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Wiens EJ, Kawa K, Kass M, Shah AH. Impact of biological sex on valvular heart disease, interventions, and outcomes. Can J Physiol Pharmacol 2024. [PMID: 38427984 DOI: 10.1139/cjpp-2023-0390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Abstract
Valvular heart disease (VHD) is common, affecting >14% of individuals aged >75, and is associated with morbidity, including heart failure and arrhythmia, and risk of early mortality. Increasingly, important sex differences are being found between males and females with VHD. These sex differences can involve the epidemiology, pathophysiology, presentation, diagnosis, and outcomes of the disease. Females are often disadvantaged, and female sex has been shown to be associated with delayed diagnosis and inferior outcomes in various forms of VHD. In addition, the unique pathophysiologic state of pregnancy is associated with increased risk for maternal and fetal morbidity and mortality in many forms of VHD. Therefore, understanding and recognizing these sex differences, and familiarity with the attendant risks of pregnancy and management of pregnant females with VHD, is of great importance for any primary care or cardiovascular medicine practitioner caring for the female patient. This review will outline sex differences in aortic, mitral, pulmonic, and tricuspid VHD, with particular focus on differences in pathophysiology, clinical presentation, and outcomes. In addition, the pathophysiology and management implications of pregnancy will be discussed.
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Affiliation(s)
- Evan J Wiens
- Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
| | - Kristal Kawa
- College of Nursing, University of Manitoba, Winnipeg, MB, Canada
| | - Malek Kass
- Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Section of Cardiology, Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Ashish H Shah
- Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Section of Cardiology, Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
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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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Thong EHE, Kong WKF, Poh KK, Wong R, Chai P, Sia CH. Multimodal Cardiac Imaging in the Assessment of Patients Who Have Suffered a Cardioembolic Stroke: A Review. J Cardiovasc Dev Dis 2023; 11:13. [PMID: 38248883 PMCID: PMC10816708 DOI: 10.3390/jcdd11010013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/21/2023] [Accepted: 12/27/2023] [Indexed: 01/23/2024] Open
Abstract
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.
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Affiliation(s)
| | - William K. F. Kong
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
| | - Kian-Keong Poh
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
| | - Raymond Wong
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
| | - Ping Chai
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
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Messiha H, Garster N, Lewandowski D, Pearson PJ, Mohananey D. Subvalvular Thrombosis of the Mitral Valve-A Rare Cause of Cardioembolic Stroke. CASE (PHILADELPHIA, PA.) 2023; 7:492-495. [PMID: 38197120 PMCID: PMC10772932 DOI: 10.1016/j.case.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
•MAC-associated subvalvular thrombosis is a rare cause of cardioembolic stroke. •Thorough evaluation of the MV is important when cardioembolic phenomena are suspected. •Surgical resection is an option in patients with high-risk thrombi.
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Affiliation(s)
- Heidi Messiha
- Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Noelle Garster
- Department of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David Lewandowski
- Department of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Paul J. Pearson
- Department of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Divyanshu Mohananey
- Department of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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Gaini R, Le S. Cardioembolic stroke in the setting of diffuse caseous calcification of the anterolateral papillary muscle. BMJ Case Rep 2023; 16:e254549. [PMID: 37977841 PMCID: PMC10660198 DOI: 10.1136/bcr-2022-254549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2023] [Indexed: 11/19/2023] Open
Abstract
A woman in her 70s was admitted for acute, painless vision loss in the left eye. Examination showed cherry red spot in the macula and plaque in the nasal vessels, consistent with central retinal artery occlusion. MRI orbits revealed multifocal subclinical acute infarcts in the right middle cerebral artery (MCA) territory and bilateral cerebella. Transthoracic echocardiogram showed calcification of the anterolateral papillary muscle. Further characterisation with cardiac MRI elucidated caseous 'toothpaste-like' calcification of the muscle complex. Stroke workup was otherwise unremarkable. The patient underwent hyperbaric treatment with mild improvement. Anticoagulation and surgical intervention were deferred due to known risks and unknown benefit for calcific emboli. The patient was continued on her home dual anti-platelet therapy (DAPT) and discharged with a loop monitor. Caseous calcification of the papillary muscle (CCPM) may be a risk factor for cardioembolic stroke. Further discussions on medical and surgical guidelines for CCPM would be beneficial for stroke prevention.
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Affiliation(s)
- Rahul Gaini
- Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Scott Le
- Neurology, Duke University Medical Center, Durham, North Carolina, USA
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Wu Z, Nie C, Zhu C, Meng Y, Yang Q, Lu T, Lu Z, Liu X, Wang S. Mitral annular calcification in obstructive hypertrophic cardiomyopathy: Incidence, risk factors, and prognostic value after myectomy. Int J Cardiol 2023; 391:131266. [PMID: 37574021 DOI: 10.1016/j.ijcard.2023.131266] [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] [Received: 03/10/2023] [Revised: 07/31/2023] [Accepted: 08/10/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Mitral annular calcification (MAC) is a risk factor for cardiac surgery, but there is limited study on the prognosis value and the impact for valve function of MAC based on computed tomography (CT) diagnosis after myectomy for hypertrophic obstructive cardiomyopathy (OHCM). METHODS Consecutive OHCM patients underwent septal myectomy were compared according to the existence of MAC and its severity in preoperative CT scans. The survival data were evaluated and compared by Kaplan Meier analysis and log rank test. Cox regression analysis was used to evaluate the impact of MAC on endpoint events. RESULTS From the entire cohort of 1035 patients, 10.8% had MAC. In multivariate regression, female (OR = 2.23), age (OR = 1.07), aortic annular calcification (OR = 2.52), aortic calcification (OR = 2.56), systolic anterior motion of the mitral valve (SAM) (OR = 0.42), mitral valve thickening (OR = 2.13), and tricuspid regurgitation (OR = 3.12) were independent predictors of MAC. All-cause mortality (3.57% vs. 1.08%, p = 0.031), major adverse cardiovascular and cerebrovascular events (MACCE) (23.32% vs. 13.65%, p = 0.014), recurrent MR > 2+ (8.04% vs. 2.49%, p = 0.001) and NYHA III-IV (11.61% vs. 5.53%, p = 0.012) were more frequent in OHCM patients with MAC after myectomy. MAC was discovered to be an independent predictor of postoperative recurrent MR > 2+ after other risk factors were taken into account (HR 2.47, 95% CI 1.08-5.67, p = 0.0329). Moderate-to-severe MAC was an independent risk factor (HR 2.03, 95% CI 1.09-3.75, p = 0.0244) for long-term major adverse cardiovascular and cerebrovascular events (MACCE). CONCLUSION MAC was detected in one-tenth of OHCM patients in preoperative CT scanning and is mainly associated with aging and atherosclerosis. OHCM patients with MAC had a worse prognosis and more recurrent mitral valve regurgitation than those without MAC after septal myectomy.
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Affiliation(s)
- Zining Wu
- Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Changrong Nie
- Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Changsheng Zhu
- Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yanhai Meng
- Department of Adult Intensive Care Unit, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qiulan Yang
- Department of Adult Intensive Care Unit, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tao Lu
- Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhengyang Lu
- Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaoxi Liu
- Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuiyun Wang
- Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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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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Hatab T, Bou Chaaya RG, Zaid S, Wessly P, Satish P, Villanueva V, Faza N, Little SH, Atkins MD, Reardon MJ, Kleiman NS, Zoghbi WA, Goel SS. Feasibility and Outcomes of Mitral Transcatheter Edge-To-Edge Repair in Patients With Variable Degrees of Mitral Annular Calcification. J Am Heart Assoc 2023; 12:e031118. [PMID: 37753800 PMCID: PMC10727232 DOI: 10.1161/jaha.123.031118] [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] [Received: 05/22/2023] [Accepted: 08/23/2023] [Indexed: 09/28/2023]
Abstract
Background The clinical significance of mitral annular calcification (MAC) in patients undergoing mitral transcatheter edge-to-edge repair is not well understood. There is limited evidence regarding the feasibility, durability of repair, and the prognostic value of MAC in this population. We sought to examine the prognostic value of MAC, its severity, and its impact on procedural success and durability of mitral transcatheter edge-to-edge repair. Methods and Results We reviewed the records of 280 patients with moderate-severe or severe mitral regurgitation who underwent mitral transcatheter edge-to-edge repair with MitraClip from March 2014 to March 2022. The primary end point was cumulative survival at 1 year. Independent factors associated with the primary end point were identified using multivariable Cox regression. Among 280 patients included in the final analysis, 249 had none/mild MAC, and 31 had moderate/severe MAC. Median follow-up was 23.1 months (interquartile range: 11.1-40.4). Procedural success was comparable in the MAC and non-MAC groups (92.6% versus 91.4%, P=0.79) with similar rates of residual mitral regurgitation ≤2 at 1 year (86.7% versus 93.2%, P=0.55). Moderate/severe MAC was associated with less improvement in New York Heart Association III/IV at 30 days when compared with none/mild MAC (45.8% versus 14.3%, P=0.001). The moderate/severe MAC group had lower cumulative 1-year survival (56.8% versus 80.0%, hazard ratio [HR], 1.98 [95% CI, 1.27-3.10], P=0.002). Moderate/severe MAC and Society of Thoracic Surgeons predicted risk of mortality for mitral valve repair were independently associated with the primary end point (HR, 2.20 [1.10-4.41], P=0.02; and HR, 1.014 [1.006-1.078], P=0.02, respectively). Conclusions Mitral TEER is a safe and feasible intervention in selected patients with significant MAC and associated with similar mitral regurgitation reduction at 1 year compared with patients with none/mild MAC. Patients with moderate/severe MAC had a high 1-year mortality and less improvement in their symptoms after TEER.
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Affiliation(s)
- Taha Hatab
- Houston Methodist DeBakey Heart and Vascular CenterHoustonTX
| | | | - Syed Zaid
- Houston Methodist DeBakey Heart and Vascular CenterHoustonTX
| | | | - Priyanka Satish
- Houston Methodist DeBakey Heart and Vascular CenterHoustonTX
| | | | - Nadeen Faza
- Houston Methodist DeBakey Heart and Vascular CenterHoustonTX
| | | | - Marvin D. Atkins
- Department of Cardiovascular SurgeryHouston Methodist HospitalHoustonTX
| | | | - Neal S. Kleiman
- Houston Methodist DeBakey Heart and Vascular CenterHoustonTX
| | | | - Sachin S. Goel
- Houston Methodist DeBakey Heart and Vascular CenterHoustonTX
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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: 0] [Impact Index Per Article: 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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10
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Makkar N, Yadav S. Unusual case of fixed left ventricular outflow obstruction. BMJ Case Rep 2023; 16:e256364. [PMID: 37714556 PMCID: PMC10510877 DOI: 10.1136/bcr-2023-256364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023] Open
Affiliation(s)
- Nayani Makkar
- Cardiology, All India Institute of Medical Sciences Cardio-Thoracic Sciences Centre, New Delhi, India
| | - Satyavir Yadav
- Cardiology, All India Institute of Medical Sciences Cardio-Thoracic Sciences Centre, New Delhi, India
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11
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Onuegbu A, Calicchio F, Kinninger A, Nakanishi R, Carr JJ, Nasir K, Gottesman R, Budoff M. Mitral annular calcification as a predictor of stroke in the multiethnic study of atherosclerosis. J Cardiovasc Med (Hagerstown) 2023; 24:680-688. [PMID: 37409651 DOI: 10.2459/jcm.0000000000001524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
BACKGROUND Mitral annular calcification (MAC) is associated with an increased risk for cardiovascular morbidity and mortality. This study provides recent data on the association between cardiac computed tomography (CT) derived MAC and 15 years of stroke risk in a racially diverse cohort. METHODS All multiethnic studies of atherosclerosis participants ( n = 6814) who completed a cardiac CT at baseline were included in this analysis. MAC score was calculated from cardiac CT using the Agatston and volume score methods. Multivariable Cox proportional hazard regression models were used to compute hazard ratios for the association between MAC and stroke after adjusting for traditional cardiovascular risk factors, inflammatory markers, coronary artery calcium score, atrial fibrillation, and left atrial size. RESULTS Overall, 9% of participants (644/6814) had MAC at baseline. Over a surveillance period of 15 years, 304 strokes occurred, and 79% were ischemic strokes. After adjusting for age, sex, race/ethnicity, SBP, diabetes, smoking, fibrinogen, IL-6, high-sensitivity C-reactive protein, and coronary artery calcium score, baseline MAC was associated with increased risk for all strokes [hazard ratio 1.68; 95% confidence interval (CI) 1.22-2.30: P = 0.0013]. When atrial fibrillation/flutter and left atrial size were included in the final multivariable model, MAC remained a predictor of all strokes (hazard ratio 1.93; 95% CI 1.22-3.05: P < 0.0051) and ischemic stroke (hazard ratio 2.03; 95% CI 1.24-3.31: P < 0.0046). CONCLUSION MAC is an independent predictor of long-term stroke risk in a racially diverse population beyond conventional cardiovascular risk factors and atrial fibrillation.
