of AV conduction disturbances.

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.

Assessment of left atrial volume and mechanical functions using real-time three-dimensional echocardiography in patients with mitral annular calcification

Objective:

Mitral annular calcification (MAC) is degeneration of the fibrous annular ring of the mitral valve. Left atrial (LA) function and volume have been evaluated by many methods; however, none have used real-time three-dimensional echocardiography (RT3DE) in patients with MAC. Our study is the first to evaluate LA volume and mechanical function using RT3DE in patients with MAC.

Methods:

Our study was a prospective cross-sectional study. In total, 32 patients with echocardiographic evidence of MAC and 30 volunteers without MAC were enrolled in the study. Kolmogorov–Smirnov test, Student’s t-test, Mann-Whitney U test, chi-square test, Pearson’s correlation test, and multiple linear regression analyses were used in this study.

Results:

LA diameter was significantly higher in patients with MAC (38.5±3.8 vs. 31.1±2.9, p<0.001). Maximum LA volume (49.6±11.2 vs. 35.6±2.5, p<0.001), minimum LA volume (23.8±7.9 vs. 12.6±2.3, p<0.001), and LA volume index (LAVI) (26.9±6.1 vs. 20.5±2.4, p<0.001) were also higher in the MAC group. LAVI was correlated with age (p<0.001), blood urea nitrogen levels (p=0.089), total cholesterol levels (p=0.055), left ventricular systolic myocardial velocity (p=0.048), E/A ratio (p<0.001), and MAC (p<0.001). Multiple linear regression analyses revealed that age (β=0.390, p<0.001) and MAC (β=0.527, p<0.001) were independent predictors of LAVI.

Conclusion:

We found that LA mechanical function was impaired in patients with MAC. Furthermore, age and MAC were independent predictors of increased LAVI according to our RT3DE examination.

Mitral annular calcification and the serum osteocalcin level in patients with chronic kidney disease

OBJECTIVE

To determine the relationships between inflammatory mediators, mitral annular calcification (MAC), and osteocalcin in patients with chronic kidney disease (CKD).

MATERIALS AND METHODS

Echocardiographic data for 60 patients diagnosed as CKD were retrospectively evaluated. The patients were divided into 2 groups; patients with MAC (MAC+ group) and patients without MAC (MAC- group). The relationships between biochemical markers-including osteocalcin-and MAC were evaluated.

RESULTS

The study included 19 female and 41 male patients. In all, 29 patients were MAC+ and 31 were MAC-. High-sensitive C-reactive protein (hsCRP) and osteocalcin levels were significantly higher in the MAC+ group (p < 0.05). The eGFR was lower, serum calcitonin (we could not obtain calcitonin data for 15 patients), Ca, PO4, CaxPO4, the erythrocyte sedimentation rate, red cell distribution width, the neutrophil/Lymphocyte rate, and PTH were higher in the MAC+ group; however, the differences between the groups were not significant (p > 0.05). The mitral E/A ratio, mitral peak Ea velocity, tricuspid E/A ratio, hsCRP, and the osteocalcin level were strongly correlated with MAC. Multivariate logistic regression analysis showed that only the osteocalcin level and mitral E/A ratio were independent variables, each with an independent effect on MAC.

CONCLUSION

CKD patients in the MAC+ group had higher osteocalcin levels than those in the MAC- group, and left ventricular diastolic dysfunction was more common in the MAC+ group.

Relationship between mean platelet volume and mitral annular calcification

Mitral annular calcification (MAC) is associated with several cardiovascular disorders including coronary artery disease (CAD), atherosclerosis, heart failure, and stroke. MAC and atherosclerosis share similar clinical risk factors for cardiovascular diseases, including age, obesity, hypertension, hyperlipidemia, and diabetes mellitus. The aim of this study was to assess the mean platelet volume (MPV), an indicator of platelet activation in patients with MAC. The study group consisted of 101 patients with MAC. An age, sex, and BMI matched control group was composed of 55 patients who were admitted to the echocardiography laboratory due to suspicion of organic heart disease and eventually found to be free of MAC. We measured platelet indices values in patients and controls. MPV was significantly higher in patients with MAC than in controls (8.9 ± 0.8 versus 8.0 ± 0.9 fl, respectively; P < 0.001) and platelet distribution width (PDW) was significantly higher in patients with MAC than in controls (15.8 ± 1.3 versus 15.0 ± 1.3%, respectively; P < 0.001). MPV was positively correlated with MAC (P < 0.001, r = 0.47), atrial fibrillation (P = 0.01, r = 0.19), left atrial (P = 0.02, r = 0.83) and negatively correlated with platelet count (P = 0.01, r = -0.20). MPV [odds ratio (OR) 3.89; 95% confidence interval (CI) 1.97-7.67; P < 0.0001], and PDW (OR 2.27; 95% CI 1.45-3.55; P < 0.0001) were independently associated with the MAC. We have shown that MPV and PDW were significantly elevated in patients with MAC. MPV was correlated with MAC, atrial fibrillation and left atrial and negatively correlated with platelet count. MPV and PDW were independently associated with MAC.

