Aortic Annular Calcification Research Articles

The feasibility of relaxation-enhanced angiography without contrast and triggering for preprocedural planning of transcatheter aortic valve implantation.

Cardiovascular MRI is advantageous in transcatheter aortic valve implantation (TAVI) planning. This study aimed to evaluate the feasibility of comprehensive non-contrast MRI [relaxation-enhanced angiography without contrast and triggering (REACT)] combined with a three-dimensional whole-heart MRI protocol for preprocedural planning of TAVI vs. computed tomography angiography (CTA). Thirty patients with severe aortic stenosis were prospectively enrolled. The anatomical properties of the aortic root anatomy, including the perimeter and area of the virtual aortic valve annulus and coronary heights, were determined from 3D whole-heart MRI and cardiac CTA (CCTA) images, respectively. The diameters of the aorta (thoracic and abdominal aorta) and iliofemoral arteries were measured from REACT and aortic CTA (ACTA) images, respectively. A paired t-test was used to compare these two modalities. Bland-Altman plots were used to assess cardiovascular MRI and CTA measurements. Transcatheter heart valve (THV) sizing was performed based on CCTA measurements and compared with 3D whole-heart MRI measurements. The extent of annular calcification on 3D whole-heart MRI images was evaluated by a four-point grading scale and compared with CCTA data. All 30 patients completed CTA and cardiovascular MRI examinations, with the TAVI procedure being administered in 25 patients. The mean acquisition time of the comprehensive MRI protocol was 18 ± 3.2 min. There were no significant differences between ACTA and REACT data in regard to the diameters of aortic and iliofemoral arteries, including the ascending thoracic aorta (37 ± 4.6 mm vs. 37.7 ± 5.2 mm, p = 0.085), descending thoracic aorta (24.3 ± 2.8 mm vs. 24.3 ± 2.8 mm, p = 0.832), abdominal aorta (20.9 ± 2.5 mm vs. 20.8 ± 2.5 mm, p = 0.602), bilateral common iliac arteries (right: 8.36 ± 1.44 mm vs. 8.42 ± 1.27 mm, p = 0.590; left: 8.61 ± 1.71 mm vs. 8.86 ± 1.46 mm, p = 0.050), and bilateral femoral arteries (right: 6.77 ± 1.06 mm vs. 6.87 ± 1.00 mm, p = 0.157; left: 6.75 ± 1.02 mm vs. 6.90 ± 0.80 mm, p = 0.142). Both modalities showed similar aortic valve morphology and semi-quantitative valve calcification (all, p's > 0.05). Overall agreement for implanted THV was found in all 25 (100%) patients assessed with both modalities. REACT combined with 3D whole-heart MRI enables reliable measurements of aortic root anatomy, annular calcification, and aorta and iliofemoral access in patients under evaluation for TAVI.

Mitral annular calcification in obstructive hypertrophic cardiomyopathy: Incidence, risk factors, and prognostic value after myectomy

BackgroundMitral 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). MethodsConsecutive 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. ResultsFrom 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). ConclusionMAC 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.

“UFO procedure” for massive aortic and mitral annular calcification involving left atrial and ventricular myocardium: a potential radical solution

BackgroundThe “UFO procedure” was initially developed as a surgical option to enlarge the aortic annulus in patients requiring valve replacement. This technique can be employed to treat extensive endocarditis located in the intervalvular fibrous body (IVFB). One of the indications for a "UFO procedure" is massive aortic and mitral valve calcification. It is a challenging surgical procedure with a high risk of intraoperative complications.Case summaryWe present a 76-year-old male patient with massive aortic and mitral valve calcification involving the left atrium, the left ventricle and the left ventricular outflow tract. Both valves exhibited severe stenosis and moderate to severe regurgitation. The left ventricle was hypertrophic and the left ventricular ejection fraction was > 55%. The patient was prediagnosed with persistent atrial fibrillation. The risk of death following heart surgery (EuroSCORE II) was calculated as 9.21%. We successfully performed a so-called “UFO procedure” including replacement of both valves without annular decalcification to avoid atrioventricular dehiscence. We enlarged the IVFB and replaced the non-coronary sinus of Valsalva with doubled bovine pericardium. The left ventricular outflow tract was decalcified. The patient was transferred to a local hospital on the 13th postoperative day.ConclusionSuccessful surgical treatment to this extent was demonstrated for the first time. Due to the high perioperative mortality, the surgical treatment of patients with this constellation would be refused in most cases. In our patient, the preoperative imaging showed extreme calcification of both valves and the surrounding myocardium. Excellent preoperative planning and a highly experienced surgical team is necessary.