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Affiliation(s)
- Afiachukwu Onuegbu
- Division of Cardiology, Lundquist Institute at Harbor UCLA Medical Center, Torrance, California, USA
| | - Francesca Calicchio
- Division of Cardiology, Lundquist Institute at Harbor UCLA Medical Center, Torrance, California, USA
| | - April Kinninger
- Division of Cardiology, Lundquist Institute at Harbor UCLA Medical Center, Torrance, California, USA
| | - Rine Nakanishi
- Department of Cardiovascular Medicine, Toho University Graduate School of Medicine, Tokyo, Japan
| | - John J Carr
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Rebecca Gottesman
- Department of Neurology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Matthew Budoff
- Division of Cardiology, Lundquist Institute at Harbor UCLA Medical Center, Torrance, California, USA
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Vishwanath R, Amin M, Cierny M, Tan C, Buletko AB. Pearls & Oy-sters: Mitral Annular Calcification as a Cause of Ischemic Stroke: A Case Report. Neurology 2023; 101:e777-e779. [PMID: 36990722 PMCID: PMC10437025 DOI: 10.1212/wnl.0000000000207248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 02/16/2023] [Indexed: 03/31/2023] Open
Abstract
Evaluation of stroke etiology is an important aspect of stroke care affecting secondary prevention measures. Despite recent advances in diagnostic testing, determining the stroke etiology can remain a challenging task particularly for less common causes of stroke such as mitral annular calcification. This case will review the benefit of histopathologic clot evaluation after thrombectomy to identify uncommon causes of embolic stroke which may change management.
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Affiliation(s)
- Rohanlal Vishwanath
- From the Medicine Institute (R.V.), Neurological Institute (M.A.), Cerebrevascular Center, (M.C., A.B.B.), and Pathology and Laboratory Medicine Institute (C.T.), Cleveland Clinic Foundation, OH.
| | - Moein Amin
- From the Medicine Institute (R.V.), Neurological Institute (M.A.), Cerebrevascular Center, (M.C., A.B.B.), and Pathology and Laboratory Medicine Institute (C.T.), Cleveland Clinic Foundation, OH
| | - Marek Cierny
- From the Medicine Institute (R.V.), Neurological Institute (M.A.), Cerebrevascular Center, (M.C., A.B.B.), and Pathology and Laboratory Medicine Institute (C.T.), Cleveland Clinic Foundation, OH
| | - Carmela Tan
- From the Medicine Institute (R.V.), Neurological Institute (M.A.), Cerebrevascular Center, (M.C., A.B.B.), and Pathology and Laboratory Medicine Institute (C.T.), Cleveland Clinic Foundation, OH
| | - Andrew B Buletko
- From the Medicine Institute (R.V.), Neurological Institute (M.A.), Cerebrevascular Center, (M.C., A.B.B.), and Pathology and Laboratory Medicine Institute (C.T.), Cleveland Clinic Foundation, OH
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13
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Rizwan A, Sadiq T. The Use of AI in Diagnosing Diseases and Providing Management Plans: A Consultation on Cardiovascular Disorders With ChatGPT. Cureus 2023; 15:e43106. [PMID: 37692649 PMCID: PMC10483170 DOI: 10.7759/cureus.43106] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2023] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND Cardiovascular diseases (CVDs) have remained the leading causes of death worldwide and substantially contribute to loss of health and excess health system costs. According to WHO, cardiovascular diseases (CVDs) take an estimated 17.9 million lives each year. One of the reasons for an immensely high fatality in CVDs is lack of efficient diagnosis and prompt treatment. Timely recognition and management are crucial to minimize mortality. In the advancing world, AI (artificial intelligence) and machine learning technologies continue to progress, this advancement has opened new avenues for innovative approaches in the field of medicine. Despite the rapid development in the field of AI, there is a limited understanding of the potential benefits among clinicians and medical practitioners. METHODS In this study, we aimed to investigate the potential that the AI language model holds to assist health practitioners in the diagnosis and treatment of cardiovascular disorders. We asked Chat Generative Pre-trained Transformer (ChatGPT) 10 hypothetical questions simulating clinical consultation. The responses given by ChatGPT were accessed for its accuracy and accessibility by a team of medical specialists and cardiologists with extensive experience in managing cardiovascular disorders. Result: Out of the 10 clinical scenarios inserted in ChatGPT, eight were perfectly diagnosed, however, the other two answers given by ChatGPT were not entirely incorrect since those conditions were associated with the actual diagnosis. Furthermore, the management plans and the treatment protocols that were given by ChatGPT were in line with the literature and current medical knowledge. The exact drug names and regimens were not provided but a general guideline that was given by this AI tool is definitely beneficial for junior doctors in getting an idea on how to proceed or refresh their previous knowledge. CONCLUSION ChatGPT is a valuable resource in the field of medicine. Its comprehensive and properly organized response in an understandable language has made it an effective and efficient tool to be used. However, it is crucial to note that its limitations, such as the need for all associated and typical signs, symptoms, and physical examination findings, and its inability to personalize treatments need to be acknowledged.
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Affiliation(s)
- Ayesha Rizwan
- Medicine and Surgery, Islamic International Medical College, Islamabad, PAK
| | - Tahira Sadiq
- Community Medicine, Islamic International Medical College, Islamabad, PAK
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Morariu PC, Tanase DM, Iov DE, Sîrbu O, Oancea AF, Mircea CG, Chiriac CP, Baroi GL, Morariu ID, Dascălu CG, Şorodoc L, Floria M. Mitral Annular Calcification and Thromboembolic Risk. Life (Basel) 2023; 13:1568. [PMID: 37511943 PMCID: PMC10381637 DOI: 10.3390/life13071568] [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: 04/19/2023] [Revised: 05/24/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
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.
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Affiliation(s)
- Paula Cristina Morariu
- Department of Internal Medicine, University of Medicine and Pharmacy "Grigore T. Popa", 16 University Street, 700115 Iasi, Romania
- Medical Clinic, "Sf. Spiridon" Emergency Hospital, 700111 Iasi, Romania
| | - Daniela Maria Tanase
- Department of Internal Medicine, University of Medicine and Pharmacy "Grigore T. Popa", 16 University Street, 700115 Iasi, Romania
- Medical Clinic, "Sf. Spiridon" Emergency Hospital, 700111 Iasi, Romania
| | - Diana Elena Iov
- Department of Internal Medicine, University of Medicine and Pharmacy "Grigore T. Popa", 16 University Street, 700115 Iasi, Romania
- Medical Clinic, "Sf. Spiridon" Emergency Hospital, 700111 Iasi, Romania
| | - Oana Sîrbu
- Department of Internal Medicine, University of Medicine and Pharmacy "Grigore T. Popa", 16 University Street, 700115 Iasi, Romania
- Medical Clinic, "Sf. Spiridon" Emergency Hospital, 700111 Iasi, Romania
| | - Alexandru Florinel Oancea
- Department of Internal Medicine, University of Medicine and Pharmacy "Grigore T. Popa", 16 University Street, 700115 Iasi, Romania
- Cardiology Clinic, "Sf. Spiridon" Emergency Hospital Iași, 700111 Iasi, Romania
| | - Cornel Gabriel Mircea
- Department of Internal Medicine, University of Medicine and Pharmacy "Grigore T. Popa", 16 University Street, 700115 Iasi, Romania
| | | | - Genoveva Livia Baroi
- Department of Internal Medicine, University of Medicine and Pharmacy "Grigore T. Popa", 16 University Street, 700115 Iasi, Romania
- Surgery Clinic, "Sf. Spiridon" Emergency Hospital Iași, 700111 Iasi, Romania
| | - Ionela-Daniela Morariu
- Department of Environmental and Food Chemistry, "Grigore T. Popa" University of Medicine and Pharmacy Iași, 700111 Iasi, Romania
| | - Cristina Gena Dascălu
- Department of Medical Informatics and Biostatistics, Faculty of Dental Medicine, University of Medicine and Pharmacy "Grigore T. Popa", 16 University Street, 700115 Iasi, Romania
| | - Laurenţiu Şorodoc
- Department of Internal Medicine, University of Medicine and Pharmacy "Grigore T. Popa", 16 University Street, 700115 Iasi, Romania
- Medical Clinic, "Sf. Spiridon" Emergency Hospital, 700111 Iasi, Romania
| | - Mariana Floria
- Department of Internal Medicine, University of Medicine and Pharmacy "Grigore T. Popa", 16 University Street, 700115 Iasi, Romania
- Medical Clinic, "Sf. Spiridon" Emergency Hospital, 700111 Iasi, Romania
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15
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Moin A, Lak HM, Zafar M, Tariq R, Shaikh FH, Mussa M, Bansal A, Shekhar S, Harb S, Unai S, Kapadia SR. A Systematic Review and Meta-Analysis of Prevalence, Characteristics, and Impact of Mitral Annular Calcification on Outcomes After Transcatheter Aortic Valve Implantation. Am J Cardiol 2023; 201:123-130. [PMID: 37385163 DOI: 10.1016/j.amjcard.2023.05.069] [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: 12/14/2022] [Revised: 04/28/2023] [Accepted: 05/27/2023] [Indexed: 07/01/2023]
Abstract
There is a paucity of data on the prognostic impact of mitral annular calcification (MAC) in patients who underwent transcatheter aortic valve implantation (TAVI) with conflicting results being reported by the studies that are published. Therefore, we performed a meta-analysis to assess the short-term and long-term outcomes of MAC in patients after TAVI. Of 25,407 studies identified after the initial database search, 4 observational studies comprising 2,620 patients (2,030 patients in the nonsevere MAC arm and 590 patients in the severe MAC arm) were included in the final analysis. Compared with patients with nonsevere MAC, the severe MAC group was associated with significantly higher incidences of overall bleeding (0.75 [0.57 to 0.98], p = 0.03, I2 = 0%) at 30 days. However, no significant difference was observed between the 2 groups for the rest of the 30-day outcomes: all-cause mortality (0.79 [0.42 to 1.48], p = 0.46, I2 = 9%), myocardial infarction (1.62 [0.37 to 7.04], p = 0.52, I2 = 0%), cerebrovascular accident or stroke (1.22 [0.53 to 2.83], p = 0.64, I2 = 0%), acute kidney injury (1.48 [0.64 to 3.42], p = 0.35, I2 = 0%), and pacemaker implantation (0.70 [0.39 to 1.25], p = 0.23, I2 = 68%). Similarly, follow-up outcomes also showed no significant difference between the 2 groups: all-cause mortality (0.69 [0.46 to 1.03], p = 0.07, I2 = 44%), cardiovascular mortality (0.52 [0.24 to 1.13], p = 0.10, I2 = 70%) and stroke (0.83 [0.41 to 1.69], p = 0.61, I2 = 22%). The sensitivity analysis, however, demonstrated significant results for all-cause mortality (0.57 [0.39 to 0.84], p = 0.005, I2 = 7%) by removing the study by Okuno et al5 and cardiovascular mortality (0.41 [0.21 to 0.82], p = 0.01, I2 = 66%) by removing the study by Lak et al.7 In conclusion, our meta-analysis corroborates the notion that isolated MAC is not an independent predictor of long-term mortality after TAVI and determines severe MAC to be a predictor of mortality at follow-up because of the higher incidence of mitral valve dysfunction associated with it.