The impact of mitral annular calcification on left ventricular function in nonagenarians

Background and Objectives

Mitral annular calcification (MAC) is known to be associated with degenerative processes of the cardiac fibrous skeleton and cardiovascular disease mortality. However, MAC has not been evaluated in an extreme age group (patients ≥90 years of age). In this study, the clinical significance of MAC associated with aging was examined in this age group and compared with MAC associated with aging in a younger (20 to 50 years of age) group of patients.

Subjects and Methods

We assessed echocardiographic parameters in 43 nonagenarians and 51 young patients. In the nonagenarian group, patient's age was 92±2 years and 27% were male; in the young control group, patient's age was 36±9 years and 51% were male. Comprehensive M-mode and Doppler echocardiography, including tissue Doppler imaging, were performed. The frequency and severity of MAC was assessed from the leading anterior to the trailing posterior edge at its largest width for least 3 cardiac cycles.

Results

Echocardiography showed that the left ventricular (LV) end-diastolic dimension was larger in the young controls (p=0.007); however, the ejection fraction (EF) was lower in the nonagenarian group (p=0.001). The frequency of MAC was greater in nonagenarians {42/43 (97%)} than in controls {9/51 (17%), p<0.0001}. The maximal width of MAC was larger in nonagenarians (0.52±0.17 mm and 0.05±0.13 mm, p<0.0001). MAC was correlated with LV mass index (g/m²) (r=0.280, p=0.014) and EF (%) (r=-0.340, p=0.001). More importantly, early mitral inflow velocity/early diastolic mitral annulus velocity (E/E') was strongly correlated with MAC in non-agenarians (r= 0.683, p<0.0001).

Conclusion

MAC may be associated with extreme age and increased LV filling pressure in nonagenarians. Further study is necessary to assess the cardiovascular mortality and structural changes related to mitral annulus calcification associated with aging.

High occurrence of mitral valve prolapse in cardiac catheterization patients with pure isolated mitral regurgitation

The aetiological spectrum of angiographically verified pure isolated mitral regurgitation (MR) was studied in 48 consecutive adult patients (35 males). Severe MR was found in 35 patients (73%) and moderate MR in 13 patients (27%). Mitral valve prolapse (MVP) syndrome was found in 21 patients (44%). These were younger than the rest of the study population (55 +/- 13 vs. 62 +/- 6 years, p less than 0.05) and 15 (71%) of them were men. Endocarditis and chordal rupture occurred in 19% and 43% of the MVP patients. Sixteen patients (33%) had MR secondary to myocardial infarction while only three patients (6%) had MR of rheumatic aetiology. Bacterial endocarditis, hypertensive heart disease, hypertrophic obstructive cardiomyopathy and mitral annulus calcification were less frequently found. Mitral valve replacement was done in 20 (57%) of the patients with severe MR and MVP was the underlying disease in 15 (75%) of these patients. In conclusion, MVP is a frequent cause of pure isolated MR and of mitral valve replacement. In contrast to the preponderance of young females amongst MVP patients in population surveys, most of the MVP patients with MR in this study are middle-aged and elderly men.

Aortic valve sclerosis: is it a cardiovascular risk factor or a cardiac disease marker?

BACKGROUND

Aortic valve sclerosis, without stenosis, has been associated with an increased cardiovascular mortality and morbidity due to myocardial infarction. However, it is unclear whether it is a cardiovascular risk factor or a cardiac disease marker. The goal of our study is to evaluate the difference in the prevalence of cardiovascular disease and risk factors among patients with or without aortic sclerosis.

METHODS

This observational study compared a group of 142 consecutive subjects with aortic valve sclerosis, assigned as group S, with a group of 101 subjects without aortic sclerosis, assigned as group C. Patients with bicuspid aortic valves and those with antegrade Doppler velocity across aortic valve leaflets exceeding 2.0 m/sec were excluded.

