Calcification Of Mitral Valve Annulus Research Articles

PASCAL device implantation for severe mitral regurgitation with acute chordae rupture and small calcified mitral valve annulus.

PASCAL device implantation for severe mitral regurgitation with acute chordae rupture and small calcified mitral valve annulus.

OA13 Multiple complication in the lifetime of limited cutaneous systemic sclerosis

Introduction/BackgroundWe are reporting the case of a 76 year old woman whose symptoms started early in her teens with Raynaud's disease and who was first diagnosed with limited cutaneous systemic sclerosis in her twenties, at which time she had calcinosis, Raynaud's phenomenon, sclerodactyly and a drawstring mouth. She was started on vasodilators and remained relatively stable for several years. However, she developed a series of complications from the late 1990s. onwards. These included digital ulceration, macrovascular disease, scleroderma bowel, pulmonary hypertension and severe calcinosis. Comorbidities included ischemic heart disease, aortic stenosis and hypothyroidism.She smoked for 5 years (19-24y).Description/MethodDominant clinical problems1980s Digital UlcerationStarted in her forties. She was treated with a series of vasodilators including nifedipine, losartan, fluoxetine and, from 2015, sildenafil. She required IV iloprost three monthly since 2004. Bosentan was considered but cautioned against, given also diagnosed with aortic stenosis.1980s CalcinosisRecurrent calcinotic fingers and the olecranon processes with cellulitis and no osteomyelitis.1999-2007 Critical ischemia of legsIn 1999, she developed left leg ischemia. Doppler ultrasound demonstrated severe stenosis, or occlusion, of all lower limb arteries. She was taking Nifedipine, Amlodipine, Losartan, Dipyridamole, Atorvastatin, Sildenafil, monthly courses of iloprost and opiate analgesia. Despite this, she proceeded to below-knee amputation in 2000. In 2006 she developed right leg ischemia and, despite transient improvement with posterior tibial angioplasty, she required below-knee amputation in 2007.1999-2021 Iron deficiency anaemiaIron deficiency anaemia was detected in 1999 (Hb 109 g/L, serum iron 5.5 umol). OGD showed oesophagitis and residual gastric contents in the oesophagus. In 2021 (Hb 112g/L) a repeat OGD showed stomach and duodenal angiodysplastic lesions.Treatment: esomeprazole and Nizatidine.2017 Suspected Pulmonary Arterial HypertensionShe was referred to the Pulmonary Vascular Diseases Unit at Royal Papworth hospital due to suspicion of pulmonary arterial hypertension following screenings:· Lung Function: FEV1 99.8%, FVC 114.9% TLCOc 56%, KCOc 67%.· ECHO LVEF 60%, normal R ventricle, normal atria, calcification of mitral valve annulus, mild tricuspid regurgitation with estimated sPAP 20-25 mmHg + RAP.· Bloods: Uric acid 180 micromol/L, NT-proBNP 321pg/ml; FBC normal Pulmonary hypertension was confirmed.· CTPA: Pulmonary emboli in right lower lobe segmental and subsegmental arteries.· Right Heart Catheterisation: mPAP 29mmHg, PAWP 7mmHg, PVR 381 dynes (Test performed after withholding Sildenafil for 5 days)Diagnosis: Chronic thromboembolic pulmonary hypertension with possible contribution from pulmonary arterial hypertension.Treatment: Warfarin and Sildenafil increased to 50mg tds.Discussion/ResultsThis patient developed both micro- and macrovascular disease. Digital ulcers were managed with escalation of vasodilators but bosentan was not added to sildenafil due to aortic stenosis. Macrovascular disease was treated with statins, angioplasty and, ultimately with amputation, she walks with two prosthetic legs and a stick. It is unclear whether her short smoking history is relevant.Iron deficiency anaemia can occur due to malabsorption due to scleroderma bowel but, in this case, recurrent bleeding from gut telangectasiae seemed most likely.Pulmonary arterial hypertension is a well-recognised complication of systemic sclerosis. However, it is important that, the underlying cause(s) of pulmonary hypertension are investigated in order to manage appropriately.Calcinosis can be debilitating and a cause of ulceration and infection. There are limited treatment options.Key learning points/ConclusionManagement of digital ulceration, with escalation of treatment and position of Sildenafil and Bosentan in treatment pathway.Importance of considering macrovascular disease in systemic sclerosis.Consideration of reasons for iron deficiency anaemia in systemic sclerosis.Screening for and diagnosis of distinct types of pulmonary hypertension.Limited management strategies for calcinosis.

