Mitral Annular Calcification Research Articles

The impact of intravenous agitated saline contrast echocardiography on subclinical neuronal injury determined by neuron-specific enolase

Abstract Introduction Patent foramen ovale (PFO) is a congenital defect in interatrial septum with 25-30% prevelance. Diagnostic methods include transesophageal echocardiography (TEE), magnetic resonance imaging (MRI), and computed tomography (CT), but transthoracic echocardiography (TTE) is the primary diagnostic method. TTE involves the injection of agitated saline intravenously, and the passage of microbubbles from the right atrium to the left atrium is monitored. The reliability of this method has been questioned in various case series, with a low incidence (0.062%) of generally transient, mild clinical cerebrovascular events reported. Silent cerebral ischemia (SSI) is asymptomatic, radiographically identified acute neuronal damage. SSI is associated with an increased risk of stroke, dementia, and cognitive impairment. Neuron-specific enolase (NSE) with high specificity for neural cells can be used to detect SSI. While symptomatic patients have been evaluated in reported case series, there is no study determining the relationship and reliability of intravenous agitated saline echocardiography (SCE) with SSI. This study aims to determine whether TTE, performed on patients with PFO without neurological history and a healthy control group, can cause SSI by evaluating NSE with SCE. Materials and methods 52 patients undergoing SCE for color flow through interatrial septum or prominent interatrial septal aneurysm and are diagnosed with PFO were included. Additionally, 51 control patients without detected PFO or ASA were also included. Serum samples were taken from the patients before and 12 hours after the SCE test, and NSE levels were measured by the ELISA method. Results The mean baseline NSE level was 12.7 ng/mL with a median of 5.3 ng/mL in the PFO group, and in the control group, the mean was 9.1 ng/mL with a median of 6.4 ng/mL. At 12 hours, the mean NSE levels in the PFO group were 9.8 ng/mL with a median of 6.6 ng/mL, and in the control group, the mean was 12.7 ng/mL with a median of 5.8 ng/mL. The increase in NSE levels after SCE, was not statistically significant when comparing the PFO and control groups (p=0.77). No relationship was found between age, presence of interatrial septal aneurysm, presence of mitral annulus calcification, the number of bubbles passed in the SCE test, and the basal and 12-hour change in NSE levels (p=0.926). NSE level changes were found to be correlated between groups (p<0.001). Conclusion This study is the first to evaluate whether SCE causes subclinical neuronal damage. Our study suggests that when evaluated with NSE, the SCE method is safe and does not cause subclinical neuronal damage in patients without underlying neuronal susceptibility.results

Predictors and Clinical Outcomes of True Mitral Stenosis in Patients Undergoing Transcatheter Aortic Valve Implantation

Abstract Aims Predictors of true degenerative mitral stenosis (MS) in patients with aortic stenosis who underwent transcatheter aortic valve implantation (TAVI) remain unknown. This study aimed to investigate the predictors and prognostic value of true degenerative MS in this population. Methods and results We retrospectively reviewed the records of 760 consecutive patients who underwent TAVI. The mitral valve area (MVA) was assessed using transthoracic echocardiography, and mitral valve calcification was assessed using multi-detector computed tomography. MS was defined as an MVA of ≤2.0 cm², and true MS was defined as moderate or severe MS following TAVI. In our TAVI cohort, we identified 72 (9.5%) patients with degenerative MS. Among these, true MS was observed in 38 (52.7%) patients. Echocardiographic data showed that the true MS group had a significantly lower MVA and higher trans-mitral gradient. The severity of mitral annular calcification was not significantly different between the two groups; however, the true MS group had significantly more posterior mitral leaflet (PML) and anterior mitral leaflet (AML) calcification. Multivariable logistic regression analysis showed that AML calcification was the independent predictor of true MS (adjusted OR, 9.23; 95% CI 2.84‒29.9). True MS was independently associated with poor prognosis (adjusted HR, 2.76; 95% CI 1.09‒6.98). Conclusions Approximately half of patients with concomitant degenerative MS who underwent TAVI had true MS, which was associated with a poor prognosis. Computed tomographic analysis of AML calcification was useful for predicting true MS.