RESULTS

Mean ages of groups S and C were 71 +/- 8, and 68.8 +/- 6 years, respectively (P value = not significant). The prevalence of smoking, diabetes, hypercholesterolemia, hypertension, pulse pressure, left ventricular diastolic dysfunction, atrial fibrillation, and stroke was not significantly different between the two groups. However, there was a significantly higher prevalence of left ventricular hypertrophy (P = 0.05), ventricular arrhythmias (P = 0.02), myocardial infarction (P = 0.04), and systolic heart failure (P = 0.04) in aortic sclerosis group.

CONCLUSIONS

Aortic sclerosis is associated with a higher prevalence of left ventricular hypertrophy, ventricular arrhythmias, myocardial infarction, and systolic heart failure, while the prevalence of cardiovascular risk factors is not different between aortic sclerosis patients and controls. Hence, aortic sclerosis represents a cardiac disease marker useful for early identification of high-risk patients beyond cardiovascular risk factors rate.

The relation between mitral annular calcification and mortality in patients undergoing diagnostic coronary angiography

To determine whether the observed association between mitral annular calcification (MAC) and mortality is independent of the severity of coronary artery disease (CAD), we analyzed data from 134 male veterans (age 63 +/- 10 years) followed for 5 years who had undergone diagnostic coronary angiography and transthoracic echocardiography within 6 months of each other. Echocardiograms were retrospectively reviewed for the presence of MAC. The relation of MAC to all-cause mortality was analyzed using logistic regression, and odds ratios (OR) were calculated. MAC was present in 49 (37%) subjects. Over the 5-year follow-up period, 38 (28%) patients expired. Five-year survival was 80% for subjects without MAC and 56% for subjects with MAC (P = 0.003). MAC (OR = 3.16, 95% confidence interval [CI]= 1.43-6.96, P = 0.003), ejection fraction (OR = 0.76, 95% CI = 0.59-0.97, P = 0.02), and left main CAD (OR = 2.70, 95% CI = 1.11-6.57, P = 0.02) were significantly associated with mortality in univariate analysis. After adjusting for left ventricular ejection fraction, number of obstructed coronary arteries and the presence of left main coronary artery stenosis, MAC significantly predicted death (OR = 2.48, 95% CI = 1.09-5.68, P = 0.03). Similarly, after adjusting for predictors of MAC, including ejection fraction, age, diabetes, peripheral vascular disease, and heart failure, MAC remained a significant predictor of death (OR = 2.38, 95% CI = 1.02-5.58, P = 0.04). MAC also predicted death independent of smoking status, hypertension, serum creatinine, low density lipoprotein cholesterol, high density lipoprotein cholesterol, and C-reactive protein levels (OR = 3.98, 95% CI = 1.68-9.40, P = 0.001). MAC detected by two-dimensional echocardiography independently predicts mortality and may provide an easy-to-perform and inexpensive way to improve risk stratification.

Carotid intima–media thickness, carotid distensibility and mitral, aortic valve calcification: a useful diagnostic parameter of systemic atherosclerotic disease

BACKGROUND

Mitral (MAC) and aortic (AVC) calcification are observed more frequently in the elderly and are associated with coronary artery disease, aortic atheroma and peripheral arterial atherosclerotic disease. Common carotid intima-media thickness (cIMT) and distensibility (cDIST) are also independent predictors of adverse cardiovascular outcomes. We examined the relationship between the degree of MAC-AVC and cIMT and cDIST.

METHODS AND RESULTS

One hundred and forty-three patients referred for transthoracic echocardiography and carotid artery echo-Doppler were evaluated; the variables measured were: systemic blood pressure, pulse pressure; body mass index, traditional risk factors, cIMT, cDIST (cDIST = [(csD - cdD)/PP]/csD; where csD and cdD were systolic and diastolic carotid diameters, respectively). MAC and AVC score, based on acoustic densitometry, were: 1 = absence of annular/valvular (av) sclerosis/calcification; 2 = av sclerosis; 3 = av calcification; 4 = av calcification; 5 = av calcification with no recognition of the leaflets; the resulting score was the highest for either valvular annulus. Mean cIMT increased linearly with increasing valvular calcification score (P < 0.0001) whereas cDIST decreased for scores 1 to 5 (P < 0.0001). Distribution of cIMT quartiles showed that 75% of the patients in the lowest quartile had a score of 1 and 70% of patients in the highest quartile had a score of 5; 47% of the patients in the highest quartile of cDIST had a score of 1, whereas 60% of patients in the lowest quartile of cDIST had a score of 4.

CONCLUSIONS

The MAC and AVC score identifies subgroups of patients with different cIMT and cDIST. These data may confirm MAC-AVC as a useful important diagnostic parameter of systemic atherosclerotic disease.

