Mitral Valve Calcification Research Articles

Efficacy of left atrial plication for atrial functional mitral regurgitation

ObjectiveAtrial functional mitral regurgitation (AFMR) is caused by atrial fibrillation and left atrial enlargement. Our study aimed to evaluate the efficacy of left atrial plication (LAP) for AFMR.MethodsOf 1164 mitral valve surgery patients at our hospital from January 2000 to May 2019, 22 patients underwent surgery for AFMR. Our retrospective analysis divided the patients with AFMR into two groups according to whether LAP was performed (LAP + group, n = 9; LAP − group, n = 13). Mitral valve angle (MV angle) (horizontal inclination of mitral valve) was measured by pre- and post-operative computed tomography scan. Individuals with type II mitral regurgitation, left ventricular ejection fraction of < 55%, males with left ventricular endo-diastolic dimension of > 60 mm and females with > 55 mm, aortic valve disease, mitral valve calcification, hypertrophic obstructive cardiomyopathy, and both “redo” and emergency cases were excluded.ResultMitral valve replacement was performed in 6 patients and mitral ring annuloplasty in 16 cases. No recurrence of mitral regurgitation or structural valve deterioration occurred during the follow-up period. There were no hospital deaths; 3 deaths occurred during the follow-up period. Compared to the LAP − group, the LAP + group demonstrated a significantly greater decrease of MV angle (16.6 ± 8.1° vs. 1.2 ± 6.9°, p < 0.01) and left atrial dimension (18.4 ± 7.0 mm vs. 6.9 ± 14.6 mm, p = 0.02).ConclusionsSurgical results of AFMR were satisfactory. LAP may be appropriate for correcting the angle of a mitral valve tilted horizontally. More cases need to be considered in the future.

The Relationship Between Primary Knee Osteoarthritis and Aortic Stiffness, Distensibility, and Valve Calcifications: A Case-Control Study.

The purpose of our study was to evaluate aortic stiffness and distensibility changes and the presence of aortic and mitral valve calcifications in patients with primary knee osteoarthritis (OA), using 2-dimensional and Doppler transthoracic echocardiography. This case-control study included 115 participants with OA and a control group between May 2019 and November 2019. The Kellgren-Lawrence classification was used for the diagnosis and classification of knee OA, based on radiological images. We compared the demographic data, 2-dimensional and Doppler transthoracic echocardiography results, and laboratory findings between the OA patient group and the control group. There was a significant difference between aortic strain, aortic distensibility, aortic stiffness, and C-reactive protein values between the OA patient group and the control group (p < 0.001 for all). Post hoc analyses revealed that aortic strain and aortic distensibility values were significantly lower, and aortic stiffness values were significantly higher in the grade 4 OA group than those of other groups (p < 0.05 for all). In addition, the C-reactive protein values of the grades 3 and 4 patients were significantly higher than those of other groups (p < 0.05 for all). No significant difference was observed between the groups in terms of aortic and mitral valve calcifications (p > 0.05 for all). Aortic strain and distensibility values were lower in the advanced grades of primary knee OA, whereas aortic stiffness values and the frequency of valve calcifications were higher.

A study on the prevalence, distribution and related factors of heart valve calcification using coronary CT angiography.