Association between mitral annulus calcification and severity of coronary artery disease assessed by SYNTAX score in patients presented with acute coronary syndrome

Association between mitral annulus calcification and severity of coronary artery disease assessed by SYNTAX score in patients presented with acute coronary syndrome

Particularities of a Cardiac Amorphous Left Ventricular Tumor in a Patient with Coronary Artery Disease—Diagnostic and Therapeutic Challenges: A Case Report and Literature Review

Background: Cardiac calcified amorphous tumors (CATs) are rare non-neoplastic formations containing amorphous fibrinous material and calcifications. In our research, we present the case of a 42-year-old male patient who developed, during his 6-months monitoring for coronary artery disease, a left ventricular (LV) CAT raising diagnostic challenges. Methods: To gather additional information on CATs, we researched the international medical literature for scientific articles published with the full text in English, on PubMed, ResearchGate, Clarivate, and Google Scholar between 2020 and 2024. Results: Compared to most described cases, our patient was a young male, without mitral annular calcification or chronic renal disease, but he was suffering from chronic peripheral and coronary artery disease, and genetic testing revealed a higher risk for thromboembolic events. During 6 months, he developed a LV CAT of 4.5/3.5/3 cm. Although we found in the medical literature 16 case reports of patients with CAT, only six authors could specify a precise postoperative evolution of the CAT, most of them sustaining that if completely removed, it would not relapse, an aspect observed also in our patient during 3 years of follow-up. Conclusions: CATs are rare heart tumors with slow growth, but with a high embolization risk that raises diagnostic and therapeutic challenges.

TCT-945 AltaValve System TMVR for the Treatment of Patients With Severe Mitral Regurgitation and Mitral Annular Calcification

TCT-945 AltaValve System TMVR for the Treatment of Patients With Severe Mitral Regurgitation and Mitral Annular Calcification

Direct Implantation of Transcatheter Valve in Mitral Annular Calcification: A Multi-Center Study

BACKGROUNDMitral valve replacement (MVR) in the setting of severe annular calcification (MAC) is associated with high morbidity and mortality. Direct surgical implantation of a transcatheter heart valve (THV) through a trans-atrial approach is a strategy to mitigate surgical risk. This study reports the peri-operative and 1-year outcomes of MVR using a THV in patients with severe circumferential MAC at three Canadian centers. METHODSCharts were reviewed between 1/1/2018 and 30/9/2023 to identify patients with severe circumferential MAC who had undergone direct implantation of a THV. Primary outcomes were 30-day mortality, debilitating stroke, and 1-year mortality. Secondary outcomes included left ventricular outflow tract obstruction (LVOTO), degree of PVL, transvalvular mean pressure gradient, and length of stay. RESULTSTwenty-two patients at the three centres underwent direct implantation of a THV. Nineteen were female with mean age 70.41±9.33 years. A THV was successfully implanted in all patients. There were two deaths at 30-days. Four died from non-cardiac causes at 1-year, and 1 patient had a post-operative stroke. Seventeen (77%) patients had none/trace paravalvular leak, 4 had mild PVL, and one patient had mild-moderate PVL. Mean trans-valvular gradient was 4.42±4.40. There were no cases of LVOTO. CONCLUSIONSDirect deployment of a THV in patients with severe MAC may be a reasonable option. Thirty-day and 1-year mortality rates of 9% and 18%, respectively, suggest that this approach should be reserved for high-risk patients who are not able to undergo conventional strategies.

TCT-614 Clinical Characteristics and Prognosis of Patients With Mitral Annular Calcification

TCT-614 Clinical Characteristics and Prognosis of Patients With Mitral Annular Calcification

TCT-613 Mitral Valve Dysfunction in Patients With Mitral Annular Calcification

TCT-613 Mitral Valve Dysfunction in Patients With Mitral Annular Calcification

Cardiovascular Risk Factors Associated with Mitral Annular Calcification in a Non-Rheumatic Population