Association between mitral annular calcification and stroke

It remains controversial as to whether mitral annular calcification (MAC) is an independent predictor of stroke. The aim of this study was to investigate whether there is an association between the presence of MAC and stroke or whether MAC is one of the predictive factors of carotid atheroma and therefore is a secondary risk for stroke. Fifty-six patients who had MAC demonstrated by echocardiography underwent carotid artery duplex sonography and computed brain tomography with various causes were enrolled in the study. They were compared with 58 control patients without MAC. MAC was defined as a dense, localized, highly reflective area larger than 5 mm at the junction of the atrioventricular groove and posterior mitral valve leaflet. Carotid artery stenosis was defined as lumen diameter narrowing exceeding 60%. Cerebral ischemia was detected by spiral tomography and was classified as infarction and lacunae. A significant association was found between the presence of MAC and carotid atheroma (P = 0.011), MAC and hyperechogen plaque (P = 0.034), and MAC and stenosis (P = 0.008). There was an association between the presence of carotid atheroma and cerebral infarction (P = 0.007). Logistic regression analysis revealed hypertension and diabetes mellitus were independent risk factors (P = 0.030, P = 0.034, respectively) for developing carotid atheroma. MAC was an independent factor for carotid stenosis (P = 0.029). MAC may not be a significant causative factor for stroke, but may be a secondary risk factor. A significant association between the presence of MAC and carotid artery atherosclerotic disease may explain the high prevalence of stroke in patients with MAC.

Epidemiology of mitral annular calcification and its predictive value for coronary events in African Americans: the Jackson Cohort of the Atherosclerotic Risk in Communities Study

BACKGROUND

Despite the potential link between mitral annular calcification (MAC) and atherosclerosis, there is limited data regarding the prevalence of MAC in African Americans and its relationship with coronary heart disease (CHD)events in this high-risk population.

METHODS

The study population included 2409 African American participants of the Artherosclerotic Risk in Communities study (ARIC) undergoing echo examinations between 1993-1996. The primary outcome was incident CHD events [defined as fatal coronary event, hospitalized myocardial infarction or cardiac procedure]. MAC was considered a binary variable (yes/no). The Cox proportional hazard model was used for the analysis and the model was adjusted for gender, age, body mass index, hypertension, diabetes, smoking status, renal function (based on serum creatinine), high LDL and low HDL.

RESULTS

Of the 2409 in the study population, 1549 (64%) were women and the mean age was 59.2 +/- 5.8 years (range 49-75). MAC was positively associated with age and renal function. The overall prevalence of MAC was 4.6% for women and 5.6% for men. In participants aged >or= 70, the prevalence of MAC was 10% in women and 15.2% in men. During a median follow-up of 4.8 years, there were 237 total incident CHD events recorded. After adjustment, the hazard ratio for CHD events among the MAC subgroup was 2.32 (95% CI, 1.11-4.87).

CONCLUSIONS

In this relatively young population of middle-aged African Americans, the prevalence of MAC is low; however, the presence of MAC incurs a significant risk for coronary events.

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

Background

Mitral annular calcification (MAC) and aortic annular calcification (AVC) may represent a manifestation of generalized atherosclerosis in the elederly. Alterations in vascular structure, as indexed by the intima media thickness (IMT), are also recognized as independent predictors of adverse cardiovascular outcomes.

Aim

To examine the relationship between the degree of calcification at mitral and/or aortic valve annulus and large artery structure (thickness).

Methods

We evaluated 102 consecutive patients who underwent transthoracic echocardiography and carotid artery echoDoppler for various indications; variables measured were: systemic blood pressure (BP), pulse pressure (PP=SBP-DBP), body mass index (BMI), fasting glucose, total, HDL, LDL chlolesterol, triglycerides, cIMT. The patients were divided according to a grading of valvular/annular lesions independent scores based on acoustic densitometry: 1 = annular/valvular sclerosis/calcification absence; 2 = annular/valvular sclerosis; 3 = annular calcification; 4 = annular-valvular calcification; 5 = valvular calcification with no recognition of the leaflets.

Results

Patient score was the highest observed for either valvular/annulus. Mean cIMT increased linearly with increasing valvular calcification score, ranging from 3.9 ± 0.48 mm in controls to 12.9 ± 1.8 mm in those subjects scored 5 (p < 0.0001). In the first to fourth quartile of cIMT values the respective maximal percentual of score were: score 1: 76.1%, score 2: 70.1%, score 4: 54.3% and score 5: 69.5% (p > 0.0001).

