Rapid progression of mitral and aortic stenosis in a patient with secondary hyperparathyroidism

Heart valve disease: the role of calcidiol deficiency, elevated parathyroid hormone levels and oxidative stress in mitral and aortic valve insufficiency

OBJECTIVES

Endothelia, intima, and connective tissues comprise the heart valves, but the relationship between heart valve damage, the pathogenesis of valve degeneration, and vitamin D, oxidative stress remains unclear. Here, we assessed serum 25(OH) vitamin D (calcidiol), parathormone (PTH), and redox balance in patients with mitral valve regurgitation (MR) and aortic valve regurgitation (AR).

METHODS

This study includes 56 chronic heart valve disease (HVD) patients. Patients were diagnosed with MR or AR depending on the echocardiographic findings. Also, 40 sex-matched healthy control participants were enrolled for comparison. Serum calcidiol, PTH, total oxidative status (TOS), and total antioxidative capacity were measured, and the oxidative stress index (OSI) was calculated.

RESULTS

Patients with HVD demonstrated significantly higher PTH, increased TOS and OSI, and a higher frequency of calcidiol deficiency than the control participants. Calcidiol and TOS were negatively correlated (r = -0.29; P <0.005), as were calcidiol and OSI (r = -0.413; P = 0.001). PTH and OSI were positively correlated (r = 0.22; P = 0.02).

DISCUSSION

We demonstrate that vitamin D deficiency and secondary increases in PTH are highly prevalent. Heart valve regurgitation (AR and MR) is correlated to oxidative stress and hypovitaminosis D.

Porcelain heart: rapid progression of cardiac calcification in a patient with hemodialysis

Cardiac calcification usually occurs in patients with end-stage renal disease. However, rapid progression of cardiac calcification is rarely associated with secondary hyperparathyroidism of end-stage renal disease. We report a patient with end-stage renal disease who showed moderate left ventricular hypertrophy at the first echocardiography, and showed severe myocardial calcification and severe mitral valve stenosis 4 years later. We suspected a rapid progression 'porcelain heart' cardiomyopathy secondary to hyperparathyroidism of end-stage renal disease. The patient underwent parathyroidectomy, and considered mitral valve replacement.

Relationship between Calcium-Phosphorus Product and Severity of Valvular Heart Insufficiency in Patients Undergoing Chronic Hemodialysis

BACKGROUND

Recent interests have mainly focused on the roles of serum calcium and phosphorus and their product (Ca-P product) in the development of valvular heart disease. The present study assessed the relationship between the Ca-P product and the severity of valvular heart disease in end-stage renal disease (ESRD) patients undergoing chronic hemodialysis.

METHODS

This cross-sectional study reviewed the clinical course of 72 consecutive patients with the final diagnosis of ESRD candidated for chronic hemodialysis. The severity of valvular heart disease was determined using M-mode two-dimensional echocardiography. The serum calcium and phosphate values adopted were those values measured on the day between the two consecutive dialyses, and the Ca-P product was calculated.

RESULTS

The most common causes of ESRD were diabetic nephropathy, malignant hypertension, and chronic glomerulonephritis. The mean Ca-P product level in the dialysis patients was 50.44 ± 17.78 mg(2)/dL(2). The receiver-operator characteristic (ROC) curve illustrated that a Ca-P product level > 42 mg(2)/dL(2) was the optimal value in terms of sensitivity and specificity for predicting the presence of valvular insufficiency. Aortic insufficiency was directly associated with a high Ca-P product value after adjustment for age, gender, serum albumin, diabetes, hypertension, hyperlipidemia, coronary artery disease, and serum creatinine (β = 0.412, SE = 158, p value= 0.011).

CONCLUSION

A positive relationship between the Ca-P product value and the severity of aortic insufficiency is expected. Achieving an appropriate control of the Ca-P product level may decrease aortic valve calcification and improve the survival of patients on chronic hemodialysis.

Myocardial calcinosis in chronic renal failure

The authors are presenting an 18 year old male with history of end stage renal disease and rejected renal transplant. In his workup echocardiogram and non contract CT of chest revealed diffuse endocardial and myocardial calcifications. Extensive cardiac calcification is a rare but important entity in relation to end stage renal disease as it may cause complications such as valvular dysfunction and fatal arrhythmia.