Mitral Annular Calcification (MAC), cardiovascular disease marker was common in non-rheumatic populations but was frequently disregarded in clinical evaluations. Objective: To MAC and to assess effect of these factors on cardiac function in non-rheumatic adult population. Methods: From September 2022 to August 2023, we conducted this cross-sectional study at Cardiac Center, Pakistan institute of medical sciences Islamabad that included 182 adults aged 50 years and older. We evaluated the patient's clinical history, demographic data and echocardiographic and laboratory results. The association between the presence of MAC and cardiovascular risk factors (age, hypertension, diabetes, dyslipidemia, smoking, obesity and chronic renal disease) was analyzed using logistic regression. Echocardiographic data were used to provide insight into cardiac function. Results: The prevalence of MAC was substantially correlated with hypertension (OR = 2.30), diabetes (OR = 2.00), dyslipidemia (OR = 1.75) and obesity (OR = 1.07). Also, smoking demonstrated a significant correlation with MAC. In comparison to those without MAC, individuals with MAC exhibited substantially lower ejection fractions, increased left atrial diameters and impaired diastolic function, as indicated by cardiac function assessments. Conclusion: In non-rheumatic population, MAC was significantly associated with conventional cardiovascular risk factors, particularly hypertension and diabetes.

Degenerative mitral stenosis by echocardiography: presentation and outcome

Abstract Aims Degenerative mitral stenosis (DMS) is due to degenerative mitral annular calcification (MAC) and valvular calcification. However, DMS impacts on the outcome, and therefore, potential treatment needs are poorly known. We aimed at evaluating survival after DMS diagnosis by Doppler echocardiography in routine practice. Methods and results A cohort of 2937 (75 ± 12 years, 67% women) consecutive patients were diagnosed between 2003 and 2014 with DMS (diastolic mean gradient ≥ 5 mmHg), with analysis of short- and long-term survival. All patients had overt mitral annular/valvular degenerative calcification without rheumatic involvement. Mean gradient was 6.5 ± 2.4 mmHg, and DMS was considered mild in 50%, moderate in 44%, and severe in 6%. DMS was associated with left atrial enlargement (52 ± 23 mL/m2) and elevated pulmonary pressure (49 ± 16 mmHg) despite generally normal ejection fraction (61 ± 13%). DMS was associated with frequent comorbid conditions (74% hypertension, 58% coronary disease, and 52% heart failure) and humoural alterations (haemoglobin 11.3 ± 1.8 g/dL and creatinine 1.5 ± 1.4 mg/dL). One-year mortality was 22%, most strongly related to older age, higher comorbidity, and abnormal haemoglobin/creatinine but only weakly to DMS severity (with anaemia 42% irrespective of DMS severity, P = 0.99; without anaemia 18, 23, and 28% with mild, moderate, and severe DMS, respectively, P < 0.0004). Long-term mortality was high (56% at 5 years) also mostly linked to aging and weakly to DMS severity [with anaemia P = 0.90; without anaemia: adjusted-hazard ratio: 1.30 (1.19–1.42), P < 0.0001, for moderate vs. mild DMS and 1.63 (1.34–1.98), P < 0.0001, for severe vs. mild DMS]. Conclusion DMS is a condition of the elderly potentially resulting in severe mitral obstruction and haemodynamic alterations. However, DMS is frequently associated with severe comorbidities imparting considerable mortality following diagnosis, whereas DMS severity is a weak (albeit independent) determinant of mortality. Hence, patients with DMS should be carefully evaluated and interventional/surgical treatment prudently considered in those with limited comorbidity burden, particularly without anaemia. Keywords: Degenerative Mitral Stenosis; Outcome; Natural history; Ecocardiography; Mitral Stenosis.