Conclusion

MAC and AVC score can identify subgroups of patients with different cIMT values which indicate different incidence and prevalence of systemic artery diseases. This data may confirm MAC-AVC as a useful important diagnostic parameter of systemic atherosclerotic disease.

Specific cardiac disorders in 402 consecutive patients with ischaemic cardioembolic stroke

BACKGROUND

To determine the cardiological substrate in acute stroke patients presenting with a cardioembolic stroke subtype.

METHODS

Data of 402 consecutive patients with cardioembolic stroke (cerebral infarction, n=347; transient ischaemic attack, n=55) were collected from a prospective hospital-based stroke registry in which data on 2000 stroke patients over a 10-year period were included. In all patients, specific cardiac disorders were identified by physical examination and results of electrocardiography and transthoracic echocardiography. Holter monitoring and more sensitive techniques of cardiac imaging were used in selected cases.

RESULTS

Cardioembolic cerebral ischaemia accounted for 20% of all acute strokes (25% of ischaemic cerebrovascular events). Cardiac sources of embolism included the following: (a) structural cardiac disorders associated with arrhythmia (n=232), the most frequent being left ventricular hypertrophic hypertensive disease (n=120) and rheumatic mitral valve disease (n=49); (b) structural cardiac disease with sustained sinus rhythm (n=81), the most frequent being systolic left ventricular dysfunction of both ischaemic (n=35) or non-ischaemic (n=24) aetiology; and (c) isolated atrial dysrhythmia (atrial fibrillation, n=88 and atrial flutter, n=1).

CONCLUSIONS

Hypertrophic hypertensive cardiac disease complicated with atrial fibrillation was the most frequent cardiac source of emboli in cardioembolic stroke. Other important cardiac sources were isolated atrial fibrillation, rheumatic mitral valve disease, and systolic left ventricular dysfunction of ischaemic and non-ischaemic cause. The incidence of traditional emboligenous-prone cardiac disorders, such as mitral valve prolapse and mitral annular calcification was low.

Mitral annular calcification is a predictor for incident atrial fibrillation

BACKGROUND

Mitral annular calcification (MAC) has been associated with adverse cardiovascular disease outcomes and stroke in longitudinal and community-based cohorts. Prospective data are limited on its association with atrial fibrillation (AF).

METHODS

We examined the association between MAC and the long-term risk of AF over 16 years of follow-up in participants in the original cohort of the Framingham Heart Study who attended a routine examination between 1979 and 1981. MAC was assessed by M-mode echocardiography. cox proportional-hazards models were used to estimate hazard ratios (hr) for incident af.

RESULTS

Of 1126 subjects who had adequate echocardiographic assessment and were AF-free at baseline, 149 (13%) had MAC. There were 217 cases of incident AF (42 in subjects with MAC). The age- and sex-adjusted incidence rate was 362 per 10,000 person-years in subjects with MAC compared with 185 per 10,000 person-years in those without MAC. In multivariable-adjusted analyses, MAC was associated with an increased risk of AF (HR 1.6, 95% CI 1.1-2.2). This association was attenuated upon further adjustment for left atrial size (HR 1.4, 95% CI 0.9-2.0).

CONCLUSIONS

The association between MAC and incident AF may be mediated partially through left atrial enlargement. These data suggest the importance of better understanding the mechanisms involved in cardiac valvular calcification.

[Echocardiography in elderly patients]

IN THE CONTEXT OF AGEING: The Doppler echocardiography is a non-invasive technique that permits assessment of the "physiological" ageing of the cardiac and vascular structures, notably including a concentric remodelling of the left ventricle associated with relaxation abnormalities, dilatation of the left atrium, valvular reorganisation and a modification in the large vessels. IN A PATHOLOGICAL CONTEXT: The Doppler echocardiography also detects the various cardiovascular affections related to ageing: valvulopathies, notably calcified aortic stenosis and mitral failure due to mitral anulus calcification or prolapsus of the valve; primary hypertrophic cardiomyopathy or secondary to arterial hypertension or an amyloidosis, and possibly leading to heart failure with spared systolic function, frequent in elderly patients; ischemic cardiopathies that have benefited, as in younger patient, from new echographical stress testing techniques, which safely study the variability in myocardial ischemia. Transoesophageal echography can also be performed in elderly patients, but the indications of this more invasive and less well-tolerated examination must be assessed case by case. It is very useful when an intra-parietal aortic hematoma is suspected or during aortic dissection or infectious endocarditis.

Mitral annular calcification predicts cardiovascular morbidity and mortality: the Framingham Heart Study

BACKGROUND

Mitral annular calcification (MAC) has been associated with stroke in longitudinal, community-based cohorts and cardiovascular disease (CVD) outcomes in many small retrospective studies. Prospective data are limited on the relation of MAC with CVD morbidity and mortality.