Impact of mitral annular calcification on hemodynamic effect in mitral stenosis in multiple valve disease: relevant or not

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Prevalence of mitral annulus calcification (MAC) and degenerative mitral stenosis thus elevated transmitral gradient (TMG) is increased with age and multivalve involvement. The management of degenerative multivalve disease is challenging, as is identification of the presence of multivalve involvement and its hemodynamic impact because of interaction between two or more valve lesions especially in degenerative valve disease. Hemodynamic interaction between significant aortic stenosis and mitral annular calcification is often combined with diastolic disfunction which can result in LA enlargement and abnormal atrioventricular coupling and left atrial and ventricular remodeling. Purpose Study aimed to assess the effect of MAC on mitral valve stenosis in patients with multiple valve disease of degenerative origin. Method We retrospectively analyzed 78 patients with elevated transmitral gradient defined as an elevated TMG >4mmHg, MAC in multivalve involvement, mainly degenerative significant aortic valve stenosis who were treated in our clinic from 2018 to 2021. We excluded patients with prior cardiac surgery, congenital heart disease, hypertrophic obstructive cardiomyopathy and with heart rate >100 bpm at time of study and significant mitral regurgitation. Baseline demographic data were extracted from the electronic medical record and echocardiographic data were analyzed from electronic saved data. Results Study identified a total of 78 patients (average age 71,89 years, 64% females). Of 57 analyzed patients 32% patients had severe MAC and calcification of chordae, and 68% patients had MAC and mild or no significant chordae calcification. Patients with aortic gradients, severe aortic stenosis (AVAi 0,80 cm/m2) were observed more often in patients with severe MAC and significant chordae calcification than in those with nonsevere MAC (p < 0.043).There was no significant difference in mitral annular distension between groups. Baseline mean MV gradients were 6,5+-1.5 mm Hg. Mean MVA (continuity equation) was 1,5+-0.4 cm2, and MVAi 0,8+-0,2 cm/m2, mean LA volume 70 ml/m2, mean E/e 35, mean EF LV 68% and mean GLS -14. Conclusion Result suggest that increasing transmitral gradient if superimposed on severe MAC with only modest mitral stenosis will result in a high mean transmitral gradient. The presence of elevated pressure transmitral gradient in patients with more severe aortic stenosis and more severe MAC combined with chordae calcification may imply hemodynamic effect or stress on mitral valve degeneration in multiple valve involvement. Other imaging modalities and further investigation for better understanding effect of hemodynamic stress in multiple valve disease are needed. These observations need to be evaluated on larger cohorts of patients during a longer period of time.

Association of dietary and gut microbiota-related metabolites with calcific aortic stenosis

Background Histopathological changes in calcific aortic stenosis (CAS) resemble changes in coronary atherosclerosis. Concerning recent evidence on dietary and gut microbiota-related metabolites representing players in atherosclerosis, we aimed to investigate the link between dietary and gut microbiota-derived metabolites and CAS. Methods We consecutively recruited eligible subjects with moderate-severe CAS (n = 60), aortic sclerosis (ASc) (n = 49) and age and gender-matched control subjects (n = 48) in May 2016-December 2016. Plasma dietary and gut microbiota-related metabolite levels, namely choline, betaine, and trimethylamine N-oxide (TMAO), were measured using ultra-performance liquid chromatography-tandem mass spectroscopy method. Histopathological examinations were performed in patients that underwent aortic valve surgery. Results Prevalence of traditional cardiovascular risk factors or co-morbidities did not differ among groups (all p > 0.05). CAS patients had higher plasma choline levels compared to both control (p < 0.001) and ASc (p = 0.006). Plasma betaine and TMAO levels were similar (both p > 0.05). Compared to the lowest quartile choline levels (<11.15 μM), patients with the highest quartile choline levels (≥14.98 μM) had higher aortic valvular (p < 0.001) and mitral annular (p = 0.013) calcification scores. Plasma choline levels were independently associated with aortic peak flow velocity (B ± SE:0.165 ± 0.060, p = 0.009). Choline levels were elevated in subjects who had aortic valves with denser lymphocyte infiltration (p < 0.001), neovascularization (p = 0.011), osseous metaplasia (p = 0.004), more severe tissue remodelling (p = 0.002) and calcification (p = 0.002). Conclusion We found a significant association between choline levels and CAS presence and severity depicted on imaging modalities and histopathological examinations. Our study may open new horizons for prevention of CAS.