The concept of active atherosclerotic disease has been accepted for heart valve calcification (HVC). We investigated prevalence, distribution and related factors of HVC in patients who had undergone coronary CT angiography (CCTA). Subjects were consecutive 200 patients who underwent CCTA. The prevalence and the distribution of HVC using ECG gated non-contrast CT were investigated. Logistic regression analysis and simple regression analysis for factors associated with presence of the calcification and quantitative calcification in the aortic and mitral valve were conducted. HVC was detected in 48.0%. Aortic valve calcification (AVC) was found in 92 cases, the most, followed by mitral valve calcification (MVC) in 25 cases, pulmonary valve in 3 cases, and tricuspid valve in 1 case. Although the left coronary cusp showed the most in 65.2%, no statistic significant difference for Agatston score was detected among each cusp in AVC. Multiple logistic regression analysis showed that age (OR:1.211, 95%C.I.:1.0716-1.1728, p<0.0001) and coronary artery calcium score (CACS) grade (grade2 OR:7.3393, 95%C.I.:1.7699-30.4349, p=0.0060, grade3 OR:7.2214, 95%C.I.:1.4376-36.2762, p=0.0164) were significant factors associated with presence of AVC. The significant factors associated with quantitative AVC were age (p=0.0043), dyslipidemia (p=0.0117), and statin use (p=0.0221). Only age (OR:1.1589, 95%C.I.:1.0726-1.2520, p=0.0002) was significant factor related to presence of MVC. No significant related factor was found in quantitative MVC. There was an association between presence of AVC and CACS, but not a significant association with presence of MVC. Neither quantitative AVC nor MVC had a significant association with CACS or coronary artery disease.

P1274THE CHARACTER OF CARDIAC REMODELING AND VALVE CALCIFICATION IN TYPE 2 DIABETIC PATIENTS WITH END-STAGE RENAL DISEASE

Abstract Background and Aims Systematic analysis of cardiac remodeling features in type 2 diabetic patients with end-stage renal disease (ESRD) is important both in stratification of cardiovascular risk and in choice of adequate treatment strategies. The lack of number and fragmentation of studies, the ambiguity of their data regarding the problem of myocardial reconstruction and cardiac valve calcification (CVC) under these conditions have substantiated the need for this study, its relevance and purpose. Method 136 ESRD patients on chronic hemodialysis (HD) were included in this observational cross-sectional study (men, 78; age, 53.9±1.0 years; HD duration, 47.6±4.2 months). The study was performed in accordance with the provisions of the Declaration of Helsinki last revision. Depending on the presence/absence of diabetic nephropathy (DN) all patients were divided into two groups: the 1st one – without DN (n=88); the 2nd one – with DN (n=48). A complete ultrasound examination of the cardiac structure and function including CVC analysis was performed. Data are presented as means±SEM. Mann-Whitney U-test was used for comparison of the quantitative variables, χ2-test – qualitative ones. Results Left ventricular (LV) hypertrophy (93.8 vs. 78.4%, р=0.020) and eccentric hypertrophy (47.9 vs. 28.4%, р=0.023) were diagnosed more often in patients with DN than those without diabetes. Prevalence of pseudonormal and restrictive types of LV diastolic dysfunction (62.5 vs. 28.4%, p&amp;lt;0.001), systolic dysfunction (27.1 vs. 9.1%, p=0.006) and pulmonary hypertension (PH) (64.6 vs. 35.2%, p=0.001) were significant in the 2nd group. CVC (66.6 vs. 38.6%, р=0.002), combined calcification of mitral (MV) and aortal (AV) valves (35.4 vs. 13.6%, p=0.003), stenoses of MV (16.7 vs. 3.4%, p=0.007) and AV (39.6 vs. 15.9%, p=0.004), and insufficiency of MV (66.7 vs. 44.3%, p=0.013) and AV (35.4 vs. 14.8%, p=0.006) were recorded more often in HD patients with DN. LV myocardial mass index (181.0±7.2 vs. 155.0±5.3 g/m2, p=0.001) as well as right ventricle (RV) diameter (2.80±0.09 vs. 2.47±0.04 cm, p=0.003) were also greater in the 2nd group. Conclusion In type 2 diabetic patients with ESRD occurs maladaptive cardiac remodeling with predominance of unfavourable (especially eccentric) types of LV hypertrophy, RV dilatation, PH, severe LV diastolic and systolic dysfunction, and widespread combined calcification of MV and AV with the valve defects. The identification of risk factors for the progression of the pathological reconstruction of myocardium and CVC in HD patients with DN will be the subject of our further research.