METHODS AND RESULTS

We examined the association between MAC assessed by M-mode echocardiography and the incidence of CVD, CVD death, and all-cause death over 16 years of follow-up in the Framingham Heart Study subjects who attended a routine examination between 1979 and 1981. Cox proportional hazards models were used to estimate hazard ratios (HRs) associated with the presence of MAC for each outcome. Of 1197(445 male, 752 female) subjects who had adequate echocardiographic assessment, 14% had MAC. There were 307 incident CVD events and 621 deaths. In multivariable adjusted analyses, MAC was associated with an increased risk of incident CVD (HR, 1.5; 95% CI, 1.1, 2.0), CVD death (HR, 1.6; 95% CI, 1.1, 2.3), and all-cause death (HR, 1.3; 95% CI, 1.04, 1.6). For each 1-mm increase in MAC, the risk of incident CVD, CVD death, and all-cause death increased by approximately 10%.

CONCLUSIONS

The independent association of MAC with incident CVD and CVD death underscores that cardiac calcification is a marker of increased CVD risk.

Echocardiographic evaluation in patients with autosomal dominant polycystic kidney disease and end-stage renal disease

Cardiovascular abnormalities have been considered important extrarenal manifestations of autosomal dominant polycystic kidney disease (ADPKD). However, little is known about their prevalence in patients with ADPKD undergoing hemodialysis (HD). To investigate whether cardiac abnormalities are more prevalent in these patients, clinical and echocardiographic manifestations of cardiovascular disease were evaluated in a group of 32 patients with ADPKD and a matched control group of 32 patients without diabetes treated by chronic HD for more than 6 months. Predialysis systolic and diastolic blood pressure (BP), prevalence of hypertension, and number of patients requiring antihypertensive medications were lower in the ADPKD group than controls. There was no difference in the prevalence of cardiac events, including cardiac failure, ischemic heart disease, and arrhythmia. Systolic dysfunction, diastolic patterns, and left ventricular hypertrophy were similar in the two groups. In patients with ADPKD, simple regression analysis showed left ventricular mass (LVM) index was correlated with hemoglobin level and predialytic systolic and diastolic BPs. In multiple regression analysis, predialysis systolic BP was the only independent variable linked to LVM index. The prevalence of aortic, mitral, and tricuspid valve disease did not differ between groups. In conclusion, the occurrence of cardiovascular complications in patients with ADPKD is similar to that of HD patients with other primary renal diseases, although hypertension is less prevalent.

Slowing of mitral valve annular calcium in systemic hypertension by nifedipine and comparisons with enalapril and atenolol

Mitral annular calcium (MAC) is a condition that often occurs in patients with systemic hypertension. To evaluate the effectiveness of nifedipine in preventing MAC, 223 patients with systemic hypertension of recent onset and without MAC were selected and randomly enrolled in 3 groups: group 1 (76 patients) received nifedipine; group 2 (72 patients) received enalapril; and group 3 (75 patients) received atenolol. After 5 years, these treatments significantly reduced systolic (p < 0.001) and diastolic (p < 0.05) blood pressure (BP) in 3 treated groups. M-mode echocardiography revealed MAC only in 2 patients in the nifedipine group (2.6%), in 13 in the enalapril group (18%) and in 15 in the atenolol group (20%). The degree of MAC was mild (< 5 mm) in the 2 patients in group 1, in 5 of the 13 in group 2, and in 6 of the 15 in the group 3, whereas it was severe (> 5 mm) in the remaining 8 in the enalapril group and in the other 9 in the atenolol group. There was also a significant correlation in the degree of MAC, left atrial enlargement and mitral regurgitation. In addition, atrial fibrillation and atrioventricular conduction defects were associated with severe MAC. These results indicate that nifedipine is an effective drug both in the long-term management of systemic hypertension and in preventing or delaying MAC.

Mitral annular calcification and the risk of stroke in an elderly cohort

BACKGROUND

Previous clinical studies have suggested that there is an association between mitral annular calcification and the risk of stroke, but it is unclear whether this association is independent of the traditional risk factors for stroke. We examined the relation between mitral annular calcification and the incidence of stroke in a population-based study.

METHODS

Subjects in the Framingham Study receiving a routine examination underwent M-mode echocardiography to determine the presence and severity (thickness in millimeters) of mitral annular calcification. The incidence of stroke during eight years of follow-up was analyzed with a proportional-hazards model adjusting for the calcification, age, sex, systolic blood pressure, diabetes mellitus, cigarette smoking, atrial fibrillation, and coronary heart disease or congestive heart failure.