Calcified mitro-aortic continuity and mitral regurgitation in patients undergoing transcatheter aortic valve replacement

Abstract Introduction Calcified aortic stenosis (AS) and mitral annular calcification (MAC) have similar etiology and pathophysiological mechanisms. Half of all patients undergoing transcatheter aortic valve implantation (TAVI) have MAC. Several studies assessed the role of mitral regurgitation (MR) following TAVI but only few examined influence of MAC on its changes after TAVI. MAC frequently coexists with the calcification of mitro-aortic continuity (CMAC). Purpose Presence of CMAC may influence the results of TAVI, especially in the case of deeper implantation, protruding to let ventricular outflow tract (LVOT). In the present study we aimed at qualitative and semi-quantitative analysis of calcifications of the mitral complex – MAC and CMAC in multi-slice computed tomography (MSCT) in patients qualified to TAVI, in order to assess their impact on the occurrence and dynamics of MR following aortic valve implantation. Methods MAC was assessed quantitatively (Calcium Score) and semi-quantitative scale in depending on the degree of annular involvement. CMAC was evaluated in semi-quantitatively scale in depending on length of calcifications in the largest dimension. Subsequently patients were classified in a dichotomous manner as having non-severe or severe MAC and CMAC. All patients underwent transthoracic echocardiographic examinations prior to the procedure and after TAVI. Changes of MR severity following TAVI were defined as no change, improvement or worsening by at least one degree. Results The study group consisted of 94 patients. Fifty six (59.6%) out of 94 patients had MAC and 21 patients (22.3%) had severe MAC. Patients with MAC had higher mean aortic gradients (54.07±13,62 mmHg vs 46.79±14.42 mmHg, p=0.02) and smaller left ventricular diastolic diameter (46.09±6.86 mm vs 51.19±8.42 mm, p=0.002). Almost half of the patients - 46 (48.9%) had CMAC and 12 patients (12.8%) had severe CMAC. Patients with CMAC had higher Calcium Score Aortic Valve (3773.67±1734.02 Hounsfield Units (HU) vs 2875.1±1352.76 HU, p=0.006) and smaller AVA (0.59±0.16 cm2 vs 0.66±0.20 cm2, p=0.052). Before TAVI 35.1% of patients had more than mild MR. MR improved by at least one grade following TAVI in 17 (18.1%) patients and worsened by at least one grade in 7 (7.5%) patients. In multivariable logistic regression analysis MR worsening was associated with higher CMAC [OR 1.092, 95% CI: 1.006–1.185, p=0.035]. Conclusions The study demonstrated CMAC is prevalent in patients undergoing TAVI. CMAC was associated with MR worsening. This is a novel finding, which may be particular importance in patients with severe AS and coexisting MR in whom arguments for and against surgical repair of concomitant mitral insufficiency are considered, as opposed to isolated aortic valve procedure. Funding Acknowledgement Type of funding source: None

Abstract MP78: Progression of Valvular Calcification and Risk of Incident Stroke: The Multi-ethnic Study of Atherosclerosis (MESA)