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Affiliation(s)
- Ariba Moin
- Department of Internal Medicine, Dow Medical College, Civil Hospital, Karachi, Pakistan
| | - Hassan Mehmood Lak
- Section of Clinical Cardiology, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marium Zafar
- Department of Internal Medicine, Dow Medical College, Civil Hospital, Karachi, Pakistan
| | - Rabbia Tariq
- Department of Internal Medicine, Dow Medical College, Civil Hospital, Karachi, Pakistan
| | - Fahad Hassan Shaikh
- Department of Cardiology, Dow Medical College, Civil Hospital, Karachi, Pakistan
| | - Muhammad Mussa
- Department of Internal Medicine, Dow Medical College, Civil Hospital, Karachi, Pakistan
| | - Agam Bansal
- Aortic Valve Center, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shashank Shekhar
- Aortic Valve Center, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Serge Harb
- Aortic Valve Center, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shinya Unai
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Samir R Kapadia
- Aortic Valve Center, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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16
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Mayfield JJ, Otto CM. Stroke and Noninfective Native Valvular Disease. Curr Cardiol Rep 2023; 25:333-348. [PMID: 36971961 DOI: 10.1007/s11886-023-01855-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/09/2023] [Indexed: 05/16/2023]
Abstract
PURPOSE OF REVIEW Embolic stroke of undetermined source is a challenging clinical entity. While less common than atrial fibrillation and endocarditis, many noninfective heart valve lesions have been associated with stroke and may be considered as culprits for cerebral infarcts when other more common causes are excluded. This review discusses the epidemiology, pathophysiology, and management of noninfective valvular diseases that are commonly associated with stroke. RECENT FINDINGS Calcific debris from degenerating aortic and mitral valves may embolize to the cerebral vasculature causing small- or large-vessel ischemia. Thrombus which may be adherent to calcified valvular structures or left-sided cardiac tumors may also embolize resulting in stroke. Tumors themselves, most commonly myxomas and papillary fibroelastomas, may fragment and travel to the cerebral vasculature. Despite this broad differential, many types of valve diseases are highly comorbid with atrial fibrillation and vascular atheromatous disease. Thus, a high index of suspicion for more common causes of stroke is needed, especially given that treatment for valvular lesions typically involves cardiac surgery whereas secondary prevention of stroke due to occult atrial fibrillation is readily accomplished with anticoagulation.
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Affiliation(s)
- Jacob J Mayfield
- Division of Cardiology, University of Washington School of Medicine, Seattle, WA, USA.
| | - Catherine M Otto
- Division of Cardiology, University of Washington School of Medicine, Seattle, WA, USA
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17
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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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18
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Novel 3D Echocardiographic Technique for Mitral Calcium Mapping. J Clin Med 2023; 12:jcm12041470. [PMID: 36836005 PMCID: PMC9959886 DOI: 10.3390/jcm12041470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/07/2023] [Accepted: 02/10/2023] [Indexed: 02/16/2023] Open
Abstract
Mitral annular calcification (MAC) is a common chronic degenerative process of the mitral valve fibrous support ring. MAC increases the risk of mitral valve dysfunction, all-cause and cardiovascular mortality, and worse outcomes in cardiac interventions. Echocardiography represents the first imaging modality for MAC assessment, but it has low specificity compared to cardiac CT in terms of distinguishing between calcium and dense collagen. Novel three-dimensional transesophageal maximal intensity projection (MIP) mapping allows for the real-time MAC distribution and depth visualization of the cardiac anatomy and represents a useful and promising tool for pre-procedural assessment and intra-procedural guidance of cardiac interventions.
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19
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Barasch E, Gottdiener JS, Tressel W, Bartz TM, Buzkova P, Massera D, deFilippi C, Biggs ML, Psaty BM, Kizer JR, Owens D. The Associations of Aortic Valve Sclerosis, Aortic Annular Increased Reflectivity, and Mitral Annular Calcification with Subsequent Aortic Stenosis in Older Individuals: Findings from the Cardiovascular Health Study. J Am Soc Echocardiogr 2023; 36:41-49.e1. [PMID: 36096340 PMCID: PMC9822849 DOI: 10.1016/j.echo.2022.08.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 08/26/2022] [Accepted: 08/31/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Although aortic valve sclerosis (AVS) is well described as preceding aortic stenosis (AS), the associations of AS with antecedent mitral annular calcification (MAC) and aortic annular increased reflectivity (AAIR) have not been characterized. In a population-based prospective study, the authors evaluated whether MAC, AAIR, and AVS are associated with the risk for incident AS. METHODS Among participants of the Cardiovascular Health Study free of AS at the 1994-1995 visit, the presence of MAC, AAIR, AVS, and the combination of all three was evaluated in 3,041 participants. Cox proportional-hazards regression was used to assess the association between the presence of calcification and the incidence of moderate or severe AS in three nested models adjusting for factors associated with atherosclerosis and inflammation both relevant to the pathogenesis of AS. RESULTS Over a median follow-up period of 11.5 years (interquartile range, 6.7-17.0 years), 110 cases of incident moderate or severe AS were ascertained. Strong positive associations with incident moderate or severe AS were found for all calcification sites after adjustment for the main model covariates: AAIR (hazard ratio [HR], 2.90; 95% CI, 1.95-4.32; P < .0005), AVS (HR, 2.20; 95% CI, 1.44-3.37; P < .0005), MAC (HR, 1.67; 95% CI, 1.14-2.45; P = .008), and the combination of all three (HR, 2.50; 95% CI, 1.65-3.78; P < .0005). In a secondary analysis, the risk for AS increased with the number of sites at which calcification was present. CONCLUSIONS In a large cohort of community-dwelling elderly individuals, there were strong associations between each of AAIR, AVS, MAC, and the combination of the three and incident moderate or severe AS. The novel finding that AAIR had a particularly strong association with incident AS, even after adjusting for other calcification sites, suggests its value in identifying individuals at risk for AS and potential inclusion in routine assessment by transthoracic echocardiography.
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Affiliation(s)
- Eddy Barasch
- Department of Research and Education, St. Francis Hospital/SUNY at Stony Brook, Roslyn, New York.
| | - John S Gottdiener
- Department of Medicine (Cardiology), University of Maryland School of Medicine, Baltimore, Maryland
| | - William Tressel
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Traci M Bartz
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Petra Buzkova
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Daniele Massera
- Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, New York
| | | | - Mary L Biggs
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Bruce M Psaty
- Departments of Medicine, Epidemiology, and Health Systems and Population Health, University of Washington and Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Jorge R Kizer
- Cardiology Section, San Francisco Veterans Affairs Health Care System and Departments of Medicine, Epidemiology, and Biostatistics, University of California, San Francisco, San Francisco, California
| | - David Owens
- Division of Cardiology, University of Washington, Seattle, Washington
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20
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Sharma R, Silverman S, Patel S, Schwamm LH, Sanborn DY. Frequency, predictors and cardiovascular outcomes associated with transthoracic echocardiographic findings during acute ischaemic stroke hospitalisation. Stroke Vasc Neurol 2022; 7:482-492. [PMID: 35697387 PMCID: PMC9811598 DOI: 10.1136/svn-2021-001170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 04/29/2022] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE To characterise the clinical utility of transthoracic echocardiography (TTE) at the time of acute ischaemic stroke (AIS). BACKGROUND The utility of obtaining a TTE during AIS hospitalisation is uncertain. METHODS We studied AIS hospitalisations at a single centre (2002-2016). TTE abnormalities were classified as findings associated with: high stroke risk (Category I), cardiac events (Category II) and of unclear significance (Category III). We performed logistic regressions to predict Category I, II and III abnormalities. The odds of 1 year recurrent stroke hospitalisation captured by ICD 9 and 10 codes as a function of Category I, II and III abnormalities were assessed. Improvement in predictive capacity for 1 year recurrent ischaemic stroke hospitalisation beyond stroke risk factors was evaluated by net reclassification improvement. RESULTS There were 5523 AIS hospitalisations. Nearly 81% of admission TTEs were abnormal (18.7% Category I, 32.7% Category II, 72.8% Category III). Older patients with coronary artery disease, atrial fibrillation, hypertension, diabetes, and patent intracranial and extracranial vessels were likely to have an abnormal TTE. Category I finding was associated with lower odds of 1-year recurrent stroke hospitalisation (OR 0.54, 95% CI 0.30 to 0.96). Category I data significantly improved the predictive value for 1-year recurrent ischaemic stroke hospitalisation beyond stroke risk factors (net reclassification improvement 0.1563, 95% CI 0.0465 to 0.2661). CONCLUSIONS TTE abnormalities associated with stroke and cardiac event risk were commonly detected during AIS hospitalisation. Detection of Category I TTE findings reduced the risk of recurrent stroke, potentially due to neutralisation of the cardioembolic source by targeted therapy, indicating the clinical utility of TTE.
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Affiliation(s)
- Richa Sharma
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Scott Silverman
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shaun Patel
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
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21
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Calcific mitral valve disease: The next challenging disease. Arch Cardiovasc Dis 2022; 115:613-616. [PMID: 36347773 DOI: 10.1016/j.acvd.2022.09.005] [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: 09/20/2022] [Accepted: 09/20/2022] [Indexed: 12/15/2022]
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22
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Siah QZ, Pang BY, Ye TT, Ho JS, Teo YH, Teo YN, Syn NL, Tan BY, Wong RC, Yeo LL, Lee EC, Li TY, Poh KK, Kong WK, Yeo TC, Chai P, Sia CH. Incidence of Acute Cerebrovascular Events in Patients with Rheumatic or Calcific Mitral Stenosis: A Systematic Review and Meta-analysis. Hellenic J Cardiol 2022; 70:80-84. [PMID: 36041698 DOI: 10.1016/j.hjc.2022.08.002] [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: 07/15/2022] [Revised: 08/16/2022] [Accepted: 08/23/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Patients with mitral stenosis (MS) may be predisposed to acute cerebrovascular events (ACE) and peripheral thromboembolic events (TEE). Concomitant atrial fibrillation (AF), mitral annular calcification (MAC) and rheumatic heart disease (RHD) are independent risk factors. Our aim was to evaluate the incidence of ACEs in MS patients and the implications of AF, MAC, and RHD on thromboembolic risks. METHODS This systematic review was registered on PROSPERO (CRD42021291316). Six databases were searched from inception to 19th December 2021. The clinical outcomes were composite ACE, ischaemic stroke/transient ischaemic attack (TIA), and peripheral TEE. RESULTS We included 16 and 9 papers, respectively, in our qualitative and quantitative analyses. The MS cohort with AF had the highest incidence of composite ACE (31.55%; 95%CI 3.60-85.03; I2=99%), followed by the MAC (14.85%; 95%CI 7.21-28.11; I2=98%), overall MS (8.30%; 95%CI 3.45-18.63; I2=96%) and rheumatic MS population (4.92%; 95%CI 3.53-6.83; I2=38%). Stroke/TIA were reported in 29.62% of the concomitant AF subgroup (95%CI 2.91-85.51; I2=99%) and in 7.11% of the overall MS patients (95%CI 1.91-23.16; I2=97%). However, the heterogeneity of the pooled incidence of clinical outcomes in all groups, except the rheumatic MS group, were substantial and significant. The logit-transformed proportion of composite ACE increased by 0.0141 (95% CI 0.0111-0.0171; p<0.01) per year of follow-up. CONCLUSION In the MS population, MAC and concomitant AF are risk factors for the development of ACE. The scarcity of data in our systematic review reflects the need for further studies to explore thromboembolic risks in all MS subtypes.