Stroke after heart valve surgery: a single center institution report

IntroductionStroke is a potentially debilitating complication of heart valve replacement surgery, with rates ranging from 1 to 10%. Despite advancements in surgical techniques, the incidence of postoperative stroke remains a significant concern, impacting patient outcomes and healthcare resources. This study aims to investigate the incidence, risk factors, and outcomes of in-hospital adverse neurologic events, particularly stroke, following valve replacement. The analysis focuses on identifying patient characteristics and procedural factors associated with increased stroke risk.MethodsThis retrospective study involves a review of 417 consecutive patients who underwent SVR between January 2004 and December 2022. The study cohort was extracted from a prospectively recorded cardiac intensive care unit database. Preoperative and perioperative data were collected, and subjects with specific exclusion criteria were omitted from the analysis. The analysis includes demographic information, preoperative risk factors, and perioperative variables.ResultsThe study identified a 4.3% incidence of postoperative stroke among SVR patients. Risk factors associated with increased stroke susceptibility included prolonged cardiopulmonary bypass time, aortic cross-clamp duration exceeding 90 min, prior stroke history, diabetes mellitus, and mitral valve annulus calcification. Patients undergoing combined procedures, such as aortic valve replacement with mitral valve replacement or coronary artery bypass grafting with AVR and MVR, (OR = 10.74, CI:2.65–43.44, p-value = < 0.001) and (OR = 11.66, CI:1.02–132.70, p-value = 0.048) respectively, exhibited elevated risks. Internal carotid artery stenosis (< 75%) and requiring prolonged inotropic support were also associated with increased stroke risk(OR = 3.04, CI:1.13–8.12, P-value = 0.026). The occurrence of stroke correlated with extended intensive care unit stay (OR = 1.12, CI: 1.04–1.20, P-value = 0.002) and heightened in-hospital mortality.ConclusionIn conclusion, our study identifies key risk factors and underscores the importance of proactive measures to reduce postoperative stroke incidence in surgical valve replacement patients.

Rapid growth of calcified amorphous tumor with mitral annulus calcification: a case report

BackgroundCalcified amorphous tumor (CAT) of the heart is a rare, non-neoplastic cardiac mass with mitral valves and annuli being the most common sites. The presence of mitral annular calcification (MAC) is associated with an increased risk of stroke or other systemic embolisms. Here, we report a case of CAT showing rapid growth with MAC and investigate the link between the two.Case presentationA 71-year-old man presented at our hospital with dyspnea and had been undergoing hemodialysis for 26 years for chronic glomerulonephritis. Transthoracic echocardiography (TTE) revealed moderate mitral stenosis with bulky MAC. Two months later, the patient developed progressive dyspnea, and follow-up TTE revealed a highly mobile mass (8 × 5 mm) attached to the left ventricular (LV) side of the posterior MAC. He underwent surgery because of congestive heart failure and a high risk of embolization. Surgical inspection revealed that the tumor was attached beneath the P3 segment of the mitral valve on the LV side and was removed. When removing the MAC, toothpaste-like contents drained from the encapsulated mass inside the MAC at the P3 segment, where the tumor was located. After reconstructing the posterior mitral annulus defect with a bovine pericardial patch, mitral valve replacement with a mechanical prosthesis, a maze procedure, and left appendage closure were performed. Histopathological examination revealed that the excised tumor contained fibrin and calcium deposits. The mass was diagnosed as a CAT.ConclusionsCAT may be one of the causes of stroke induced by MAC. Routine follow-up echocardiography should be recommended for patients with MAC, especially those undergoing hemodialysis.

Rethinking Mitral Annular Calcification and Its Clinical Significance: From Passive Process to Active Pathology.

Mitral annulus calcification is a chronic degenerative condition affecting the fibrous base of the mitral valve. Historically viewed as an age-related phenomenon, recent studies suggest it is driven by active mechanisms involving systemic inflammation, hemodynamic stress, abnormal calcium-phosphorus metabolism, and lipid accumulation. Despite often being asymptomatic and incidentally detected, its clinical relevance stems from its strong association with increased cardiovascular disease risk, higher cardiovascular mortality, and elevated overall mortality. This article investigates the complexities and controversies surrounding mitral annular calcification as a potential embolic source, focusing on its diagnosis, its relationship with systemic inflammation, and its links to metabolic and chronic disorders. The findings highlight that mitral annular calcification is not merely a passive marker of aging but an active indicator of atherosclerotic burden with significant implications for cardiovascular health. Mitral annulus calcification should be recognized as an important factor in cardiovascular risk assessment, offering insight into systemic inflammatory processes and metabolic dysregulation.

Transcatheter aortic valve implantation for combined aortic and mitral stenoses: Insights from the OCEAN-TAVI Registry.