Introduction: Stroke is a leading cause of morbidity and mortality in the United States. Identification of individuals at risk for stroke is important for implementation of preventive therapies. Prevalent valvular calcification (VC) has been shown to be associated with stroke but less is known about associations of VC progression with stroke. Methods: Progression (interval increase &gt;0 Agatston units/year) of aortic valvular calcification (AVC) and mitral annular calcification (MAC) was assessed by two cardiac CTs over a median of 2.4 years. We determined the risk of adjudicated total and ischemic stroke using Cox regression adjusted for cardiovascular disease (CVD) risk factors. Results: We studied 5,606 multiethnic participants (39.6% White, 26.9% Black, 21.4% Hispanic, 12.2% Chinese) free of baseline CVD enrolled in MESA. Baseline mean ± SD age was 62 ± 10 years; 53% were women; 12% had prevalent AVC and 9% prevalent MAC at the baseline visit; 83% had no progression of VC, 14%, progression at one site (AVC or MAC), and 3% progression at both sites (AVC and MAC) at follow-up. Over a median of 12 years, 214 total and 170 ischemic strokes occurred. The number of sites with VC progression (range 0-2) was not associated with total and ischemic stroke (all p&gt;0.05). We found MAC progression to be associated with increased risk of total stroke [adjusted hazard ratios (95% CI) 1.59 (1.11 - 2.27)] and ischemic stroke [1.64 (1.10 - 2.43)] in the whole cohort (model 3) and after further adjustment for baseline coronary artery calcification (model 4) ( Table ). Results remained significant for total stroke risk after excluding participants with interim atrial fibrillation or coronary heart disease [1.60 (1.01 - 2.54)]. In women, AVC progression was associated with ischemic stroke [1.87 (1.04 - 3.36)] (p-for-interaction=0.03). Conclusion: Progression of MAC over 2.4 years is associated with increased risk of total and ischemic stroke, and in women, AVC progression with higher ischemic stroke risk.

The "UFO" procedure.

The term "UFO" is not a medical term, but helps emphasize the extremely high degree of complexity of a surgical repair that is akin to someone observing an unidentified flying object. It involves replacement of the mitral and aortic valves with reconstruction of the intervalvular fibrous body (IVFB). Specific pathologies that render this operation necessary usually involve the IVFB, which is located between the aortic and mitral valves and constitutes a major portion of the fibrous skeleton of the heart. Patients that most often require such an operation are those with extensive aortic and mitral valve endocarditis with perivalvular extension into the IVFB. Other infrequent situations such as severe aortic and mitral annular calcification involving the IVFB, double valve replacement in patients with extremely small aortic and mitral annuli or double valve reoperations in which no IVFB is available following excision of both valves, necessitating the UFO procedure. The basic surgical principle has been first described as early as 1980. Depending on the extent of excised tissue due to the underlying disease, modifications and additional complex repair techniques have to be adopted. It is of utmost importance to have adequate visibility and exposure. There are certain important structures, which are at a risk of either injury or neglect, that can result in development of life-threatening complications during this operation, which a surgeon should be aware of. A step by step description of the "UFO" procedure can help guide the surgeon to perform this operation safely and efficiently. Although clinical complications are high, they are often related to the underlying disease and not specifically to the procedure itself, if performed perfectly.

Electrocardiographic and echocardiographic features in patients with major arterial vascular disease assigned to surgical revascularization

Background: We aimed to depict the electrocardiographic and echocardiographic aspects in patients before elective major vascular surgery.Methods: We evaluated through standard 12 lead electrocardiography and transthoracic echocardiography 469 patients with asymptomatic large abdominal aortic aneurysm (AAA), 334 with critical carotid stenosis (CAS), and 238 with advanced peripheral artery disease (PAD) before surgical revascularization.Results: Patients with AAA were predominantly males (p < .001) with normal sinus rhythm (p = .026), were more affected by atrioventricular block (p = .033) and left anterior fascicular block (p < .001). They also presented larger aortic root size (p < .001) and septal hypertrophy (p = .036), in addition, atrial fibrillation was less frequent in the same group (p = .023). Patients with CAS were of older age (p < .001) with a substantial number of females (p < .001). They presented less left ventricular segmental kinetic disorders and fewer dilated ventricles (p = .004 and p < .001 respectively). Finally, those with PAD had reduced septal and posterior wall thickness (p < .01, p = .009 respectively), greater mitral and aortic annular calcification (p < .001), and were more affected by previous myocardial infarction (p < .001). The PR interval, left anterior fascicular block and aortic root size were independently associated with aneurysm, previous myocardial infarction with PAD, while smaller left ventricular end systolic volumes with carotid artery stenosis.Conclusions: Patients with AAA were mostly affected by cardiac conduction disorders, septal hypertrophy, aortic root dilation and less affected by atrial fibrillation. Patients with CAS were older with more normal sized ventricles, whereas, previous myocardial infarction was most common amongst patients with peripheral artery disease.