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Affiliation(s)
- Qi Zhuang Siah
- School of Medicine, Cardiff University, Wales, United Kingdom.
| | - Bao Yu Pang
- Prince Charles Hospital, Cwm Taf Morgannwg University Health Board, Wales, United Kingdom.
| | - Tiffany Ts Ye
- School of Medicine, Cardiff University, Wales, United Kingdom.
| | - Jamie Sy Ho
- Academic Foundation Year Programme, North Middlesex Hospital University Trust, London, United Kingdom.
| | - Yao Hao Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | - Yao Neng Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | - Nicholas Lx Syn
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | - Benjamin Yq Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, Department of Medicine, National University Hospital, Singapore.
| | - Raymond Cc Wong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore.
| | - Leonard Ll Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, Department of Medicine, National University Hospital, Singapore.
| | - Edward Cy Lee
- Department of Cardiology, National University Heart Centre Singapore, Singapore.
| | - Tony Yw Li
- Department of Cardiology, National University Heart Centre Singapore, Singapore.
| | - Kian-Keong Poh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore.
| | - William Kf Kong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore.
| | - Tiong-Cheng Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore.
| | - Ping Chai
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore.
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre Singapore, Singapore.
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23
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Churchill TW, Yucel E, Deferm S, Levine RA, Hung J, Bertrand PB. Mitral Valve Dysfunction in Patients With Annular Calcification: JACC Review Topic of the Week. J Am Coll Cardiol 2022; 80:739-751. [PMID: 35953139 PMCID: PMC10290884 DOI: 10.1016/j.jacc.2022.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/30/2022] [Accepted: 05/31/2022] [Indexed: 10/15/2022]
Abstract
Mitral annular calcification (MAC) is a common clinical finding and is associated with adverse clinical outcomes, but the clinical impact of MAC-related mitral valve (MV) dysfunction remains underappreciated. Patients with MAC frequently have stenotic, regurgitant, or mixed valvular disease, and this valvular dysfunction is increasingly recognized to be independently associated with worse prognosis. MAC-related MV dysfunction is a distinct pathophysiologic entity, and importantly much of the diagnostic and therapeutic paradigm from published rheumatic MV disease research cannot be applied in this context, leaving important gaps in our knowledge. This review summarizes the current epidemiology, pathophysiology, diagnosis, and classification of MAC-related MV dysfunction and proposes both an integrative definition and an overarching approach to this important and increasingly recognized clinical condition.
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Affiliation(s)
- Timothy W Churchill
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/TimChurchillMD
| | - Evin Yucel
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sébastien Deferm
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Robert A Levine
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Judy Hung
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Philippe B Bertrand
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium.
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Chehab O, Roberts-Thomson R, Bivona A, Gill H, Patterson T, Pursnani A, Grigoryan K, Vargas B, Bokhary U, Blauth C, Lucchese G, Bapat V, Guerrero M, Redwood S, Prendergast B, Rajani R. Management of Patients With Severe Mitral Annular Calcification: JACC State-of-the-Art Review. J Am Coll Cardiol 2022; 80:722-738. [PMID: 35953138 DOI: 10.1016/j.jacc.2022.06.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/17/2022] [Accepted: 06/21/2022] [Indexed: 11/28/2022]
Abstract
Mitral annular calcification (MAC) is a common and challenging pathologic condition, especially in the context of an aging society. Surgical mitral valve intervention in patients with MAC is difficult, with varying approaches to the calcified annular anatomy, and the advent of transcatheter valve interventions has provided additional treatment options. Advanced imaging provides the foundation for heart team discussions and management decisions concerning individual patients. This review focuses on the prognosis of, preoperative planning for, and management strategies for patients with MAC.
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Affiliation(s)
- Omar Chehab
- Departments of Cardiology and Cardiac Surgery, St Thomas' Hospital, Westminster Bridge Road, London, United Kingdom
| | - Ross Roberts-Thomson
- Departments of Cardiology and Cardiac Surgery, St Thomas' Hospital, Westminster Bridge Road, London, United Kingdom; Department of Cardiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Antonio Bivona
- Departments of Cardiology and Cardiac Surgery, St Thomas' Hospital, Westminster Bridge Road, London, United Kingdom
| | - Harminder Gill
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Tiffany Patterson
- Departments of Cardiology and Cardiac Surgery, St Thomas' Hospital, Westminster Bridge Road, London, United Kingdom; School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Amit Pursnani
- Division of Cardiology, Evanston Hospital, Northshore University Health System, Evanston, Illinois, USA
| | - Karine Grigoryan
- Departments of Cardiology and Cardiac Surgery, St Thomas' Hospital, Westminster Bridge Road, London, United Kingdom
| | - Bernardo Vargas
- Division of Cardiology, Evanston Hospital, Northshore University Health System, Evanston, Illinois, USA
| | - Ujala Bokhary
- Division of Cardiology, Evanston Hospital, Northshore University Health System, Evanston, Illinois, USA
| | - Christopher Blauth
- Departments of Cardiology and Cardiac Surgery, St Thomas' Hospital, Westminster Bridge Road, London, United Kingdom
| | - Gianluca Lucchese
- Departments of Cardiology and Cardiac Surgery, St Thomas' Hospital, Westminster Bridge Road, London, United Kingdom
| | - Vinayak Bapat
- Center for Valve and Structural Heart Disease, Minneapolis Heart Institute, Minneapolis, Minnesota, USA
| | - Mayra Guerrero
- Department of Cardiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Simon Redwood
- Departments of Cardiology and Cardiac Surgery, St Thomas' Hospital, Westminster Bridge Road, London, United Kingdom; School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Bernard Prendergast
- Departments of Cardiology and Cardiac Surgery, St Thomas' Hospital, Westminster Bridge Road, London, United Kingdom.
| | - Ronak Rajani
- Departments of Cardiology and Cardiac Surgery, St Thomas' Hospital, Westminster Bridge Road, London, United Kingdom; School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
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Clinical Outcomes of Mitral Valve Disease With Mitral Annular Calcification. Am J Cardiol 2022; 174:107-113. [PMID: 35450733 DOI: 10.1016/j.amjcard.2022.03.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/09/2022] [Accepted: 03/15/2022] [Indexed: 12/20/2022]
Abstract
The prevalence of mitral valve disease with mitral annular calcification (MAC) and its clinical outcomes remain uncertain. This study sought to evaluate the prevalence of significant mitral disease due to MAC, and the impact of intervention on the clinical outcomes in these patients. All patients who underwent transthoracic echocardiography (TTE) between January 2014 and December 2015 in our health care system were reviewed and identified for having MAC with significant mitral valve disease (i.e., either≥moderate mitral regurgitation (MR) or mitral stenosis (MS)). The primary endpoints of the study were all-cause mortality and a composite outcome of mortality or heart failure hospitalization at 3-year follow-up. Of 41,136 patients who underwent TTE, MAC was identified in 2,855 (6.9%) patients, including 434 (1.1% of total) patients who had significant MR and/or MS (median age [IQR], 80 [73 to 87] years; 63% women). MAC predominately involved the posterior annulus (95%), with the majority having calcification of both trigones (55%), the leaflets (71%), and circumferential involvement (67%). During 3-year follow-up, 59 (14%) patients underwent surgical or transcatheter MV intervention. Patients who did not undergo mitral intervention had higher all-cause mortality (HR 2.80, 95% CI 1.60 to 4.92; p <0.001) and a greater risk of the composite outcome (HR 1.43, 1.00 to 2.04; p = 0.05) than those treated. Survival at 3-year follow-up was markedly greater in those with mitral intervention (78% vs 50%; p <0.001). This survival benefit remained after multivariable adjustment. In conclusion, MAC affects approximately % of patients who undergo echocardiography. Those with significant mitral valve disease due to any degree of MAC have poor survival, which may be ameliorated with transcatheter or surgical intervention.
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Potential role of conventional and speckle-tracking echocardiography in the screening of structural and functional cardiac abnormalities in elderly individuals: Baseline echocardiographic findings from the LOOP study. PLoS One 2022; 17:e0269475. [PMID: 35658048 PMCID: PMC9165786 DOI: 10.1371/journal.pone.0269475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 05/22/2022] [Indexed: 11/18/2022] Open
Abstract
Background
Elderly individuals occupy an increasing part of the general population. Conventional and speckle-tracking transthoracic echocardiography may help guide risk stratification in these individuals. The purpose of this study was to evaluate the potential utility of conventional and speckle-tracking echocardiography in the screening of cardiac abnormalities in the elderly population.
Methods
Two cohorts of elderly individuals (sample size: 1441 and 944) were analyzed, who were part of a randomized controlled clinical trial (LOOP study) and of an observational study (Copenhagen City Heart Study), recruiting participants from the general population >70 years of age with cardiovascular risk factors (arterial hypertension, diabetes mellitus, heart failure, or prior stroke) and sinus rhythm. Participants underwent a comprehensive transthoracic echocardiographic examination, including myocardial speckle tracking. Cardiac abnormalities were defined according to the ASE/EACVI guidelines.
Results
Structural cardiac abnormalities such as left ventricular (LV) remodeling, mitral annular calcification (MAC), and aortic valve sclerosis (with or without stenosis) were highly prevalent in the LOOP study (40%, 39%, and 27%, respectively). Moreover, a high prevalence of functional cardiac alterations such as LV diastolic dysfunction (LVDD), abnormal LV longitudinal systolic strain (GLS), and abnormal left atrial (LA) reservoir strain was present in the LOOP study (27%, 18%, and 9%, respectively). Likewise, the rate of LVDD, abnormal GLS, and abnormal LA reservoir strain was comparable in the validation sample from the Copenhagen City Heart Study. In line with these findings, subjects with LV remodeling, MAC, and aortic valve changes had a higher prevalence of LVDD, abnormal GLS, and abnormal LA reservoir strain than those without structural cardiac alterations.
Conclusion
The findings of this study highlight the potential clinical utility of conventional and speckle-tracking echocardiography in the screening of structural and functional cardiac abnormalities in the elderly population. Further studies are warranted to determine the prognostic relevance of these findings.
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Willner N, Burwash IG, Beauchesne L, Chan V, Vulesevic B, Ascah K, Coutinho T, Promislow S, Stadnick E, Chan KL, Mesana T, Messika-Zeitoun D. Natural History of Mitral Annulus Calcification and Calcific Mitral Valve Disease. J Am Soc Echocardiogr 2022; 35:925-932. [PMID: 35618253 DOI: 10.1016/j.echo.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 03/05/2022] [Accepted: 05/10/2022] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- Nadav Willner
- Department of Cardiology, University of Ottawa Heart Institute, Ottawa, Canada
| | - Ian G Burwash
- Department of Cardiology, University of Ottawa Heart Institute, Ottawa, Canada
| | - Luc Beauchesne
- Department of Cardiology, University of Ottawa Heart Institute, Ottawa, Canada
| | - Vince Chan
- Department of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Canada
| | - Branka Vulesevic
- Department of Cardiology, University of Ottawa Heart Institute, Ottawa, Canada
| | - Kathy Ascah
- Department of Cardiology, University of Ottawa Heart Institute, Ottawa, Canada
| | - Thias Coutinho
- Department of Cardiology, University of Ottawa Heart Institute, Ottawa, Canada
| | - Steve Promislow
- Department of Cardiology, University of Ottawa Heart Institute, Ottawa, Canada
| | - Ellamae Stadnick
- Department of Cardiology, University of Ottawa Heart Institute, Ottawa, Canada
| | - Kwan L Chan
- Department of Cardiology, University of Ottawa Heart Institute, Ottawa, Canada
| | - Thierry Mesana
- Department of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Canada
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Grory BM, Yaghi S, Cordonnier C, Sposato LA, Romano JG, Chaturvedi S. Advances in Recurrent Stroke Prevention: Focus on Antithrombotic Therapies. Circ Res 2022; 130:1075-1094. [PMID: 35420910 PMCID: PMC9015232 DOI: 10.1161/circresaha.121.319947] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The past decade has seen significant advances in stroke prevention. These advances include new antithrombotic agents, new options for dyslipidemia treatment, and novel techniques for surgical stroke prevention. In addition, there is greater recognition of the benefits of multifaceted interventions, including the role of physical activity and dietary modification. Despite these advances, the aging of the population and the high prevalence of key vascular risk factors pose challenges to reducing the burden of stroke. Using a cause-based framework, current approaches to prevention of cardioembolic, cryptogenic, atherosclerotic, and small vessel disease stroke are outlined in this paper. Special emphasis is given to recent trials of antithrombotic agents, including studies that have tested combination treatments and responses according to genetic factors.