Calcificación Anillo Mitral. Reemplazo mitral con prótesis mecánica en posición supra anular

An 84 year old woman presented with recurrent severe heart failure. She had a heavily calcified mitral valve annulus. Radiological images before and after a mechanical valve was implanted in a supra annular position are shown.

Mitral valve replacement in severely calcified mitral valve annulus: a 10-year experience.

Severe calcification in the mitral valve annulus is a challenging problem during mitral valve surgery. We describe our experience with mitral valve replacement in severely calcified mitral valve without decalcification of the annulus. Between April 2001 and July 2011, 61 patients underwent mitral valve replacement with severe mitral annulus calcification without decalcification of the annulus. This retrospective study was performed to assess the surgical and the long-term postoperative outcomes in this group. The mean age of the patients was 75.2 ± 9.2 years. Twenty-four patients (53%) were in New York Heart Association Class III/IV. Twenty-six patients (58%) had good left ventricular function. Mean logistic EuroSCORE was 8.75. Isolated mitral valve replacement was performed in 12 patients (27%). Coronary artery bypass grafting was done in 13 patients (29%). In-hospital mortality was 4.9% (3 patients). Postoperative morbidity included re-exploration for bleeding in 3 patients (7%) and transient renal impairment in 10 patients (22%). Three patients required intra-aortic balloon pump (7%) for low cardiac output syndrome. Seven patients (16%) required permanent pacemaker, and 1 patient (2%) had thromboembolic event. The 1-year survival was 93.3%, and the 5-year survival was 78.8%. The mean echocardiography follow-up was 40 months. There was no paravalvular leak detected in any patient in the long-term follow-up. None of the patients had valve-related reoperation. Mitral valve replacement without annular decalcification in severely calcified mitral valve annulus is a safe and an effective approach and has good long-term outcome.

Video-atlas on minimally invasive mitral valve surgery-the Mohr technique.

Minimally-invasive mitral valve surgery was introduced into the surgical routine by Alain Carpentier, one of the pioneers of mitral valve surgery, in 1996 (1). It was at this time that minimally-invasive access was also performed at the Leipzig Heart Center for the first time. Since then, this technique has become routine at our institution with an annual number of up to 400 cases (2). It has been shown to be a safe technique not only in patients with impaired left ventricular function (3) and in patients of advanced aged (4), but also in selected patients who have had a previous sternotomy (5). In the majority of cases, the mitral valve is operated under direct vision. However, some cases are performed using pure videoscopic vision, as it has been promoted by Hugo Vanerman and others (6). The goal of minimally-invasive mitral valve surgery is to perform the operation with the same high repair rate compared to conventional mitral valve surgery through a median sternotomy and without putting the patient at a higher surgical risk. Avoiding sternotomy has major advantages for the patient, such as decreased surgical trauma and therefore improved recovery, less postoperative pain and improved cosmesis. These issues are of major importance for patients. There are, however, specific contraindications to this access, which have to be taken into account. In particular, a heavily calcified mitral valve annulus or severe annular abscess formation with the need to perform extensive annular reconstruction techniques should necessitate a conventional approach. Previous right chest surgery with severe adhesions of the right lung to the chest wall is an additional contraindication to minimally-invasive access. In addition, aortic valve regurgitation >I° is in our experience also a reason to perform a conventional sternotomy, in order to avoid insufficient administration of cardioplegia. In all other cases, minimally-invasive access can be used to perform the surgery. An article featured in this issue, “Consensus statement on Minimally Invasive Mitral Valve Surgery”, will address important issues when and when not to perform minimally-invasive access. In 2000 Mohr and von Oppel (7) introduced the “Loop technique”. This technique simplified even complex repairs of mitral disease using initially self-manufactured polytetrafluoroethylene neochordae (Gore-Tex loops), which became later available as premanufactured loops in different lengths. This technique has been shown to achieve excellent surgical results with a very high rate of mitral valve repair even in complex mitral valve pathologies (2). We were further able to demonstrate in a prospective randomized trial, that the “loop technique” had specific advantages compared to the leaflet resection technique in patients with mitral valve prolapse (8). Aside from significantly greater length of coaptation, patients undergoing the “loop technique” also received significantly larger annuloplasty rings in this study. In summary, the “loop technique” simplifies mitral valve repair, especially through a minimally-invasive surgical approach.