Clinical and electrophysiological characteristics of patients with paroxysmal intra-His block with narrow QRS complexes

Atrioventricular (AV) block is usually due to infranodal disease and associated with a wide QRS complex; such patients often progress to complete AV block and pacemaker dependency. Uncommonly, infranodal AV block can occur within the His bundle with a narrow QRS complex. The aims of this study were to define clinical/echocardiographic characteristics of patients with AV block within the His bundle and report progression to pacemaker dependency. We retrospectively identified patients with narrow QRS complexes and documented intra-His delay or block at electrophysiology study (group A) or with electrocardiogram-documented Mobitz II AV block/paroxysmal AV block (group B). Clinical, electrophysiological, and echocardiographic variables at presentation and pacemaker parameters at the last follow-up visit were evaluated. Twenty-seven patients (19 women) were identified (mean age 64 ± 13 years; range, 38-85 years). Four patients who had <1 month of follow-up were excluded. There were 12 patients in group A and 11 in group B; 21 of 23 presented with syncope/presyncope. All patients received pacemakers: 8 single chamber and 15 dual chamber. After a median follow-up of 6.4 years, the median percentage of ventricular pacing was 1% (interquartile range 0%-4.66%). One patient developed true pacemaker dependency. Aortic and/or mitral annular calcification was present in 13 of 22 patients with available echocardiograms. Patients who present with syncope and narrow QRS complexes with intra-His delay or Mobitz II paroxysmal AV block with narrow QRS complexes rarely progress to pacemaker dependency and require infrequent pacing. This entity is more common in women, with a higher prevalence of aortic and/or mitral annular calcification. If confirmed by additional studies, single-chamber pacemaker may be sufficient.

Associations of Mitral and Aortic Valve Calcifications with Complex Aortic Atheroma in Patients with Embolic Stroke of Undetermined Source

This study investigated the associations of mitral and aortic valve calcification with complex aortic atheroma among patients with embolic stroke of undetermined source. We included 52 consecutive patients (mean age 58.1 years; 75.0% male) with embolic stroke of undetermined source. Mitral annular calcification, aortic annular calcification, and aortic valve sclerosis were assessed by transthoracic echocardiography. Complex aortic atheroma was assessed by transesophageal echocardiography and was defined as plaque protruding greater than or equal to 4 mm into the lumen or with ulcerated or mobile components. Ten patients (19.2%) had complex aortic atheroma. Patients with and without complex aortic atheroma showed significant differences in terms of hypertension (80.0% versus 38.1%, P = .017), dyslipidemia (90.0% versus 31.0%, P <.01), chronic kidney disease (60.0% versus 14.3%, P <.01), previous coronary artery disease (30.0% versus 4.8%, P = .013), prior stroke (40.0% versus 7.1%, P <.01), left atrial dimension (4.0 cm versus 3.6 cm, P = .023), aortic valve sclerosis (80.0% versus 26.2%, P <.01), aortic valve calcification (aortic annular calcification or aortic valve sclerosis) (80.0% versus 26.0%, P <.01), and left-sided valve calcification (mitral annular calcification or aortic annular calcification or aortic valve sclerosis) (80.0% versus 28.6%, P <.01). In multivariate analysis, left-sided valve calcification was independently associated with complex aortic atheroma (odds ratio 4.1, 95% confidence interval 1.3-26.1, P = .049). Mitral or aortic valve calcification detected by transthoracic echocardiography can be a useful marker for predicting complex aortic atheroma in patients with embolic stroke of undetermined source.