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Affiliation(s)
| | | | - Charlotte Cordonnier
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, F-59000 Lille, France
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29
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Islam H, Puttagunta SM, Islam R, Kundu S, Jha SB, Rivera AP, Flores Monar GV, Sange I. Risk of Stroke With Mitral Stenosis: The Underlying Mechanism, Treatment, and Prevention. Cureus 2022; 14:e23784. [PMID: 35518523 PMCID: PMC9063730 DOI: 10.7759/cureus.23784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2022] [Indexed: 12/04/2022] Open
Abstract
Mitral stenosis (MS), a valvular heart disease, is defined by the narrowing of the mitral valve orifice. The common risk factors for stroke include mitral annular calcification (MAC), diabetes mellitus (DM), male gender, hypertension (HTN), hyperlipidemia, and obesity. Endothelial damage, hypercoagulability, and blood stasis in the left atrium promote the development of the thrombus. Among all the risk factors described, MAC is the independent predictor of stroke. The complicated mechanisms responsible for thromboembolism, predisposing factors for thromboembolism, the risk of cerebrovascular accident (CVA) in MS patients, advanced standardized assessment models for identifying those at risk for stroke, and the possible advantages and disadvantages of available therapies have all been discussed in this review article. We have also discussed newer oral anticoagulants (NOACs) like dabigatran, edoxaban, apixaban, and rivaroxaban. Non-pharmacological therapies are also highlighted such as left atrial appendage ligation and occlusion devices. We also conducted a thorough review of the literature on the efficacy and safety of various NOACs in reducing the risk of stroke.
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30
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Yamamoto H, Hashimoto K, Yamada H, Ikeda Y, Takahashi T, Hashimoto T. Case Report: “Methicillin-Resistant Staphylococcus aureus Endocarditis Overlying Calcified Mitral Annular Abscess Misdiagnosed as Klebsiella pneumoniae Endocarditis”. Front Microbiol 2022; 12:818219. [PMID: 35116015 PMCID: PMC8804532 DOI: 10.3389/fmicb.2021.818219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 12/23/2021] [Indexed: 11/13/2022] Open
Abstract
Infective endocarditis (IE) involving mitral annular calcification (MAC) is a rare disease, but is potentially lethal due to frequent serious periannular complications, and therefore requires early diagnosis and prompt treatment. However, either reaching the correct diagnosis or the detection of periannular complications, even with conventional transesophageal echocardiography (TEE), remains challenging because calcium deposition obscures clear visualization of the area around the MAC. We describe a unique case of methicillin-resistant Staphylococcus aureus (MRSA) IE involving a calcified mitral annular abscess, which was initially misdiagnosed as Klebsiella pneumoniae IE. Accurate diagnosis of MAC-related IE as well as detection of the annular abscess were made possible by 4D TEE, leading to successful cardiac surgery, which confirmed MRSA IE pathologically, and the associated annular abscess. This case highlights the usefulness of 4D TEE for the accurate diagnosis and proper surgical planning. In addition, this case raises the limitations of the modified Duke criteria in cases of definite IE with dual bacteremia.
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Affiliation(s)
- Hiroyuki Yamamoto
- Department of Cardiovascular Medicine, Narita-Tomisato Tokushukai Hospital, Chiba, Japan
- *Correspondence: Hiroyuki Yamamoto
| | - Katsuya Hashimoto
- Department of Cardiovascular Medicine, Narita-Tomisato Tokushukai Hospital, Chiba, Japan
| | - Hiroyuki Yamada
- Department of Cardiovascular Surgery, Narita-Tomisato Tokushukai Hospital, Chiba, Japan
| | - Yoshihiko Ikeda
- Department of Pathology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takashi Takahashi
- Laboratory of Infectious Diseases, Graduate School of Infection Control Sciences & Omura Satoshi Memorial Institute, Kitasato University, Tokyo, Japan
| | - Toru Hashimoto
- Department of Cardiovascular Medicine, Narita-Tomisato Tokushukai Hospital, Chiba, Japan
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31
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Fukushima K, Komukai K, Kashiwagi Y, Okuyama T, Maehara T, Kamba T, Oki Y, Shirasaki K, Kubota T, Miyanaga S, Naganuma H, Yoshimura M. A case of cardiac calcified amorphous tumor complicated with acute myocardial infarction. J Cardiol Cases 2022; 25:396-399. [DOI: 10.1016/j.jccase.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 12/04/2021] [Accepted: 01/08/2022] [Indexed: 10/19/2022] Open
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Sharma A, Ogunmoroti O, Fashanu OE, Zhao D, Ouyang P, Budoff MJ, Thomas IC, Michos ED. Associations of endogenous sex hormone levels with the prevalence and progression of valvular and thoracic aortic calcification in the Multi-Ethnic Study of Atherosclerosis (MESA). Atherosclerosis 2022; 341:71-79. [PMID: 34785061 PMCID: PMC8760158 DOI: 10.1016/j.atherosclerosis.2021.11.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 10/24/2021] [Accepted: 11/04/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND AIMS Sex hormones (SH) may contribute to sex differences in cardiovascular disease (CVD). High free testosterone (T) and low sex hormone binding globulin (SHBG) have been associated with progression of coronary artery calcification in women. We now examined the association of SH with extra-coronary calcification (ECC) prevalence and progression among MESA participants. METHODS We studied 2,737 postmenopausal women and 3,130 men free of clinical CVD with baseline SH levels. ECC measurements [ascending and descending thoracic aortic calcification (ATAC, DTAC), mitral annular calcification (MAC), aortic valve calcification (AVC)] were obtained by computed tomography at baseline and after 2.4 ± 0.9 years. We used multivariable Poisson regression to evaluate associations with ECC prevalence and incidence (Agatston scores >0) and linear mixed effects models for ECC progression, per 1-SD increment in log(SH) in women and men separately. RESULTS The mean age was 65 ± 9 and 62 ± 10 years for women and men, respectively. In women, greater free T and lower SHBG were associated with MAC incidence in a demographic-adjusted model only. In men, lower free T was associated with MAC prevalence, DTAC incidence and progression, while greater SHBG was associated with MAC prevalence and DTAC progression after further adjusting for CVD risk factors. CONCLUSIONS In this diverse cohort free of CVD, we found some associations of SH with ECC measures. In particular, free T was inversely associated with prevalent MAC and DTAC progression in men independent of CVD risk factors. SH may influence vascular calcification, but further work is needed to understand clinical implications of these findings.
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Affiliation(s)
- Apurva Sharma
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Oluseye Ogunmoroti
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Di Zhao
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Pamela Ouyang
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Isac C. Thomas
- Division of Cardiology, University of California San Diego, San Diego, CA, USA
| | - Erin D. Michos
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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33
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Greer DM, Aparicio HJ, Siddiqi OK, Furie KL. Cardiac Diseases. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00032-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Asymptomatic Stroke in the Setting of Percutaneous Non-Coronary Intervention Procedures. Medicina (B Aires) 2021; 58:medicina58010045. [PMID: 35056353 PMCID: PMC8778528 DOI: 10.3390/medicina58010045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 12/21/2021] [Accepted: 12/23/2021] [Indexed: 11/16/2022] Open
Abstract
Advancements in clinical management, pharmacological therapy and interventional procedures have strongly improved the survival rate for cardiovascular diseases (CVDs). Nevertheless, the patients affected by CVDs are more often elderly and present several comorbidities such as atrial fibrillation, valvular heart disease, heart failure, and chronic coronary syndrome. Standard treatments are frequently not available for “frail patients”, in particular due to high surgical risk or drug interaction. In the past decades, novel less-invasive procedures such as transcatheter aortic valve implantation (TAVI), MitraClip or left atrial appendage occlusion have been proposed to treat CVD patients who are not candidates for standard procedures. These procedures have been confirmed to be effective and safe compared to conventional surgery, and symptomatic thromboembolic stroke represents a rare complication. However, while the peri-procedural risk of symptomatic stroke is low, several studies highlight the presence of a high number of silent ischemic brain lesions occurring mainly in areas with a low clinical impact. The silent brain damage could cause neuropsychological deficits or worse, a preexisting dementia, suggesting the need to systematically evaluate the impact of these procedures on neurological function.
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35
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Patlolla SH, Schaff HV, Nishimura RA, Geske JB, Lahr BD, Lee AT, Eleid MF, Ommen SR, Dearani JA. Mitral Annular Calcification in Obstructive Hypertrophic Cardiomyopathy: Prevalence and Outcomes. Ann Thorac Surg 2021; 114:1679-1687. [PMID: 34822847 DOI: 10.1016/j.athoracsur.2021.09.077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/11/2021] [Accepted: 09/20/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The prevalence and clinical impact of mitral annular calcification (MAC) in patients with obstructive hypertrophic cardiomyopathy (HCM) are largely unknown. METHODS We reviewed 2113 HCM patients who underwent septal myectomy from January 2000 to April 2016. Preoperative and intraoperative echocardiograms along with operative notes were reviewed to identify MAC. Survival was estimated and compared using Kaplan-Meier analysis and log-rank test. Cox regression analysis was used to identify factors independently associated with mortality. RESULTS MAC was identified in 390 (18.5%) patients. Older age, female sex, and presence of mitral valve leaflet calcification were strongly associated with higher odds of having MAC. Patients with MAC had higher resting LVOT gradients, more likely to have worse mitral valve regurgitation (MR) preoperatively, and more likely to undergo a concomitant mitral valve replacement (6% vs 1%, P<0.001) compared to those without MAC. Postoperatively, patients with MAC had marginally higher residual MR (13% vs 8%). After a median follow-up of 6.95 (IQR 3.7- 12.1) years, survival of patients with MAC at 1, 5 and 10 years was 99%, 92% and 69% respectively. Adjusted analysis identified MAC as an independent predictor of poor survival (HR 1.46, 95% CI 1.08 to 1.97; P=.014). CONCLUSIONS MAC is a frequent finding in older patients with obstructive HCM, more likely to be seen in females, and is associated with higher rates of concomitant mitral valve replacement. Despite higher prevalence of comorbidities, MAC remained an independent predictor for overall mortality following septal myectomy.
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Affiliation(s)
| | | | | | - Jeffrey B Geske
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester
| | - Brian D Lahr
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester
| | - Alexander T Lee
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester
| | - Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester
| | - Steve R Ommen
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester
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36
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Karan A, Feghaly J, Guo HJ, Akinjogbin TO, Sattiraju S. A Case of Multiple Calcific Embolic Strokes in a Patient With a Porcelain Left Atrium. Cureus 2021; 13:e18585. [PMID: 34765352 PMCID: PMC8575342 DOI: 10.7759/cureus.18585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 10/07/2021] [Indexed: 11/21/2022] Open
Abstract
Mitral annular calcification (MAC) commonly manifests as an incidental, asymptomatic finding that is associated with several cardiovascular risk factors, atherosclerosis, cardiovascular death, and all-cause mortality. Very rarely, patients with severe MAC can have extensive dystrophic calcification extending into the left atrial wall, termed porcelain left atrium. In this case report, we describe a patient who experienced multiple calcific acute embolic strokes in the setting of severe mitral annular calcification and porcelain left atrium. Our patient presented with multiple, small bilateral acute infarcts scattered throughout the cerebrum and cerebellum confirmed on magnetic resonance imaging (MRI). He was placed on continuous telemetry and underwent multimodal imaging with transthoracic and transesophageal echocardiography, carotid neck ultrasound (US), head and neck computed tomography angiogram (CTA), and cardiac MRI. There were no arrhythmic events detected on telemetry, and all imaging excluded left ventricular thrombi, aortic atheroma, carotid artery stenosis, intracardiac shunting, or large vessel stenosis. Noted on imaging, however, was severe mitral annular calcification with numerous, highly mobile calcific extensions and densely calcified plaque along the posterior left atrial wall, presumed to be the source of this patient's embolic stroke. Cardiac catheterization was significant for severe three-vessel disease requiring coronary artery bypass grafting, and our patient was subsequently discharged to outpatient follow-up on event monitoring and aspirin monotherapy. This case serves to highlight a previously unreported complication of calcific embolic stroke in severe MAC and porcelain left atrium, and highlight the need for further randomized controlled trials to determine the optimum management of these cases.