P1030ENDOTHELIAL DYSFUNCTION AND CARDIAC VALVE CALCIFICATION IN PATIENTS WITH DIABETIC KIDNEY DISEASE UNDERGOING CHRONIC HEMODIALYSIS

Abstract Background and Aims The character of endothelial dysfunction (ED), especially of nitric oxide (NO) system, in patients with diabetic kidney disease (DKD) undergoing chronic hemodialysis (HD) was not asserted enough. In this condition not clearly established the relationship of structural and functional activity of endothelium with the presence and severity of cardiac valve calcification (CVC) as independent predictor of cardiovascular morbidity and mortality. The purpose of the current study was to determine the role of ED in mechanisms of mitral (MVC) and aortic (AVC) valve calcification in HD patients with DKD. Method We enrolled 136 patients undergoing HD (male/female, 78/58; age, 53.9±1.0 years; HD duration, 47.6±4.2 month) in this observational cross-sectional study. According to the study design, depending on the presence of type 2 diabetes mellitus with kidney injury patients were divided into two groups: the 1st one – without DKD (n=88); the 2nd one – with DKD (n=48). All subjects underwent echocardiographical examination for detection of CVC; the MVC and AVC degree were scored as follows: 1, no calcification; 2, valve thickening without calcification; 3, valve annulus or cusps calcification. Vasomotional function of endothelium was assessed using a test with reactive hyperemia (brachial artery flow-mediated dilatation (FMD)). Plasma content of nitrites (NO2), circulating endothelial cells (СECs) and serum concentration of C-reactive protein (CRP) were measured as markers of ED. Data are expressed as means±SEM. Used nonparametric statistics methods: Mann-Whitney U-test, χ2-test, Spearman’s rank R correlations. Results In group of HD patients with DKD indices of СECs (22.3±1.3 vs. 14.2±0.7 × 104/L, Z=4.98, p&amp;lt;0.001), CRP (9.94±1.12 vs. 7.07±1.09 mg/L, Z=3.47, p&amp;lt;0.001) were higher, and NO2 (4.16±0.41 vs. 9.01±1.37 umol/L, Z=3.15, p=0.002), FMD (2.27±0.66 vs. 5.13±0.52%, Z=3.26, p=0.001) – lower compared to the group without diabetes. CVC was detected in 66.6% of patients with DKD with predominance of calcification of both valves (35.4%) over isolated MVC (20.8%) and AVC (10.4 %). Combined valve calcification in the HD patients of the 2nd group was observed 2.6 times more often (χ2=8.78, p=0.003) than in the 1st one. For the first time it was established that in DKD the presence of CVC closely associated with indices of FMD (Rs=-0.59, p&amp;lt;0.001), NO2– (Rs=-0.56, p&amp;lt;0.001), СECs (Rs=0.63, p&amp;lt;0.001) and СRP (Rs=0.54, p&amp;lt;0.001). The MVC as well as AVC degree were related with the level of FMD (Rs=-0.47, p&amp;lt;0.001; Rs=-0.43, p=0.003), content of NO2– (Rs=-0.40, p=0.005; Rs=-0.62, p&amp;lt;0.001), СECs (Rs=0.47, p&amp;lt;0.001; Rs=0.62, p&amp;lt;0.001) and СRP (Rs=0.48, p&amp;lt;0.001; Rs=0.41, p=0.004) concentrations respectively. Conclusion (1) HD patients with DKD are combined with damaged endothelium, disturbance of vasoreactivity and lack of NO. (2) Type 2 diabetes mellitus with kidney injury is characterized by the large-scale combined MVC and AVC, which in turn are closely associated with the ED markers. (3) Complex estimation of the character of CVC and endothelium activity in HD patients with DKD permits a better identification of their cardiovascular risk.