Abstract 21410: Utility of Ratio of Maximum Leaflet Thickness to Residual Radius in Predicting Aortic Root Rupture or Hematoma During Transcatheter Aortic Valve Replacement

Introduction: Aortic root rupture or hematoma (ARR or ARH) is a serious complication of transcatheter aortic valve replacement (TAVR). In addition to excessive oversizing (annular area/TAVR stent area) and aortic annular calcification. Hypothesis: We hypothesize that combination of small sinus of Valsalva (SOV) and excessive calcification of aortic leaflets is a significant risk factor for ARR or ARH. Methods: Patients who experienced ARR or ARH during TAVR were selected. A matched cohort who had no complications during the procedure were identified from a prospectively maintained database. Dynamic 4-D cardiac computed tomography was used to assess respective thickness of the three aortic cusps, SOV, annular area, LVOT, and the presence and extent of calcification of the LVOT. The ratio of maximum leaflet thickness (MLT) to residual radius (RR): (SOV diameter - TAVR stent diameter)/2), and TAVR stent oversizing: (TAVR stent area - aortic annular area)/TAVR stent area were calculated and severity of annular calcification graded. Stepwise logistic regression using backward selection was used to determine factors associated with ARR or ARH during TAVR. Results: Out of 800 TAVR patients, ARR/ARH occurred in 18 (2.2%) during the procedure. There were 19 well-matched (no complication) patients who served as a control group. Baseline clinical characteristics were similar in ARR/ARH - patients and ARR/ARH + patients. LVOT calcification was ≥ moderate in 61 % of ARR+ patients and 31 % in ARR- patients. The overall incidence of bio prosthetic valve oversizing 37% (n=14). On multivariable logistic regression analysis, an MLT/RR ratio &gt; 1.4, prosthetic valve oversizing ≥ 20% and ≥ moderate or greater annular calcification were significantly associated with ARR during TAVR. Conclusions: In addition to excessive oversizing of &gt;20% and annular calcification, a high MLT/RR ratio, a parameter for a combination of small sinus of Valsalva and excessive leaflet calcification, is an independent predictor of ARR or ARH.

Relationship of bone mineral density with valvular and annular calcification in community-dwelling older people: The Cardiovascular Health Study.

The process of cardiac calcification bears a resemblance to skeletal bone metabolism and its regulation. Experimental studies suggest that bone mineral density (BMD) and valvular calcification may be reciprocally related, but epidemiologic data are sparse. We tested the hypothesis that BMD of the total hip and femoral neck measured by dual-energy X-ray absorptiometry (DXA) is inversely associated with prevalence of three echocardiographic measures of cardiac calcification in a cross-sectional analysis of 1497 older adults from the Cardiovascular Health Study. The adjusted association of BMD with aortic valve calcification (AVC), aortic annular calcification (AAC), and mitral annular calcification (MAC) was assessed with relative risk (RR) regression. Mean (SD) age was 76.2 (4.8)years; 58% were women. Cardiac calcification was highly prevalent in women and men: AVC, 59.5 and 71.0%; AAC 45.1 and 46.7%; MAC 42.8 and 39.5%, respectively. After limited and full adjustment for potential confounders, no statistically significant associations were detected between continuous BMD at either site and the three measures of calcification. Assessment of WHO BMD categories revealed a significant association between osteoporosis at the total hip and AVC in men (adjusted RR compared with normal BMD=1.24 (1.01-1.53)). In graded sensitivity analyses, there were apparent inverse associations between femoral neck BMD and AVC with stenosis in men, and femoral neck BMD and moderate/severe MAC in women, but these were not significant. These findings support further investigation of the sex-specific relationships between low BMD and cardiac calcification, and whether processes linking the two could be targeted for therapeutic ends.

Abstract P212: The Association Between Serum Vitamin D and Valvular Calcification in the Multi-Ethnic Study of Altherosclerosis