Mitral stenosis (MS) occasionally coexists with aortic stenosis (AS). Limited data are available regarding the functional class and clinical outcomes of patients who undergo transcatheter aortic valve implantation (TAVI) for combined AS and MS. This study compared the clinical outcomes in patients with and without MS who underwent TAVI for severe AS and assessed the impact of mitral annulus calcification (MAC) severity, transmitral gradient (TMG) and mitral valve area (MVA) on outcomes in patients with combined AS and MS. We investigated patients in the OCEAN-TAVI registry who underwent TAVI. MS was defined as an MVA≤1.5cm2 or TMG≥5mmHg. The composite of all-cause death and admission for heart failure was compared between patients with and without MS. The impact of MAC, TMG and MVA on outcomes was assessed in patients with combined AS and MS. We identified 106 patients with MS (MAC 84%; TMG 6.4±2.6mmHg; MVA 1.10±0.31cm2) and 6570 without MS as controls. The MS group was older (85±5 vs. 84±5years, P=0.033), more of women (85 vs. 67%, P<0.01), and had a higher risk of surgery (the Society of Thoracic Surgeons Mortality Score 8.7±5.1 vs. 7.6±5.9, P=0.047) than the controls. In the MS group, the New York Heart Association Functional Class was 3 or 4 in 56% of the patients at baseline and 6% at 1year after TAVI. Thirty-day mortality (2.8% vs. 1.3%, P=0.18) and early composite outcomes (17% vs. 15%, P=0.56) were comparable between patients with and without MS. During a median follow-up of 2.1years, the presence of MS was associated with a higher incidence of adverse events compared with controls (adjusted hazard ratio [HR] 1.84; 95% confidence interval [CI] 1.34-2.51, P<0.01), even on propensity score matched analysis (adjusted HR 1.91; 95% CI 1.14-3.22, P<0.01). Moderate or severe MAC contributed to increased risk of adverse events in patients with MS (adjusted HR 2.89; 95% CI 1.20-6.99, P=0.018), but TMG and MVA did not. In patients undergoing TAVI for severe AS, those with moderate or severe MS experienced worse outcomes after TAVI compared with those without MS. Patients with combined AS and MS sustained symptom improvement at 1-year post-TAVI. MAC severity was a useful predictor of adverse events compared with MS haemodynamics such as TMG and MVA in patients with combined AS and MS.

Robotic mitral surgery: recent advances and outcomes.

This review explores recent advancements in robotic cardiac surgery, specifically focusing on its application in diverse mitral valve surgeries. The aim is to provide an overview of current clinical practices and supporting evidence in this evolving field. A literature review indicates a 30% surge in robotic mitral valve repair from 2015 to 2021, paralleled by a decline in sternotomy-based repair per the STS database. Robotic mitral valve repair consistently shows effective and safe outcomes, with comparable mortality but lower morbidity risks than sternotomy and thoracotomy. The robotic approach exhibits lower conversion to valve replacement, shorter ICU stays, and reduced 30-day readmissions. For experienced programs, robotic techniques prove versatile in various pathologies, including rheumatic heart valve disease, infective endocarditis, ischemic cardiomyopathy, and mitral annular calcification necessitating valve replacement. Literature supports their selective use in high-risk scenarios, including redo surgeries and elderly patients. Recent evidence supports the growing use of robotic approaches in mitral valve surgery, highlighting their efficacy with comparable mortality rates but lower morbidity risks. Robotic techniques consistently yield positive outcomes across various pathologies and patient profiles, signaling a potential paradigm shift in mitral valve interventions.

Predictive markers for aortic atheromatosis and mitral annular calcification in type 2 diabetes patients without established cardiovascular disease

Predictive markers for aortic atheromatosis and mitral annular calcification in type 2 diabetes patients without established cardiovascular disease

Presentation and outcomes of women and men undergoing surgery for degenerative mitral regurgitation.