Predictors of Complications During Percutaneous Multitrack Balloon Mitral Valvuloplasty

Introduction: Mitral Stenosis (MS) is characterized by a decrease in Mitral Valve (MV) orifice area leading to compromised left ventricular filling. The consequence is stagnation of blood proximal to the MV that results in elevated left atrial, pulmonary venous, and pulmonary artery pressure. Aim of the work: Trace the complication of mitral regurgitation during the procedure percutaneous Balloon Mitral Valvuloplasty (PMV) by using multitrack balloon. Subjects and methods: This interventional non-randomized cohort study was conducted on 121 patients who presented with moderate to severe MS and subjected to PMV using multitrack balloon technique and were divided into 2 groups, according to resultant mitral regurgitation: Group A: included patients with no or mild mitral regurgitation and Group B: included patients with severe mitral regurgitation. Results: Multivariate regression identified MV balloon sizing (OR 3.877, CI 95% 1.131-13.289, P value 0.031), MV commissural asymmetry (OR 67.48, CI 95% 5.759-790.72, P value 0.001). Conclusion: Mitral valve calcification, balloon sizing and MV asymmetry are significant factors that can predict the development of severe MR after balloon valvuloplasty.

The influence of cardiac valvular calcification on all-cause and cardiovascular mortality in maintenance hemodialysis patients.

To investigate the effect of cardiac valve calcification (CVC) on all-cause and cardiovascular mortality in maintenance hemodialysis (MHD) patients. A retrospective cohort study was conducted in 183 long-term hemodialysis patients with complete follow-up data from January 1, 2012, to December 30, 2015. The baseline data between CVC and non-CVC groups were compared. Kaplan-Meier method was used to analyze all-cause and cardiovascular mortality. The effect of CVC on prognosis was analyzed using the Cox proportional hazardregressionmodel and subgroup analysis. Among 183 patients under hemodialysis, 104 (56.8%) were males, with an average age of 56.1 ± 17.0years and 68 (37.2%) were complicated with valvular calcification. The median follow-up period was 30.8months. All-cause and cardiovascular mortality were 50% vs. 14.8% and 25% vs. 7.0% in the CVC and non-CVC groups, respectively (P < 0.05). Kaplan-Meier indicated that differences in all-cause and cardiovascular mortality were statistically significant between the two groups (P < 0.001). Cox regression analysis showed that CVC significantly increased all-cause (hazards ratio [HR] 2.161 [1.083-4.315]) and cardiovascular mortality (3.435 [1.222-9.651]) after adjusting for multiple factors. Meanwhile, CVC also increases the incidence of new-onset cardiovascular events. Subgroup analysis revealed that all-cause and cardiovascular mortality were significantly higher in patients with aortic valve calcification (AVC) than in patients with mitral valve calcification (MVC). Multivariate calibration showed that AVC increased the risk of cardiovascular death (HR 5.486 [1.802-16.702]) (P < 0.05), whereas MVC did not. By further comparing the echocardiographic data of the two groups, the incidence of LVH and pulmonary hypertension in the AVC group was significantly higher than that in the MVC group. Valve calcification increases the risk of all-cause and cardiovascular mortality in MHD patients, also new-onset cardiovascular events, and aortic valve calcification contributes more to the risk of cardiovascular mortality.

Abstract P435: Associations of Endogenous Sex Hormone Levels With the Prevalence and Progression of Valvular and Thoracic Aortic Calcification in the Multi-Ethnic Study of Atherosclerosis (MESA)