Risk factors for progression of calcific aortic stenosis and potential therapeutic targets

Current thought regarding the progression of calcific aortic stenosis (AS) is presented. After summarizing contemporary ideas about AS pathogenesis, the present article examines the factors that may affect disease progression. Data indicate that this process may be accelerated by aortic valve structure, degree of valvular calcification, chronic renal insufficiency and cardiovascular risk factors such as diabetes and dyslipidemia. Finally, the present review discusses potential therapeutic targets to slow AS progression.

Accelerated Progression and Morbidity in Patients With Aortic Stenosis on Chronic Dialysis

BACKGROUND

Progression of aortic stenosis (AS) influences the prognosis in chronic dialysis (CD) patients, but there have been few studies in Japanese patient populations.

METHODS AND RESULTS

The progression of AS was examined in 16 CD patients (68+/-10 years) and 82 non-dialysis patients (73+/-11 years). The mean follow-up was 32 and 40 months, respectively. The calcium-phosphate product was increased in CD patients (49+/-14 mg/dl vs 30+/-5 mg/dl; p<0.0001). At entry, the peak transaortic gradient detected by Doppler echocardiography was lower in CD patients (42+/-12 mmHg vs 57+/-22 mmHg; p<0.05). At follow-up, there was no difference between the 2 groups in that value (69+/-31 mmHg vs 71+/-27 mmHg). Decreasing rate of calculated aortic valvular area was increased in CD patients (0.14+/-0.13 cm2/year vs 0.06+/-0.09 cm2/year; p<0.05) and the calcification of the aortic valve was more severe at follow up in CD patients. The mortality was higher in CD patients (75 vs 28%; p<0.001).

CONCLUSIONS

AS appeared to progress rapidly in CD patients and therefore early aortic valve replacement may be necessary.

Valvular and perivalvular abnormalities in end-stage renal disease

Valvular and perivalvular involvement in end-stage renal disease (ESRD) is most commonly manifested as mitral annular calcification and aortic valve calcification. Both mitral and aortic valve calcification (MAC) occur more frequently and at younger age in those with ESRD than in those with normal renal function. Aortic valve calcification progresses to aortic stenosis more commonly and at a more accelerated rate than in the general population. Altered calcium and phosphate metabolism are thought to predispose to these valvular and perivalvular abnormalities. No treatment is necessary for MAC unless severe mitral regurgitation or stenosis occur (both are rare). Mitral valve repair or replacement and aortic valve replacement are indicated for severe symptomatic valve stenosis or regurgitation, albeit at a higher risk than in those with normal renal function. Infective endocarditis may complicate MAC or aortic stenosis in patients with ESRD and is associated with a high mortality rate in such patients.

New insights into the progression of aortic stenosis: implications for secondary prevention

BACKGROUND

The risk factors affecting aortic stenosis (AS) progression are not clearly defined. Insights into this may allow for its secondary prevention.

METHODS AND RESULTS

We investigated predictors of AS progression in 170 consecutive patients with AS who had paired echocardiograms > or =3 months (23+/-11) apart. Various clinical, echocardiographic, and biochemical variables were related to the change in aortic valve area (AVA). The annual rate of reduction in AVA was 0.10+/-0.27 cm(2) or 7+/-18% per year. The reduction in AVA per year was significantly related to initial AVA (r = 0.46, P<0.0001), the mean aortic valve gradient (r = 0.27, P = 0.04), left ventricular (LV) outflow tract velocity (r = 0.26, P = 0.001), and LV end-diastolic diameter (r = 0.20, P = 0.04) and marginally to serum creatinine level (r = 0.15, P = 0.08). Patients with a rate of reduction in AVA faster than the mean had higher serum creatinine (P = 0.04) and calcium (P = 0.08) levels. Those with a serum cholesterol level >200 mg/dL had a rate of AVA reduction roughly twice that of those with a lower cholesterol level (P = 0.04). Stepwise multiple regression analysis identified initial AVA, current smoking, and serum calcium level as the independent predictors of amount of AVA reduction per year.

CONCLUSIONS

Absolute and percentage reduction in AVA per year in those with AS is greater in those with milder degrees of stenosis and is accelerated in the presence of smoking, hypercholesterolemia, and elevated serum creatinine and calcium levels. These findings may have important implications in gaining further insights into the mechanism of AS progression and in formulating strategies to retard this process.