RESULTS

Among 1159 subjects whose echocardiograms could be assessed for mitral annular calcification and who had no history or current evidence of stroke at the index examination (51 percent of all subjects), the prevalence of mitral annular calcification was 10.3 percent in the men and 15.8 percent in the women. Multivariate analysis demonstrated that the presence of mitral annular calcification was associated with a relative risk of stroke of 2.10 (95 percent confidence interval, 1.24 to 3.57; P = 0.006). There was a continuous relation between the incidence of stroke and the severity of mitral annular calcification; each millimeter of thickening as shown on the echocardiogram represented a relative risk of stroke of 1.24 (95 percent confidence interval, 1.12 to 1.37; P less than 0.001). Furthermore, even when subjects with coronary heart disease or congestive heart failure were excluded from the analysis, subjects with mitral annular calcification still had twice the risk of stroke.

CONCLUSIONS

In an elderly, longitudinally followed population-based cohort, mitral annular calcification was associated with a doubled risk of stroke, independently of traditional risk factors for stroke. Whether such calcification contributes causally to the risk of stroke or is merely a marker of increased risk because of its association with other precursors of stroke remains unknown.

Cardiac conduction defects associated with aortic and mitral valve calcification in dialysis patients

The prevalence of aortic valve and mitral valve or mitral annular calcification by echocardiography was studied in 66 dialysis patients and correlated with results of 24-h ambulatory and resting ECG data and 12-month survival. The well-known association of mitral valve or mitral annular calcification with cardiac conduction defects was confirmed. Those patients with mitral valve or mitral annular calcification demonstrated a higher prevalence of first-degree atrioventricular block and bundle branch block. Despite advanced age and these conduction defects, those patients with mitral valvular calcification did not show decreased survival at 12 months.

Cardiac conduction abnormalities during percutaneous balloon mitral or aortic valvotomy

To evaluate the electrophysiologic changes in the cardiac conduction system that occur during percutaneous mitral or aortic balloon valvotomy, we prospectively studied the conduction system in 19 patients (10 mitral, 8 aortic, and 1 both) undergoing this procedure. A His bundle electrogram was recorded in all patients, and when sinus rhythm was present, the atrioventricular (AV) node effective refractory period was measured. Holter monitoring was performed during and for 24 hours after the procedure. Follow-up electrocardiograms (ECG) were available in 11 patients 2.3 +/- 1.5 months after the procedure. The AV node effective refractory period before (276 +/- 86 msec) and after valvotomy (298 +/- 85 msec) were not significantly different. The maximum His-Purkinje conduction time (HV interval) observed during valvotomy (66 +/- 20 msec) was significantly longer (p less than 0.01) than that measured before (57 +/- 10 msec) or after (60 +/- 18 msec) valvotomy. The mean HV intervals before and after valvotomy were not significantly different. The mean QRS complex duration increased from 95 +/- 28 to 112 +/- 28 msec during valvotomy and remained significantly prolonged (109 +/- 26 msec) 24 hours after the procedure (p less than 0.01). A new intraventricular conduction defect (QRS complex duration greater than 100 msec) or bundle branch block occurred in five of 13 patients who had normal QRS duration before the procedure. The change in HV interval did not correlate with the change in QRS complex duration. In four patients, the newly acquired intraventricular conduction defect was still present on follow-up ECG tracing. Complete heart block was not observed in any patient.(ABSTRACT TRUNCATED AT 250 WORDS)

Intracardiac calcification in patients under chronic haemodialysis

Echocardiographic examination revealed intracardiac calcification in 20 out of 70 chronically dialysed patients. The process appeared more frequently in those suffering from severe renal osteodystrophy. It was often associated with rhythm disorder. Parathyroid hyperfunction is rated as one cause of intracardiac calcification.

Frequency of mitral valve dysfunction from mitral anular calcium as detected by Doppler echocardiography

Doppler echocardiography is useful for detecting and quantifying mitral regurgitation (MR) and mitral stenosis (MS). To determine the prevalence of these abnormalities in patients with mitral anular calcium (MAC), 51 consecutive patients who had an echocardiographic diagnosis of MAC were examined by Doppler ultrasound. Transmitral flow was evaluated to determine the presence of MR or left ventricular inflow obstruction (MS) by continuous and pulsed-wave Doppler echocardiography. The severity of these hemodynamic abnormalities was quantitated by previously described techniques. Eleven patients (22%) had mild MR, 17 (33%) had moderate to severe MR and 4 (8%) had significant MS. Clinical findings such as a systolic murmur, evidence of congestive heart failure, and dyspnea on exertion were not helpful in distinguishing patients with no or mild MR from those who had moderate to severe MR. M-mode measured left atrial size was significantly larger (p less than 0.05) in patients with moderate to severe MR. This study suggests that MR is often associated with MAC, that MS is not a rare finding with MAC, and that Doppler echocardiography can quantitate these lesions in the elderly when symptoms are not specific and physical findings are inconclusive or absent.