Background: Sex hormone (SH) levels may contribute to sex differences in cardiovascular disease (CVD) risk among women and men. We previously found that high free testosterone (T) and low sex hormone binding globulin (SHBG) were associated with progression of coronary artery calcification in women. Extra-coronary calcification (ECC) predicts incident clinical CVD independent of traditional risk factors. We examined whether SH were also associated with ECC prevalence and progression among MESA participants free of clinical CVD at baseline. Methods: We studied 2883 postmenopausal women and 3164 men who had endogenous SH levels measured at baseline. ECC was measured by non-contrast cardiac CT at baseline and at a follow-up visit up to 5 years later. ECC included ascending and descending thoracic aortic calcification (ATAC, DTAC), mitral annular calcification (MAC) and aortic valve calcification (AVC). We used multivariable Poisson regression to evaluate associations with ECC prevalence and risk of developing ECC (Agatston scores &gt;0) and linear mixed effects models for ECC progression, per 1 SD increment in log (SH) level in women and men separately. Results: The mean (SD) age was 64 (9) years for women and 62 (10) years for men. In women, greater free T and lower SHBG were associated with MAC incidence in a demographic-adjusted model but were no longer statistically significant after adjustment for CVD risk factors ( Table ). In men, lower free T was associated with MAC prevalence, DTAC incidence and progression while greater SHBG was associated with MAC prevalence and DTAC progression in fully adjusted models. We did not find associations of SH with AVC or ATAC in either men or women. Conclusion: In this diverse cohort free of CVD, we found certain associations of SH with measures of ECC. In particular, free T was inversely associated with prevalent MAC and DTAC progression in men independent of CVD risk factors. SH may influence vascular calcification but further work is needed to understand the clinical implications of these findings.

Evaluation of serum sclerostin level and its correlation with valvular calcification in haemodialysis patients

Abstract Background The majority of hemodialysis patients are affected by the cardiovascular calcification. Vascular/valvular calcification contributes to an extremely high cardiovascular morbidity and mortality in HD patients. Objective To asses circulating levels of Scl in ESRD patients receiving HD and their relation to aortic and mitral valve calcification detected by echocardiography as well. Patients and Methods The study included 80 ESRD patients undergoing HD in Al-Sahel Nephrology and Dialysis unit. Routine chemical investigations, serum sclerostin by ELISA were done to all patients, as well a trans-thoracic Echocardiography. Results serum Scl level ranged from 0.41 ng\ml to 1.65 ng\ml. calcification was documented in 53/80 (66.2%) of our HD patients: 26/80 had aortic valve calcification only(32.5%), 6/80 patients (7.5%) had mitral valve calcification alone, while 21/80 of patients had both aortic and mitral valves calcification (26.25%). 27/80 (33.75%) patients had no calcification. We didn’t find any significant correlation between serum Scl level and valvular calcification nor age, sex or HD duration. Conclusion valvular calcification are prevalent in HD population. Serum Scl was not associated with valvular calcification.

Long-term results after reconstruction of a new annulus in heavily calcified mitral annulus.

In 2009 our group described a new surgical technique for patients with severe mitral valve calcification undergoing mitral valve surgery. This technique creates a new mitral annulus with plication of the mitral leaflet and the atrial wall. Our objective is to report the long-term results of the experience at our institution. From 2007 to 2016, a total of 18 patients (mean age 70.5 ± 7.8 years) underwent mitral valve replacement at our institution with this technique. One patient died on the second postoperative day. Clinical and echocardiographic in-hospital and long-term follow-up (55.5 ± 40.4 months) were performed on all the remaining 17 patients. Functional improvement was achieved in all patients. Two patients died 6 and 8 years after surgery (cancer and hemorrhagic stroke). No prosthetic dysfunction, periprosthetic leak, or annular dehiscence were detected in the long-term echocardiographic examinations. The reconstruction of the mitral annulus by using our technique in patients with severe calcification of the mitral annulus has low long-term mortality, good functional results, and a lack of prosthetic complications.

Presentation and management of calcific mitral valve disease

Little is known about the prevalence, presentation and management of calcific mitral valve disease (CMVD). We identified 167 patients (80 ± 10 years; 79% women) with significant CMVD undergoing transthoracic echocardiography at our institution in 2016. Patients presented with significant co-morbidities, 47% had moderate/severe mitral stenosis, 38% had 3+/4+ mitral regurgitation and 15% had a combination of both. Fifty-eight percent were symptomatic. Most symptomatic patients were managed conservatively and incurred higher mortality and mortality/heart failure admission rates than those managed surgically. These data highlight the importance of gaining mechanistic insights into CMVD to prevent its occurrence and avoid the need for high-risk surgery, which is seldom performed in contemporary practice.