Degenerative mitral regurgitation is associated with heart failure, arrhythmia and mortality. The impact of sex on timing of surgical referral and outcomes has not been reported comprehensively. We examined preoperative status and surgical outcomes of male versus female degenerative mitral valve regurgitation patients undergoing surgery. We reviewed our institutional database for all patients undergoing surgery for degenerative mitral regurgitation between 2013 and 2021. Preoperative clinical and echocardiographic variables, surgical characteristics and outcomes were compared, and left atrial strain in available images. Of 963 patients, 314 (32.6%) were female. Women were older (67 vs 64 years, P = 0.031) and more often had bileaflet prolapse (19.4% vs 13.8%, P = 0.028), mitral annular calcification (12.1% vs 5.4%, P < 0.001) and tricuspid regurgitation (TR; 31.8% vs 22.5%, P = 0.001). Indexed left ventricular end-diastolic and end-systolic diameters were higher in women, with 29.4 vs 26.7 mm/m2 (P < 0.001) and 18.2 vs 17 mm/m2 (P < 0.001), respectively, and left atrial conduit strain lower (17.6% vs, 21.2%, P = 0.001). Predicted risk of mortality was 0.73% vs 0.54% in men (P = 0.023). Women required mechanical circulatory support more frequently (1.3% vs 0%, P = 0.011), had longer intensive care unit stay (29 vs 26 h, P < 0.001), mechanical ventilation (5.4 vs 5 h, P = 0.036), and overall hospitalization (7 vs 6 days, P < 0.001). There was no difference in long-term reoperation-free survival (P = 0.35). Women undergoing mitral valve repair are older and show indicators of more advanced disease with long-standing left ventricular impairment. Guidelines may need to be adjusted and address this disparity, to improve postoperative recovery times and outcomes.

Commentator Discussion: Complete excision of mitral annular calcification and double valve replacement with aortomitral curtain reconstruction

Commentator Discussion: Complete excision of mitral annular calcification and double valve replacement with aortomitral curtain reconstruction

Cardiac calcified amorphous tumor in a patient with lung cancer

BackgroundCalcified amorphous tumor of the heart is a rare non-neoplastic cardiac mass composed of calcified nodules over amorphous fibrous tissue with degeneration and some chronic inflammation. Calcified amorphous tumor is often associated with mitral annular calcification in patients with end-stage renal disease on dialysis. However, the exact etiology of calcified amorphous tumors remains uncertain.Case presentationA 77-year-old female with lung cancer showed a tumor with large mobility in the left ventricular outflow tract on transthoracic echocardiography. She had mitral annular calcification, although her renal function was normal. The tumor was excised surgically. Pathologically, the extracted specimen consisted of a calcified lesion without tumor tissue and was diagnosed as a calcified amorphous tumor.ConclusionsAs the patient had no other risk factors for calcified amorphous tumor except mitral annular calcification, we considered the association of blood coagulation abnormalities due to cancer-related thrombosis. This case suggests that calcified amorphous tumors may be associated with malignant tumors.

Durability of annuloplasty in patients with atrial functional mitral regurgitation associated with atrial fibrillation

ObjectiveTo determine the durability of mitral valve repair (MVr) with complete ring or flexible band annuloplasty in patients with atrial functional mitral regurgitation (AFMR) due to atrial fibrillation (AF) and identify risk factors associated with postoperative recurrence of mitral regurgitation. MethodsBetween January 1, 2000, and January 1, 2023, 194 adults with a history of AF underwent MVr with annuloplasty alone for moderate/severe AFMR. Exclusion criteria were prior cardiac surgery, additional repair techniques, ejection fraction <45%, ischemic heart disease, aortic valve disease, mitral annular calcification, and concomitant procedures other than surgical ablation or tricuspid repair/replacement. The durability of annuloplasty was assessed using longitudinal analysis of postoperative echocardiographic data. ResultsComplete ring annuloplasty was performed in 126 of 194 patients (65%); partial ring (posterior band) in the other 68 (35%). Concomitantly, 124 of the 194 patients underwent tricuspid valve surgery, and 173 (89%) had a procedure for AF, including biatrial Cox-Maze III/IV lesion set in 152 (88%) and pulmonary vein isolation in 21 (12%). All patients were discharged with no/trace MR. Freedom from moderate/severe MR after repair with annuloplasty alone was 89% at 10 years, and no significant differences were noted between complete and partial ring annuloplasty (early, P = .41; late, P = .92). Forty-eight percent of patients developed AF at 3 months or longer after surgery, and the presence of postoperative AF was not associated with a greater likelihood of recurrence of MR (P = .15). Freedom from mitral reintervention was 96% at 10 years. ConclusionsIn appropriate patients with AFMR, the long-term durability of annuloplasty is excellent with complete ring and posterior band annuloplasty techniques.