Background: Serum 25-hydroxyvitamin D [25(OH)D] levels have been identified as a possible modifiable risk factor for cardiovascular disease (CVD) but the association may not be linear. Whether 25(OH)D is associated with valvular calcification is unknown. We examined the association of 25(OH)D with Aortic Valve Calcification (AVC) and Mitral Annular Calcification (MAC) in a multi-ethnic cohort. We hypothesized that both deficient and excess 25(OH)D levels are associated with increased calcification (i.e. U-shaped distribution of risk). Methods: We studied 5,392 MESA participants who had 25(OH)D levels and a cardiac CT performed at baseline (2000-2002) and a follow-up CT scan at the 2 nd or 3rd Exam. AVC and MAC were quantified by the Agatston score. Using relative risk regression, we evaluated the multivariable adjusted risk of prevalent and incident AVC and MAC by 25(OH)D quintiles with median quintile as reference. Results: The mean age of participants was 62 ±10 yrs; 53% were women and 26% black. Prevalent AVC and MAC were observed in 12% and 9%, respectively. There was no statistically significant association between 25(OH)D and prevalent AVC or MAC in cross-sectional analyses. Over a mean follow-up of 2.5 yrs, 4.1% developed incident AVC and 4.5% developed incident MAC. After adjusting for demographic variables, the 5 th quintile of 25(OH)D was associated with a 33% [RR 0.67 (95% CI 0.45, 0.99)] lower risk of incident MAC compared to the 3 rd quintile. However, this association was no longer significant after adjusting for lifestyle and CVD risk factors [ TABLE ]. There was no association of 25(OH)D with incident AVC [0.89 (0.59, 1.36) for 5 th vs. 3 rd quintile, Model 1]. Conclusion: Low 25(OH)D levels were not associated with increased likelihood of prevalent valvular calcification. Higher 25(OH)D were associated with reduced risk of incident MAC independent of demographics, but not with incident AVC. In sum, 25(OH)D may be associated with progression of mitral calcification, but future studies with longer follow-up are needed.

Association of inflammatory, lipid and mineral markers with cardiac calcification in older adults

ObjectiveCalcification of the aortic valve and adjacent structures involves inflammatory, lipid and mineral metabolism pathways. We hypothesised that circulating biomarkers reflecting these pathways are associated with cardiac calcification in older...

Preinterventional screening of the TAVI patient: how to choose the suitable patient and the best procedure

Transcatheter aortic valve implantation (TAVI) is a novel therapy, which has transformed the management of inoperable patients presenting with symptomatic severe aortic stenosis (AS). It is also a proven and less invasive alternative therapeutic option for high-risk symptomatic patients presenting with severe AS who are otherwise eligible for surgical aortic valve replacement. Patient age is not strictly a limitation for TAVI but since this procedure is currently restricted to high-risk and inoperable patients, it follows that most patients selected for TAVI are at an advanced age. Patient frailty and co-morbidities need to be assessed and a clinical judgment made on whether the patient will gain a measureable improvement in their quality of life. Risk stratification has assumed a central role in selecting suitable patients and surgical risk algorithms have proven helpful in this regard. However, limitations exist with these risk models, which must be understood in the context of TAVI. When making final treatment decisions, it is essential that a collaborative multidisciplinary "heart team" be involved and this is stressed in the most recent guidelines of the European Society of Cardiology. Choosing the best procedure is contingent upon anatomical feasibility, and multimodality imaging has emerged as an integral component of the pre-interventional screening process in this regard. The transfemoral route is now considered the default approach although vascular complications remain a concern. A minimal vessel diameter of 6mm is required for currently commercial available vascular introducer sheaths. Several alternative access routes are available to choose from when confronted with difficult iliofemoral anatomy such as severe peripheral vascular disease or diffuse circumferential vessel calcification. The degree of aortic valve leaflet and annular calcification also needs to be assessed as the latter is a risk factor for post-procedural paravalvular aortic regurgitation. The ultimate goal of patient selection is to achieve the highest procedural success rate while minimizing complications and to choose patients most likely to derive tangible benefit from this procedure.

Prediction of Paravalvular Regurgitation After Transcatheter Aortic Valve Implantation by Computed Tomography: Value of Aortic Valve and Annular Calcification

The purpose of this study was to quantify and characterize aortic valve leaflet and aortic annular calcification with computed tomography angiography (CTA) and to define whether they predict paravalvular regurgitation (PAR) after transcatheter aortic valve implantation. In all, 94 patients (aged 83.6 years) with severe aortic stenosis underwent CTA. Annular calcification was measured in two planes and defined as "protruding" (depth greater than length), "round," or "adherent" (length less than depth) for the right, left, and noncoronary annulus. Leaflet calcification severity and asymmetry were scored. Transthoracic echocardiography graduation of PAR severity was performed after the procedure (0.5 scale). Thirty-two percent of patients had no or trivial PAR (grade less than 1) and 68% had mild to severe PAR (≥ 1 [mild 45.7%, moderate 20.2%, moderate to severe 2.1%]). The size of annular calcium was higher in patients with moderate to severe PAR greater than 1 (p = 0.015, p = 0.007, and p = 0.004) and predictive (c = 0.67, 0.71, and 0.711) for noncoronary, left, and total annular calcium size, respectively. Increasing PAR severity was correlated with increasing total calcium size (r = 0.422, p < 0.001). Protruding annular calcification greater than 4 mm (p = 0.02) was more frequently found in moderate to severe PAR greater than 1, and predictive (c = 0.7). Adherent calcium greater than 4 mm did not predict PAR greater than 1 and PAR of 1 or less. There was no association of leaflet calcium severity and asymmetry with PAR severity. Protruding annular calcium greater than 4 mm predicts moderate to severe PAR after transcatheter aortic valve implantation. Increasing annular calcium size is another predictor, whereas adherent calcium has a "sealing" effect.