Mitral valve replacement in patients with severely calcified mitral valve annulus: Surgical technique

Mitral valve replacement in patients with severely calcified mitral valve annulus: Surgical technique

Mitral annulus calcification and sudden death

Mitral valve annulus calcification is a degenerative cardiac condition often found at autopsy in the elderly. While usually considered incidental to the cause of death, we report two cases where mitral valve annulus calcification with valve stenosis was associated with sudden death. Case 1: a 61-year-old female who had underlying atherosclerosis and hypertension collapsed at home. At autopsy there was marked mitral valve annulus calcification with valve stenosis and cardiomegaly. Case 2: a previously well 74-year-old female collapsed in a toilet. At autopsy there was marked calcification of the mitral valve annulus with valve stenosis. In both cases death was attributed to the effects of the calcified mitral valve annulus. Although such calcification may be unrelated to the terminal lethal mechanism, the association with left atrial enlargement, atrial fibrillation, mitral regurgitation, mitral stenosis, bacterial endocarditis, ischaemic and thromboembolic stroke, myocardial infarction, and arrhythmias, means that it should not be overlooked in the differential diagnosis in cases of sudden and unexpected death.

Mitral Valve Annular Calcification Is Associated with Poor Outcome after Intracerebral Hemorrhage (P06.230)

Objective: We sought to determine the prevalence of MAC and evaluate associations between MAC and adverse events and early functional outcomes in patients with intracerebral hemorrhage (ICH). Background Hypertension (HTN) is the major cause of ICH. Structural and functional hypertensive changes are frequently detected in patients with ICH. Mitral valve annular calcification (MAC), associated with adverse cardiovascular disease, including stroke, has not been studied in patients with ICH. Design/Methods: We retrospectively analyzed all patients presenting with spontaneous ICH from July 2008 to December 2010. Patients were included if a transthoracic echocardiogram (TTE) was performed during acute hospitalization. Baseline demographics, clinical characteristics, and TTE results were analyzed using Chi square and Mann-Whitney U. Results: Of 119 patients who were screened, 75 (68% of patients with ICH) subjects had TTE data which included description of the mitral valve: 57% male, 70% African American with a median age of 58 (19-90), and median NIHSS 15 (IQR 6,21). 1 in 5 ICH patients had MAC on TTE. Patients with MAC were older (p Conclusions: This is the first study to document a relationship between the presence of MAC and worse outcome in patients with ICH. MAC may merely serve as a surrogate marker for medically complex patients at higher risk of poor outcome. Disclosure: Dr. Burak has nothing to disclose. Dr. Albright has nothing to disclose. Dr. Sartor has nothing to disclose. Dr. Sisson has nothing to disclose. Dr. Martin-Schild has nothing to disclose. Dr. Denny has nothing to disclose.

Multimodality imaging of exuberant mitral annular calcification in a patient presenting with transient ischaemic attack

We report an unusual case of calcification of mitral valve annulus imaged with multiple non-invasive modalities in a patient who suffered a transient ischaemic attack, probably from thrombus overlying the mitral annular calcification. Both this mode of presentation and the imaging features of the annular calcification were relatively unusual, and the images obtained are remarkably clear and diagnostic.

Folding mitral valvuloplasty without posterior leaflet resection for calcified mitral annulus

Mitral valve annular calcification has long been a challenge in repairing posterior mitral valve prolapse. Folding valvuloplasty of the posterior leaflet without resection provides a means of circumventing common procedural complications. This report demonstrates the success of folding valvuloplasty without resection in the treatment of mitral valve prolapse and severe annular calcification.