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Affiliation(s)
- Abhinav Karan
- Internal Medicine, University of Florida College of Medicine, Jacksonville, USA
| | - Julien Feghaly
- Cardiology, University of Florida College of Medicine, Jacksonville, USA
| | - Hui Jun Guo
- Internal Medicine, University of Florida College of Medicine, Jacksonville, USA
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37
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Seo J, Jeong H, Cho I, Hong GR, Ha JW, Shim CY. Sex Differences in Mitral Annular Calcification and the Clinical Implications. Front Cardiovasc Med 2021; 8:736040. [PMID: 34722668 PMCID: PMC8551453 DOI: 10.3389/fcvm.2021.736040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 09/22/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Heterogeneous mechanisms may contribute to the occurrence of mitral annular calcification (MAC), however, little is known about the sex differences in MAC and the clinical implications of these differences. This study aimed to investigate clinical and imaging differences of MAC according to sex. Methods: In total, 537 patients (221 men) with MAC were identified by transthoracic echocardiography at a single center from January 2012 to June 2016. Moderate-to-severe MAC was defined as calcification extent ≥120° of the mitral annulus. Significant functional mitral stenosis (MS) was defined as a transmitral mean diastolic pressure gradient ≥5 mmHg. Results: Women more frequently had moderate-to-severe MAC and concomitant mitral regurgitation than men; however, significant functional MS was comparable between sexes. In the logistic regression analysis, old age, uncontrolled hypertension, end-stage renal disease (ESRD), and obstructive hypertrophic cardiomyopathy were significantly associated with moderate-to-severe MAC in women, whereas ESRD and moderate-to-severe aortic stenosis were in men. In the Cox regression analysis, significant functional MS was associated with all-cause death in both sexes, although an independent association was found in only women. Conclusion: Women had more extended MAC than men. Significant functional MS was independently associated with unfavorable clinical outcomes in patients with MAC, which was more pronounced in women than in men.
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Affiliation(s)
- Jiwon Seo
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyeonju Jeong
- Division of Cardiology, Department of Internal Medicine, Myongji Hospital, Hanyang University Medical Center, Seoul, South Korea
| | - Iksung Cho
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Geu-Ru Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jong-Won Ha
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Chi Young Shim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
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Okura H, Nakada Y, Nogi M, Ishihara S, Okamura A, Okayama S, Watanabe M, Kawakami R, Saito Y. Prevalence of mitral annular calcification and its association with mitral valvular disease. Echocardiography 2021; 38:1907-1912. [PMID: 34719060 DOI: 10.1111/echo.15236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/13/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Mitral annular calcification (MAC) is increasingly observed in elderly population. The purpose of this study was to investigate incidence of MAC and its association with mitral valvular disease (MVD). METHODS A total of 13,483 consecutive patients who underwent echocardiography were enrolled. MAC was defined as an echo-dense, shelf-like structure with an irregular, lumpy appearance involving the mitral valve annulus, with acoustic shadowing. Prevalence of MAC and its association with significant mitral stenosis (MS) or mitral regurgitation (MR) were studied. Significant (≥moderate) MS was defined as mean transmitral valvular pressure gradient > 5 mm Hg and significant MR was defined as ≥moderate MR based on quantitative or semi-quantitative Doppler methods. RESULTS MAC was present in 1881 of 13,483 patients (14%). Patients with MAC (MAC group) was older and more female gender than those without MAC (non-MAC group). Significant MS was present in 2.2% of MAC and in .6% of the non-MAC group (p < 0.0001). Significant MR was present in 11.9% of MAC and in 5.0% of the non-MAC group (p < 0.0001). Co-existence of MAC and aortic valve replacement (AVR) was associated with increased prevalence of MVD (MS:11.4%, MR:17.2%, respectively). CONCLUSION MAC was present in 14% of the patients and was associated with significant MVD. Co-existence of MAC and AVR may increase the risk of MVD.
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Affiliation(s)
- Hiroyuki Okura
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan.,Department of Cardiology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yasuki Nakada
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan
| | - Maki Nogi
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan
| | - Satomi Ishihara
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan
| | - Akihiko Okamura
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan
| | - Satoshi Okayama
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan
| | - Makoto Watanabe
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan
| | - Rika Kawakami
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan
| | - Yoshihiko Saito
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan
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Mak G, Lu JQ, Perera K. Histopathologic analysis of retrieved cerebral thrombi in acute ischemic stroke patients with proximal anterior circulation occlusions amenable to endovascular thrombectomy. J Neurol Sci 2021; 429:117617. [PMID: 34461551 DOI: 10.1016/j.jns.2021.117617] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 07/06/2021] [Accepted: 08/13/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Gloria Mak
- McMaster University, Department of Medicine, Hamilton Health Science, 237 Barton Street East, Hamilton, Ontario L8L 2X2, Canada.
| | - Jian-Qiang Lu
- McMaster University, Department of Pathology and Molecular Medicine, Hamilton Health Science, 237 Barton Street East, Hamilton, Ontario L8L 2X2, Canada.
| | - Kanjana Perera
- McMaster University, Department of Medicine, Population Health Research Institute, C4-106, 30 Copeland Avenue, Hamilton, Ontario L8L 2X2., Canada.
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Xu B, Kocyigit D, Wang TKM, Tan CD, Rodriguez ER, Pettersson GB, Unai S, Griffin BP. Mitral annular calcification and valvular dysfunction: multimodality imaging evaluation, grading, and management. Eur Heart J Cardiovasc Imaging 2021; 23:e111-e122. [PMID: 34591959 DOI: 10.1093/ehjci/jeab185] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 09/02/2021] [Indexed: 11/12/2022] Open
Abstract
Mitral annular calcification (MAC) refers to calcium deposition in the fibrous skeleton of the mitral valve. It has many cardiovascular associations, including mitral valve dysfunction, elevated cardiovascular risk, arrhythmias, and endocarditis. Echocardiography conventionally is the first-line imaging modality for anatomic assessment, and evaluation of mitral valve function. Cardiac computed tomography (CT) has demonstrated importance as an imaging modality for the evaluation and planning of related procedures. It also holds promise in quantitative grading of MAC. Currently, there is no universally accepted definition or classification system of MAC severity. We review the multimodality imaging evaluation of MAC and associated valvular dysfunction and propose a novel classification system based on qualitative and quantitative measurements derived from echocardiography and cardiac CT.
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Affiliation(s)
- Bo Xu
- Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J1-5, Cleveland, OH 44195, USA
| | - Duygu Kocyigit
- Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J1-5, Cleveland, OH 44195, USA
| | - Tom Kai Ming Wang
- Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J1-5, Cleveland, OH 44195, USA
| | - Carmela D Tan
- Department of Cardiovascular Anatomical Pathology, Cleveland Clinic, Cleveland, OH 44195, USA
| | - E Rene Rodriguez
- Department of Cardiovascular Anatomical Pathology, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Gösta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Shinya Unai
- Department of Thoracic and Cardiovascular Surgery, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Brian P Griffin
- Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J1-5, Cleveland, OH 44195, USA
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Han D, Kuronuma K, Rozanski A, Budoff MJ, Miedema MD, Nasir K, Shaw LJ, Rumberger JA, Gransar H, Blumenthal RS, Blaha MJ, Berman DS. Implication of thoracic aortic calcification over coronary calcium score regarding the 2018 ACC/AHA Multisociety cholesterol guideline: results from the CAC Consortium. Am J Prev Cardiol 2021; 8:100232. [PMID: 34467259 PMCID: PMC8385171 DOI: 10.1016/j.ajpc.2021.100232] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 07/26/2021] [Accepted: 08/02/2021] [Indexed: 12/16/2022] Open
Abstract
TAC in segments of the ascending and descending thoracic aorta can be assessed by routine CAC scanning. TAC assessment with the threshold of 300 improved risk prediction and reclassification for CVD mortality when added to the ASCVD risk score and CAC. TAC >300 may improve patient selection for those who would benefit more strongly from statin use, from intermediate ASCVD risk patients who should consider a statin (CAC=1-100), and those where a statin is not recommended (CAC=0).
Objective TAC is associated with an increased atherosclerotic cardiovascular disease (ASCVD) risk, but it is unclear how to interpret thoracic aortic calcification (TAC) findings in conjunction with ASCVD risk and coronary artery calcium (CAC) score according to 2018 ACC/AHA Multisociety cholesterol guidelines. We evaluate the incremental value of thoracic aortic calcification TAC over CAC for predicting and reclassifying ASCVD mortality risk. Method The study included 30,630 asymptomatic individuals (mean age: 55 ± 8 years, male: 64%) from the CAC Consortium. TAC was categorized as TAC 0, 1-300, and >300. Patients were categorized as low (<5%), borderline (5–7.5%), intermediate (7.5–20%), or high (≥20%) 10-year ASCVD risk according to the Pooled Cohorts Equation. In the intermediate risk group, the utility of TAC beyond CAC for statin eligibility was assessed according to the guideline. CAC was categorized as CAC=0 (no statin), CAC 1-100 (favors statin), or CAC>100 (initiate stain). Results During the median 11.2 years (IQR 9.2–12.4) follow-up, 345 (1.1%) CVD deaths occurred. TAC>300 was associated with increased CVD mortality after adjusting for ASCVD risk and CAC (HR:4.72, 95% CI: 3.39–6.57, p<0.001). In borderline and intermediate risk groups, TAC improved discrimination when added to a model included ASCVD risk and CAC (C-statistic: 0.77 vs. 0.68 in borderline group; 0.67 vs. 0.63 in intermediate group, both p < 0.05). The addition of TAC over CAC improved risk reclassification in borderline, intermediate and high-risk groups (categorical net reclassification index: 0.40, 0.29, and 0.49, respectively, all p < 0.001). Of intermediate risk participants for whom consideration of CAC was recommended based on the guideline, TAC >300 was associated with an increased CVD mortality risk across each statin eligibility group (all p < 0.001, compared to TAC 0). Conclusion TAC was independently associated with CVD death. Among individuals with borderline or intermediate ASCVD risk, a TAC threshold of 300 may provide added prognostic and reclassification value beyond the current guideline-based approach.