Risk of stroke in patients with mitral annulus calcification

63 patients with mitral annulus calcification (MAC) were followed for an average of 3.4 years. Two patients experienced TIA, both ipsilateral to a previous endarterectomy site, and IV-DSA demonstrated normal extracranial vessels. There were 3 strokes (5%), all fatal, but none could be attributed to embolism. Embolic stroke due to MAC is rare and difficult to prove due to coexistent atherosclerosis. Associated cardiac conditions such as atrial fibrillation, which might increase the risk of embolism, usually occur with MAC greater than or equal to 5 mm. In many patients, MAC may be better viewed as a marker of generalized calcific atherosclerosis rather than as an immediate embolic source.

Calcification of the tricuspid anulus diagnosed by two-dimensional echocardiography

An 84-year-old female who previously underwent repair of an atrial septal defect had evidence of increased reflectiveness of the posterior tricuspid anulus in the apical four-chamber view and the right ventricular two-chamber view. In addition, the inferior vena cava was dilated and during contrast echocardiography, contrast echoes appeared during systole suggesting tricuspid regurgitation. Tricuspid annular calcification was confirmed by fluoroscopic examination. Tricuspid annular calcification is extremely rare and in the present series occurred in 1 of 80 patients with mitral annular calcification. Lateral resolution echoes from a calcified aortic valve and echoes originating from a calcified right coronary artery have to be distinguished from tricuspid annular calcification.

Conduction disturbances related to the site and severity of mitral anular calcification: a 2-dimensional echocardiographic and electrocardiographic correlative study

To investigate an apparent association of mitral anular calcium (MAC) and electrocardiographic abnormalities, the relation between location of 2-dimensional (2-D) echo-quantified MAC and conduction disturbances was studied in 140 patients with MAC (MAC group) and in 135 age- and sex-matched patients without MAC (control group). The MAC group was subclassified regarding site and severity of calcium in the mitral anulus. The site of MAC was defined as Type I, near the primary conduction system--MAC located in the medial segment and/or extending to the anterior mitral leaflet; and Type II--MAC located at the central and/or lateral segments away from the primary conduction system. The severity of MAC was graded on 2-D echocardiography as mild (localized within 1 segment) and moderate to severe (greater than 1 segment). Seven patients with MAC, and only 1 control subject, had pacemakers in place. Conduction disturbances were present in 44 (31%) of 140 patients with MAC, and in 37 (27%) of 135 control patients (difference not significant). But there were more conduction disturbances in patients with Type I MAC (53%) than in those with Type II MAC (26%) (p less than 0.01). Specifically, complete left bundle branch block and intraventricular conduction delay were more prevalent when MAC was near the conduction system. Conduction disturbances also were more prevalent in patients with Type I MAC than in the control group: intraventricular conduction delay (Type I, 12% versus control, 4%; p less than 0.05) and total conduction disturbances (53 versus 28%; p less than 0.01). These data suggest that moderate to severe degrees of MAC located near the conduction system are associated with conduction disturbances, especially intraventricular conduction delay.

Aortic stenosis and rupture of mitral chordae tendineae

Ten patients with aortic stenosis and ruptured mitral chordae tendineae constituted 8% of 125 consecutive surgical cases of chordal rupture. Their ages ranged from 54 to 87 years (mean 68). Six patients presented with acute onset of congestive heart failure, and eight were in New York Heart Association functional class III or IV at the time of cardiac catheterization. Extensive mitral anulus calcification was observed by fluoroscopy in seven patients. The mean aortic valve area index was 0.4 cm2/m2 and nine patients had moderate to severe mitral regurgitation by angiography. Calcific aortic stenosis affected a tricuspid valve in nine cases and a bicuspid valve in one case. One patient had a rheumatic mitral valve and one a redundant myxomatous mitral valve; the remaining eight had no abnormality of the mitral apparatus commonly regarded as predisposing to chordal rupture. Mitral anulus calcification and ventricular anatomic and hemodynamic alterations in aortic stenosis may contribute to rupture of the mitral chordae tendineae.