Continuity equation is the echocardiographic method of choice to assess degenerative mitral stenosis

We present a rare case of a patient with severe, symptomatic degenerative calcific mitral stenosis (MS). Calcification of mitral valve annulus (MVA) is a frequent finding in elderly patients. It can be isolated or associated more often with mitral valve insufficiency than MS. In rare cases, it results in severe MS. An accurate measurement of MVA in degenerative calcific MS is problematic because the limiting orifice is near the annulus and not at the leaflet tips as in rheumatic MS. Continuity equation is the best echocardiographic method to assess the MVA in degenerative MS, correlating well with invasive methods. Real-time three-dimensional echocardiography is a promising tool and provides an accurate measurement of MVA in calcific MS, with a very good correlation compared to continuity equation. On the other hand, the use of pressure half-time is often inaccurate and should be avoided, while two-dimensional planimetry is difficult and not reliable in degenerative MS. The values of mean gradient and systolic pulmonary artery pressure depend on several factors and should be only supportive signs and should not be considered as surrogate markers of the severity of MS.

Upregulation of Connexin43 Expression in Mitral Valves in a Rabbit Model of Hypercholesterolemia

Background: Connexin 43-mediated gap junctional communication plays an important role in atherosclerosis. Numerous studies have demonstrated a correlation between mitral valve annular calcification and atherosclerotic disease. However, the relevance of connexin 43 to mitral valve disease remains unclear. We hypothesized that the mechanism contributing to mitral valve disease is associated with alterations in cell-to-cell communication mediated by changes in Connexin 43 expression. Material and Method: Twenty male New Zealand rabbits were divided into two groups: animals in group 1 (n=10) were fed a normal chow diet, whilst those in group 2 (n=10) received a diet containing 1% cholesterol for 12 weeks. After sacrificing the animals, the mitral valves were excised and analyzed with immunohistochemical staining and Real-time Reverse Transcriptase polymerase chain reaction (real time RT-PCR). Result: Myofibroblasts and macrophages were found concentrated within the endothelial layer on the ventricular side of the leaflet in the cholesterol diet group. Immunohistochemial staining showed elevated expression of connexin43 in the cholesterol diet group. Real-time RT-PCR revealed increased connexin43 mRNA levels in mitral valves from hypercholesterolemic animals. Conclusion: Our finding that connexin43 expression is increased in mitral valves of hypercholesterolemic rabbits suggests that alterations in cell-to-cell communication via connexin43 containing gap junctions play a role in the development of mitral valve disease in hypercholesterolemia.

Caseous Degeneration of a Calcified Mitral Valve Annulus

Caseous Degeneration of a Calcified Mitral Valve Annulus

Modification of the intra-atrial mitral valve prosthesis implantation in cases of heavy mitral annulus calcification

We read with interest the case report titled ‘Intra-atrial implantation of a mitral valve prosthesis in a heavily calcified mitral annulus’ by Atoui et al. [1]. As noted in the article, in cases of severe mitral valve annulus calcification there is always difficulty implanting the prosthetic valve. We agree that the presented technique can be life saving; however, it should be remembered that there remains the risk of dehiscence due to the weakness of the left atrial wall and paravalvular leak is an important and common complication. In a similar patient who had presented to our centre with severe congenital mitral regurgitation in childhood, due to impossibility of implanting the prosthetic valve in the annulus, the valvewas placed in the left atrialwall. Thepatient presented2 years laterwith severe paravalvular leak and the next surgeon considering this as only a paravalvular leak proceeded with closing the leak. Unfortunately, the patient developed paravalvular leak and dehiscence again as a result of the left atrial wall weakness. In such cases, we recommend using a two-layered Dacron patch to reduce tension to the left atrial wall. A hole is made in the centre of the patch where the valve is to be placed and sutured. Then the Dacron with the prosthetic valve implanted in its centre is sutured to the left atrial wall. With this technique the chance of dehiscence from the left atrial wall is reduced.

Surgical treatment of caseous mitral valve annulus calcification

Mitral annular calcification (MAC) is common in the elderly population. It can cause mitral regurgitation, mitral stenosis, and heart block and can complicate attempts to repair or replace the mitral valve. Extensive MAC can undergo liquefaction and simulate an intracardiac mass. Previously this rare entity was believed to be a benign incidental finding on imaging. We describe a case of caseous MAC mimicking a cardiac tumor and causing spontaneous cerebral embolization.