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Affiliation(s)
- Donghee Han
- Department of Imaging and Medicine, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Los Angeles, CA 90048, United States
| | - Keiichiro Kuronuma
- Department of Imaging and Medicine, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Los Angeles, CA 90048, United States
| | - Alan Rozanski
- Division of Cardiology, Mount Sinai St. Luke's Hospital, New York, United States
| | - Matthew J Budoff
- Department of Medicine, Harbor-UCLA Medical Center, University of California Los Angeles, Los Angeles, CA, United States
| | - Michael D Miedema
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN, United States
| | - Khurram Nasir
- Division Cardiovascular Prevention and Wellness, Houston Methodist Hospital, Houston, TX, United States
| | - Leslee J Shaw
- Department of Radiology, New York-Presbyterian Hospital and Weill Cornell Medicine, New York United States
| | | | - Heidi Gransar
- Department of Imaging and Medicine, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Los Angeles, CA 90048, United States
| | - Roger S Blumenthal
- Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University, Baltimore, MD, United States
| | - Michael J Blaha
- Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University, Baltimore, MD, United States
| | - Daniel S Berman
- Department of Imaging and Medicine, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Los Angeles, CA 90048, United States
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Birudaraju D, Cherukuri L, Pranesh S, Budoff MJ. Current methods to assess mitral annular calcification and its risk factors. Expert Rev Cardiovasc Ther 2021; 19:787-800. [PMID: 34348555 DOI: 10.1080/14779072.2021.1964361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Divya Birudaraju
- Division Of Cardiology, Lundquist Institute For Biomedical Innovation At Harbor-UCLA, Torrance, California, USA
| | - Lavanya Cherukuri
- Division Of Cardiology, Lundquist Institute For Biomedical Innovation At Harbor-UCLA, Torrance, California, USA
| | - Shruthi Pranesh
- Division Of Cardiology, Penn State Holy Spirit Hospital, Harrisburg, Pennsylvania, USA
| | - Matthew J Budoff
- Division Of Cardiology, Lundquist Institute For Biomedical Innovation At Harbor-UCLA, Torrance, California, USA
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Molina-Fuentes MF, Neumann R, Behringer W, Franz M, Schulze PC, Witte OW, Günther A, Klingner C, Lehmkuhl L, Steiniger B, Teichgräber U, Rod JE, Mayer TE. Feasibility of the Big 5-Jena eCS Protocol : First Experience Implementing a New Extended CT Protocol in the Initial Diagnostics of Ischemic Stroke. Clin Neuroradiol 2021; 31:901-909. [PMID: 34379134 PMCID: PMC8356684 DOI: 10.1007/s00062-021-01058-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 06/18/2021] [Indexed: 10/25/2022]
Abstract
PURPOSE The most common protocols in the initial diagnostic of acute ischemic stroke do not assess cardiogenic or aortic causes of embolism. These are usually evaluated later by transthoracic (TTE) or transesophageal (TEE) echocardiography. This study aimed to evaluate the feasibility of a diagnostic tool for thoracic cardiovascular thrombi according to the first experience with a new extended cardio-stroke protocol (Big 5-Jena eCS protocol) in acute stroke patients. METHODS Retrospective analyses of the tomography scans database of the Jena University Hospital were performed. We included a total of 67 patients in the feasibility analyses, based on the evaluation of three outcomes. RESULTS Primary outcome: the Big 5-Jena eCS protocol was able to detect thoracic cardiovascular thrombi in a total of 20 patients in different locations including the arch of the aorta, the aortic valve, the left atrium, the left atrial appendage, the left ventricle, and the pulmonary arteries. Secondary outcome: implementating the protocol did not result in a significant elevation of the radiation exposure compared to traditional protocols. Tertiary outcome: the new protocol identified seven cases that were considered negative by echocardiography. CONCLUSION The implementation of an extended cardio-stroke protocol is feasible, no significantly time-consuming, acquiring assessable imaging, and maintaining radiation exposure acceptable. The Big 5-Jena eCS protocol was also able to detect some thrombi not reported by TTE or TEE; however, due to our data's explorative character, a conclusive comparison with cardiac ultrasound is not possible. A prospective pilot study and clinical trials should be conducted to assess the diagnostic accuracy of this protocol compared to echocardiography and determine the potential impact on diagnostic and treatment decisions.
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Affiliation(s)
- Moisés F Molina-Fuentes
- Department of Neuroradiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany. .,Department of Diagnostic and Interventional Radiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany. .,Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany.
| | - Rotraud Neumann
- Department of Neuroradiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany.,Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Wilhelm Behringer
- Emergency Department, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Marcus Franz
- Department of Internal Medicine, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - P Christian Schulze
- Department of Internal Medicine, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Otto W Witte
- Hans Berger Department of Neurology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Albrecht Günther
- Hans Berger Department of Neurology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Carsten Klingner
- Hans Berger Department of Neurology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Lukas Lehmkuhl
- Clinic for Radiology, Rhön-Klinikum Campus Bad Neustadt, Bad Neustadt a. d. Saale, Germany
| | - Beatrice Steiniger
- Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Ulf Teichgräber
- Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - J E Rod
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Thomas E Mayer
- Department of Neuroradiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany.,Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
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Cohen A, Donal E, Delgado V, Pepi M, Tsang T, Gerber B, Soulat-Dufour L, Habib G, Lancellotti P, Evangelista A, Cujec B, Fine N, Andrade MJ, Sprynger M, Dweck M, Edvardsen T, Popescu BA. EACVI recommendations on cardiovascular imaging for the detection of embolic sources: endorsed by the Canadian Society of Echocardiography. Eur Heart J Cardiovasc Imaging 2021; 22:e24-e57. [PMID: 33709114 DOI: 10.1093/ehjci/jeab008] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 01/07/2021] [Indexed: 12/28/2022] Open
Abstract
Cardioaortic embolism to the brain accounts for approximately 15-30% of ischaemic strokes and is often referred to as 'cardioembolic stroke'. One-quarter of patients have more than one cardiac source of embolism and 15% have significant cerebrovascular atherosclerosis. After a careful work-up, up to 30% of ischaemic strokes remain 'cryptogenic', recently redefined as 'embolic strokes of undetermined source'. The diagnosis of cardioembolic stroke remains difficult because a potential cardiac source of embolism does not establish the stroke mechanism. The role of cardiac imaging-transthoracic echocardiography (TTE), transoesophageal echocardiography (TOE), cardiac computed tomography (CT), and magnetic resonance imaging (MRI)-in the diagnosis of potential cardiac sources of embolism, and for therapeutic guidance, is reviewed in these recommendations. Contrast TTE/TOE is highly accurate for detecting left atrial appendage thrombosis in patients with atrial fibrillation, valvular and prosthesis vegetations and thrombosis, aortic arch atheroma, patent foramen ovale, atrial septal defect, and intracardiac tumours. Both CT and MRI are highly accurate for detecting cavity thrombosis, intracardiac tumours, and valvular prosthesis thrombosis. Thus, CT and cardiac magnetic resonance should be considered in addition to TTE and TOE in the detection of a cardiac source of embolism. We propose a diagnostic algorithm where vascular imaging and contrast TTE/TOE are considered the first-line tool in the search for a cardiac source of embolism. CT and MRI are considered as alternative and complementary tools, and their indications are described on a case-by-case approach.
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Affiliation(s)
- Ariel Cohen
- Assistance Publique-Hôpitaux de Paris, Saint-Antoine and Tenon Hospitals, Department of Cardiology, and Sorbonne University, Paris, France.,INSERM unit UMRS-ICAN 1166; Sorbonne-Université, Paris, France
| | - Erwan Donal
- University of Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, F-35000 Rennes, France
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Mauro Pepi
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, 20141, Milan, Italy
| | - Teresa Tsang
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bernhard Gerber
- Service de Cardiologie, Département Cardiovasculaire, Cliniques Universitaires St. Luc, Division CARD, Institut de Recherche Expérimental et Clinique (IREC), UCLouvainAv Hippocrate 10/2803, B-1200 Brussels, Belgium
| | - Laurie Soulat-Dufour
- Assistance Publique-Hôpitaux de Paris, Saint-Antoine and Tenon Hospitals, Department of Cardiology, and Sorbonne University, Paris, France.,INSERM unit UMRS-ICAN 1166; Sorbonne-Université, Paris, France
| | - Gilbert Habib
- Aix Marseille Univ, IRD, MEPHI, IHU-Méditerranée Infection, APHM, La Timone Hospital, Cardiology Department, Marseille, France
| | - Patrizio Lancellotti
- University of Liège Hospital, GIGA Cardiovascular Sciences, Department of Cardiology, CHU SartTilman, Liège, Belgium.,Gruppo Villa Maria Care and Research, Maria Cecilia Hospital, Cotignola, and Anthea Hospital, Bari, Italy
| | - Arturo Evangelista
- Servei de Cardiologia. Hospital Universitari Vall d'Hebron-VHIR. CIBER-CV. Pº Vall d'Hebron 119. 08035. Barcelona. Spain
| | - Bibiana Cujec
- Division of Cardiology, University of Alberta, 2C2.50 Walter Mackenzie Health Sciences Center, 8440 112 St NW, Edmonton, Alberta, Canada T6G 2B7
| | - Nowell Fine
- University of Calgary, Libin Cardiovascular Institute, South Health Campus, 4448 Front Street Southeast, Calgary, Alberta T3M 1M4, Canada
| | - Maria Joao Andrade
- Maria Joao Andrade Cardiology Department, Hospital de Santa Cruz-Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos 2790-134 Carnaxide, Portugal
| | - Muriel Sprynger
- Department of Cardiology-Angiology, University Hospital Liège, Liège, Belgium
| | - Marc Dweck
- British Heart Foundation, Centre for Cardiovascular Science, Edinburgh and Edinburgh Imaging Facility QMRI, University of Edinburgh, United Kingdom
| | - Thor Edvardsen
- Faculty of medicine, Oslo University, Oslo, Norway and Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Bogdan A Popescu
- Cardiology Department, University of Medicine and Pharmacy 'Carol Davila', Emergency Institute for Cardiovascular Diseases 'Prof. Dr. C. C. Iliescu', Sos. Fundeni 258, sector 2, 022328 Bucharest, Romania
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Urena M, Lemann T, Chong-Nguyen C, Brochet E, Ducrocq G, Carrasco JL, Iung B, Vahanian A, Himbert D. Causes and predictors of mortality after transcatheter mitral valve implantation in patients with severe mitral annulus calcification. Catheter Cardiovasc Interv 2021; 98:981-989. [PMID: 34263517 DOI: 10.1002/ccd.29874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/13/2021] [Accepted: 07/05/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To evaluate the causes and predictors of mortality after valve-in-mitral annulus calcification (MAC) transcatheter mitral valve implantation (TMVI). BACKGROUND Conventional surgical mitral valve replacement is associated with a high risk in patients with mitral valve disease associated with severe MAC. In this population, TMVI may be an attractive alternative option. However, its prognostic factors are poorly understood. METHODS All patients undergoing valve-in-MAC TMVI from 2013 to 2018 in our center were included. Indication for TMVI relied on the judgment of the local heart team. Patients were followed at 30 days and 1 year. RESULTS A total of 34 patients underwent valve-in-MAC TMVI. The mean age was 79 ± 11 years and 73% of patients were women. Their mean EuroSCORE 2 was 8 ± 7%. The transseptal approach was used in 79% of patients and a hybrid transatrial in 29%. Balloon expandable transcatheter heart valves were used in all the patients. Technical success was achieved in 76% of the patients. Thirty-day and 1-year all-cause mortality rates were 14.7% and 32.4%, respectively. The main two causes of 1-year mortality were congestive heart failure (8.8%) and infective endocarditis (5.9%). In multivariate analysis, the only predictor of 1-year mortality was the presence of periprothetic mitral regurgitation grade 2 (HR, 5.69; 95%CI, 1.59-27.88, p = 0.032). CONCLUSION Early and mid-term mortality remains high after valve-in-MAC TMVI and seems to be associated with the presence of paravalvular mitral regurgitation. However, whether the latter is a prognostic factor or marker remains to be determined to improve clinical outcomes in this high-risk population.