REDUCED DEFORMATION AND HIGHER CALCIFICATION OF THE AORTIC ANNULUS PREDICTS POST–PROCEDURAL AORTIC INSUFFICIENCY IN PATIENTS UNDERGOING TAVR: A MULTI–MODALITY IMAGING STUDY

In patients undergoing transcatheter aortic valve replacement (TAVR), residual aortic insufficiency (AI) is associated with higher mortality. We hypothesized that aortic annular deformation & calcification play a role. We sought to assess predictors of post–TAVR AI, using echo & multidetector

Transcatheter Aortic Valve Implantation in a Patient With Severe Aortic Insufficiency and Minimal Aortic Annular Calcification

Severe aortic insufficiency with minimal aortic annular calcification has been considered a relative contraindication to transcatheter aortic valve implantation (TAVI) because of a lack of calcium for fluoroscopic visualization and radial stent fixation. We report a patient with severe aortic insufficiency after previous coronary artery bypass and aortic valve repair who underwent successful TAVI. Intraoperative transesophageal echocardiography was critical to guide valve implantation and previous surgical pledgets were used to seat an oversized TAVI prosthesis within the aortic annulus. In follow-up, the patient remained New York Heart Association class I and echocardiography demonstrated a well-functioning TAVI prosthesis with no aortic insufficiency.

CT predictors of post-procedural aortic regurgitation in patients referred for transcatheter aortic valve implantation: an analysis of 105 patients

Cardiac computed tomography (CT) allows accurate and detailed analysis of the anatomy of the aortic root and valve, including quantification of calcium. We evaluated the correlation between different CT parameters and the degree of post-procedural aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) using the balloon-expandable Edwards Sapien prosthesis. Pre-intervention contrast-enhanced dual source CT data sets of 105 consecutive patients (48 males, mean age 81 ± 6 years, mean logEuroSCORE 34 ± 13%) with symptomatic severe aortic valve stenosis referred for TAVI using the Edwards Sapien prosthesis (Edwards lifesciences, Inc., CA, USA) were analysed. The degrees of aortic valve commissural calcification and annular calcification were visually assessed on a scale from 0 to 3. Furthermore, the degree of aortic valve calcification as quantified by the Agatston score, aortic annulus eccentricity, aortic diameter at the level of the sinus of valsalva and at the sinotubular junction were assessed. Early post-procedural AR was assessed using aortography. Significant AR was defined as angiographic AR of at least moderate degree (AR ≥ 2). Visual assessment of the degree of aortic annular calcification as well as the Agatston score of aortic valve calcium correlated weakly, yet significantly with the degree of post-procedural AR (r = 0.31 and 0.24, p = 0.001 and 0.013, respectively). Compared to patients with AR < 2, patients with AR ≥ 2 showed more severe calcification of the aortic annulus (mean visual scores 1.9 ± 0.6 vs. 1.5 ± 0.6, p = 0.003) as well as higher aortic valve Agatston scores (1,517 ± 861 vs. 1,062 ± 688, p = 0.005). Visual score for commissural calcification did not differ significantly between both groups (mean scores 2.4 ± 0.5 vs. 2.5 ± 0.5, respectively, p = 0.117). No significant correlation was observed between the degree of AR and commissural calcification, aortic annulus eccentricity index or aortic diameters. The extent of aortic valve annular calcification, but not of commissural calcification, predicts significant post-procedural AR in patients referred for TAVI using the balloon-expandable Edwards Sapiens prosthesis.