Repair of spontaneous rupture of the posterior wall of the left ventricle after mitral valve replacement

One of the most serious complications in cardiac surgery is the occurrence of a rupture of the posterior wall of the left ventricle after mitral valve replacement. This is a challenging and often humbling experience to the cardiac surgeon, carrying a significant morbidity and mortality. The original reports of this complication were documented in the late 60s and early 70s. 1-3 Since then, multiple reports of isolated cases or short series have appeared in the literature, describing the events and proposing different technical approaches to prevent and correct the problem. The etiologic factors have become well recognized, and preventive measures, including new developments and technical approaches to mitral valve surgery, have reduced markedly the incidence of this problem and virtually eliminated the potential occurrence of certain types of left ventricular rupture. Three specific types of rupture are described (Fig 1) and they have been classified according to their anatomic location. 2,4 TYPE I A Type I rupture is located at the atrioventricular groove. This remains the most common site and can be seen in the following circumstances: ● Heavily calcified mitral valve annulus requiring considerable dissection and debridement of calcium sediment from the atrioventricular groove. ● Cases of bacterial endocarditis with mitral valve annular abscess, requiring extensive debridement at the time of mitral valve replacement.5 ● Resection of the posterior leaflet with placement of subannular sutures for valvular replacement, with consequent local trauma, hematoma, and rupture. ● Improper inspection of the left ventricular posterior wall after mitral valve replacement, by lifting the heart from the pericardial cavity, erroneously using the atrioventricular groove as a fulcrum.

Mitral valve repair in the extensively calcified mitral valve annulus

Mitral valve replacement in patients with an extensively calcified mitral annulus is associated with an increased risk of ventricular rupture. Until now techniques of mitral valve repair have not been applied to patients with a heavily calcified mitral valve annulus. We present 12 patients who underwent extensive decalcification of the annulus with subsequent mitral valve repair between 1987 and 1990. Ages ranged from 11 to 78 years; 6 patients were in New York Heart Association functional class II, 4 were in class III, and 2 were in class IV. All patients had varying degrees of mitral insufficiency. There were no deaths, reoperations, or thromboembolic events. Post-operative echocardiography revealed minimal residual mitral insufficiency in only 2 of 12 patients. All patients are currently in New York Heart Association class I or II. We believe mitral valve repair can be done safely on patients with an extensively calcified mitral annulus, thus avoiding the risks of left ventricular rupture, thromboembolic events, and hemorrhagic complications associated with mitral valve replacement.

Myocardial Imaging Artifacts Caused by Mitral Valve Annulus Calcification

Knowledge of imaging artifact of myocardial perfusion studies with thallium-201 is critical for improving the diagnostic accuracy of coronary artery disease. Three patients are described who underwent exercise or pharmacologic stress thallium-201 imaging studies and had a moderate, fixed myocardial perfusion defect (scar) involving the posterolateral and inferoposterior walls of the left ventricle. This was an imaging artifact caused by a heavily calcified mitral valve annulus.

Severe mitral stenosis secondary to massive calcification of the mitral annulus with unusual echocardiographic manifestations

In mitral annular calcifications, hemodynamic documentation of a significant diastolic gradient across the mitral valve has been rarely demonstrated, and then only with the associated finding of a small left ventricular cavity with hypertrophic left ventricular wall. We present a patient with severe mitral annular calcification, with a significant diastolic gradient and unusual echocardiographic manifestations which include a densely calcified mitral valve annulus with anterior mitral valve leaflets consistent with what is seen in patients with mitral stenosis. When recordings were made immediately below the mitral valve annulus at the free edge of the mitral valve, its leaflets were seen departing in opposite directions, certainly not suggestive of outflow obstruction of the left atrium. Although in previous studies it has been suggested that mitral stenosis does not exist in the presence of mitral annulus calcification, our present report indicates that significant diastolic gradients can be found in patients with mitral annular calcifications. Because of the predominance of this condition in the elderly population, it is suggested that a more aggressive approach be taken in those patients in whom it is warranted by clinical circumstance.