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Affiliation(s)
- Marina Urena
- University of Paris, Paris, France.,Department of Cardiology, Assistance Publique - Hôpitaux de Paris, Bichat-Claude Bernard Hospital, Paris, France.,INSERM U 1148, Paris, France
| | - Thomas Lemann
- Department of Cardiology, Assistance Publique - Hôpitaux de Paris, Bichat-Claude Bernard Hospital, Paris, France
| | - Caroline Chong-Nguyen
- Department of Cardiology, Assistance Publique - Hôpitaux de Paris, Bichat-Claude Bernard Hospital, Paris, France
| | - Eric Brochet
- Department of Cardiology, Assistance Publique - Hôpitaux de Paris, Bichat-Claude Bernard Hospital, Paris, France
| | - Grégory Ducrocq
- University of Paris, Paris, France.,Department of Cardiology, Assistance Publique - Hôpitaux de Paris, Bichat-Claude Bernard Hospital, Paris, France.,INSERM U 1148, Paris, France
| | - Jose-Luis Carrasco
- Assistance Publique - Hôpitaux de Paris, Department of Anaesthesiology, Bichat-Claude Bernard Hospital, Paris, France
| | - Bernard Iung
- University of Paris, Paris, France.,Department of Cardiology, Assistance Publique - Hôpitaux de Paris, Bichat-Claude Bernard Hospital, Paris, France.,INSERM U 1148, Paris, France
| | - Alec Vahanian
- University of Paris, Paris, France.,INSERM U 1148, Paris, France
| | - Dominique Himbert
- Department of Cardiology, Assistance Publique - Hôpitaux de Paris, Bichat-Claude Bernard Hospital, Paris, France.,INSERM U 1148, Paris, France
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Nishiguchi Y, Matsuyama H, Shindo A, Matsuura K, Niwa A, Hirota Y, Fukuma T, Ito H, Kozuka Y, Tomimoto H. Cerebral Embolism Associated with Calcified Amorphous Tumor: A Review of Cerebral Infarction Cases. Intern Med 2021; 60:2315-2319. [PMID: 33612675 PMCID: PMC8355388 DOI: 10.2169/internalmedicine.6262-20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Calcified amorphous tumor (CAT) is a non-neoplastic tumor composed of calcified nodules consisting of amorphous fibrous material, and it may eventually cause cerebral infarction (CI). We experienced a 67-year-old woman with CAT who had recurrent CI. After excision of the CAT, the CI did not show recurrence. A review of previous papers on CI due to CAT in Pubmed revealed that 7 of 13 studies originated in Japan and that CI can occur even with small CAT. Surgical treatment is recommended to prevent CI recurrence, especially when CAT is accompanied by mitral annular calcification or has marked mobility.
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Affiliation(s)
- Yamato Nishiguchi
- Department of Neurology, Mie University Graduate School of Medicine, Japan
| | - Hirofumi Matsuyama
- Department of Neurology, Mie University Graduate School of Medicine, Japan
| | - Akihiro Shindo
- Department of Neurology, Mie University Graduate School of Medicine, Japan
| | - Keita Matsuura
- Department of Neurology, Mie University Graduate School of Medicine, Japan
| | - Atsushi Niwa
- Department of Neurology, Mie University Graduate School of Medicine, Japan
| | - Yumi Hirota
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan
| | - Tomoyuki Fukuma
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan
| | - Hisato Ito
- Department of Thoracic and Cardiovascular Surgery, Mie University Graduate School of Medicine, Japan
| | - Yuji Kozuka
- Department of Pathology, Mie University Graduate School of Medicine, Japan
| | - Hidekazu Tomimoto
- Department of Neurology, Mie University Graduate School of Medicine, Japan
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Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021; 52:e364-e467. [PMID: 34024117 DOI: 10.1161/str.0000000000000375] [Citation(s) in RCA: 1004] [Impact Index Per Article: 334.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Garg PK, Buzkova P, Meyghani Z, Budoff MJ, Lima J, Criqui M, Cushman M, Allison M. Valvular calcification and risk of peripheral artery disease: the Multi-Ethnic Study of Atherosclerosis (MESA). Eur Heart J Cardiovasc Imaging 2021; 21:1152-1159. [PMID: 31740939 DOI: 10.1093/ehjci/jez284] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 09/20/2019] [Accepted: 10/25/2019] [Indexed: 11/13/2022] Open
Abstract
AIMS The detection of cardiac valvular calcification on routine imaging may provide an opportunity to identify individuals at increased risk for peripheral artery disease (PAD). We investigated the associations of aortic valvular calcification (AVC) and mitral annular calcification (MAC) with risk of developing clinical PAD or a low ankle-brachial index (ABI). METHODS AND RESULTS AVC and MAC were measured on cardiac computed tomography in 6778 Multi-Ethnic Study of Atherosclerosis participants without baseline PAD between 2000 and 2002. Clinical PAD was ascertained through 2015. Incident low ABI, defined as ABI <0.9 and decline of ≥0.15, was assessed among 5762 individuals who had an ABI >0.9 at baseline and at least one follow-up ABI measurement 3-10 years later. Adjusted Cox proportional hazards and Poisson regression modelling were used to determine the association of valvular calcification with clinical PAD and low ABI, respectively. There were 117 clinical PAD and 198 low ABI events that occurred over a median follow-up of 14 years and 9.2 years, respectively. The presence of MAC was associated with an increased risk of clinical PAD [hazard ratio 1.79; 95% confidence interval (CI) 1.04-3.05] but not a low ABI (rate ratio 1.28; 95% CI 0.75-2.19). No significant associations were noted for the presence of AVC and risk of either clinical PAD. CONCLUSION MAC is associated with an increased risk of developing clinical PAD. Future studies are needed to corroborate our findings and better understand whether MAC holds any predictive value as a risk marker for PAD.
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Affiliation(s)
- Parveen K Garg
- Division of Cardiology, University of Southern California Keck School of Medicine, 1510 San Pablo St. Suite 322, Los Angeles, CA, USA
| | - Petra Buzkova
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Zahra Meyghani
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew J Budoff
- Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Joao Lima
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael Criqui
- Division of Preventive Medicine, University of California, San Diego School of Medicine, San Diego, CA, USA
| | - Mary Cushman
- Department of Medicine and Pathology & Laboratory Medicine, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Matthew Allison
- Division of Preventive Medicine, University of California, San Diego School of Medicine, San Diego, CA, USA
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Martínez Fernández L, Sánchez-Alvarez JE, Morís de la Tassa C, Bande Fernández JJ, María V, Fernández E, Valdivielso JM, Betriu A. Risk factors associated with valvular calcification in patients with chronic kidney disease. Analysis of NEFRONA study. Nefrologia 2021; 41:337-346. [PMID: 36166249 DOI: 10.1016/j.nefroe.2021.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 08/14/2020] [Indexed: 06/16/2023] Open
Abstract
INTRODUCTION Patients with chronic kidney disease (CKD) are at high risk of cardiovascular morbidity and mortality. Subclinical cardiac structural alterations have prognostic value in these patients. The aim was to analyse the prevalence of valvular calcification, the evolution and the relationship with different risk factors. MATERIAL AND METHODS Part of the sample of the NEFRONA study was randomly selected. Aortic and mitral valve calcification were analysed in echocardiograms performed at the baseline visit and at 24 months. RESULTS We included 397 patients, the estimated basal glomerular filtrate (eGFR) was 33 ml/min with significant decrease to 30.9 ml/min. There was an increase in the area of carotid and femoral plaque, as well as an increase in patients with aortic and mitral calcification at 24 months. A positive association of mitral calcification at 24 months with age, ankle-brachial index (ABI) and calcium-phosphorus product (CaxP) at baseline visit was observed, without association with eGFR. Aortic calcification at 24 months was positively associated with age, phosphorous and total carotid plaque area at baseline, with no relationship to eGFR. CONCLUSIONS A significant prevalence of valvular calcification was observed in patients with CKD without known cardiovascular disease.Two-year progression was observed independently of the eGFR. Patients with higher risk of mitral valve calcification were those with older age, higher ABI and CaxP product. Patients with a higher risk of aortic calcification were those with older age, higher phosphorous levels and larger area of carotid plaque. Identifying these higher risk patients would help to avoid future cardiovascular events intensifying follow-ups.
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Affiliation(s)
| | - J Emilio Sánchez-Alvarez
- Hospital Universitario de Cabueñes, Gijón, Asturias, Spain; Red de Investigación Renal (REDINREN), Spain
| | | | | | - Virtudes María
- Vascular and Renal Translational, Research Group, Institut de Recerca Biomèdica, Lleida, Spain
| | - Elvira Fernández
- Vascular and Renal Translational, Research Group, Institut de Recerca Biomèdica, Lleida, Spain
| | - Jose M Valdivielso
- Vascular and Renal Translational, Research Group, Institut de Recerca Biomèdica, Lleida, Spain
| | - Angels Betriu
- Vascular and Renal Translational, Research Group, Institut de Recerca Biomèdica, Lleida, Spain
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Alexis SL, Malik AH, El‐Eshmawi A, George I, Sengupta A, Kodali SK, Hahn RT, Khalique OK, Zaid S, Guerrero M, Bapat VN, Leon MB, Adams DH, Tang GHL. Surgical and Transcatheter Mitral Valve Replacement in Mitral Annular Calcification: A Systematic Review. J Am Heart Assoc 2021; 10:e018514. [PMID: 33728929 PMCID: PMC8174336 DOI: 10.1161/jaha.120.018514] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Mitral annular calcification with mitral valve disease is a challenging problem that could necessitate surgical mitral valve replacement (SMVR). Transcatheter mitral valve replacement (TMVR) is emerging as a feasible alternative in high-risk patients with appropriate anatomy. PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched from inception to December 25, 2019 for studies discussing SMVR or TMVR in patients with mitral annular calcification; 27 of 1539 articles were selected for final review. TMVR was used in 15 studies. Relevant data were available on 82 patients who underwent hybrid transatrial TMVR, and 354 patients who underwent transapical or transseptal TMVR. Outcomes on SMVR were generally reported as small case series (447 patients from 11 studies); however, 1 large study recently reported outcomes in 9551 patients. Patients who underwent TMVR had a shorter median follow-up of 9 to 12 months (range, in-hospital‒19 months) compared with patients with SMVR (54 months; range, in-hospital‒120 months). Overall, those undergoing TMVR were older and had higher Society of Thoracic Surgeons risk scores. SMVR showed a wide range of early (0%-27%; median 6.3%) and long-term mortality (0%-65%; median at 1 year, 15.8%; 5 years, 38.8%, 10 years, 62.4%). The median in-hospital, 30-day, and 1-year mortality rates were 16.7%, 22.7%, and 43%, respectively, for transseptal/transapical TMVR, and 9.5%, 20.0%, and 40%, respectively, for transatrial TMVR. Mitral annular calcification is a complex disease and TMVR, with a versatile option of transatrial approach in patients with challenging anatomy, offers a promising alternative to SMVR in high-risk patients. However, further studies are needed to improve technology, patient selection, operative expertise, and long-term outcomes.
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Affiliation(s)
- Sophia L. Alexis
- Department of Cardiovascular SurgeryMount Sinai Health SystemNew YorkNY
| | - Aaqib H. Malik
- Department of MedicineWestchester Medical CenterValhallaNY
| | - Ahmed El‐Eshmawi
- Department of Cardiovascular SurgeryMount Sinai Health SystemNew YorkNY
| | - Isaac George
- Division of Cardiac SurgeryNew York Presbyterian Hospital/Columbia University Medical CenterNew YorkNY
| | - Aditya Sengupta
- Department of Cardiovascular SurgeryMount Sinai Health SystemNew YorkNY
| | - Susheel K. Kodali
- Division of CardiologyNew York Presbyterian Hospital/Columbia University Medical CenterNew YorkNY
| | - Rebecca T. Hahn
- Division of CardiologyNew York Presbyterian Hospital/Columbia University Medical CenterNew YorkNY
| | - Omar K. Khalique
- Division of CardiologyNew York Presbyterian Hospital/Columbia University Medical CenterNew YorkNY
| | - Syed Zaid
- Department of CardiologyWestchester Medical CenterValhallaNY
| | | | - Vinayak N. Bapat
- Department of Cardiothoracic Surgery, Minneapolis Heart InstituteAbbott Northwestern HospitalMinneapolisMN
| | - Martin B. Leon
- Division of CardiologyNew York Presbyterian Hospital/Columbia University Medical CenterNew YorkNY
| | - David H. Adams
- Department of Cardiovascular SurgeryMount Sinai Health SystemNew YorkNY
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