Predictors of Complications during Percutaneous Multitrack Balloon Mitral Valvuloplasty

Background: Percutaneous mitral balloon valvuloplasty is the main procedure in mitral stenosis (MS). It can replace surgical commissurotomy in many cases; however, mitral regurgitation (MR) remains the major procedure complication. Objectives: This study was conducted to investigate predictors of MR as a complication followingpercutaneous mitral valvuloplasty (PMV) using multitrack balloon technique. Methods: This cohort study was conducted at both Menoufia University Hospital and Mabaret Misr Elkadima Hospital. We enrolled 121 patients with moderate to severe MS who were subjected to PMV using multitrack balloon technique during the period from October 2017 to October 2019. Transthoracic echocardiographic evaluation was performed for all patients before and after the procedure. Patients who developed severe MR post procedure were compared with other patients to identify important distinction points. Results: Most patients (N = 109, 90.1%) developed no/mild MR (group A), whereas 12 (9.9%) patients developed severe MR (group B) after PMV. Those who developed severe MR had significantly higher weight, height, body mass index, and body surface area (P value 35.8%, P - 13.289, P = 0.031) and MV commissural asymmetry of calcification (OR 67.48, CI 95% 5.759 - 790.72, P = 0.001) as significant predictors of outcomes of MV commissurotomy. Conclusion: Mitral valve calcification, balloon sizing, and MV asymmetry are significant factors that can predict the development of MR after balloon valvuloplasty.

The Relationship between Plasma Vitamin D Level and Heart Valves Calcification

Background: There is conflicting data regarding the association between low levels of plasma vitamin D and ischemic heart disease (IHD). We aimed to investigate the relationship between plasma vitamin D levels and heart valve calcification in hospitalized patients with IHD versus non-IHD controls. Methods: A prospective case control study comprising two age and gender-matched groups. The study group included consecutive patients hospitalized due to acute coronary syndrome (ACS); the control group included consecutive non- IHD patients hospitalized for non-cardiac causes. Blood samples for 25-hydroxyvitamin D level (25(OH)D) were drawn. An echocardiogram was performed during the first 3 days of hospitalization and reviewed for presence and degree of valvular calcification (VC). Results: Forty patients with ACS and 40 controls (age 58 ± 11 years, 64% male in both groups) were included. Mean plasma 25(OH)D vitamin level in the entire cohort was 24.5 ± 8 ng/ml. Valve calcification rates were similar in ACS versus non-ACS group (28 vs. 21 had VC; 18 vs. 12 had aortic valve calcification (AVC); 21 vs. 14 had mitral valve calcification (MVC), respectively; p=NS for all). We found no significant relationship between vitamin D level and VC, AVC, or MVC rate or degree in the entire cohort and in each group alone (p=NS for all). There was a negative correlation between 25(OH)D levels and age in the ACS group (r=-0.399, p=0.012). Conclusions: We did not find a significant relationship between plasma vitamin D levels and the rate or degree of calcification of either aortic/mitral/both valves in hospitalized patients with/without IHD.

Mitral valve calcium assessment: An independent predictor of balloon valvuloplasty results

ObjectivePercutaneous mitral valvuloplasty (PMV) is an effective treatment for patients with mitral valve stenosis. Echocardiographic score (ES) is a useful predictor of outcomes. However, mitral valve calcification (MVC) has been shown to predict immediate results even in patients with otherwise low ES. We sought to evaluate the usefulness of MVC assessment as a predictor of immediate and long-term outcomes after PMV. MethodsPMV was performed in 168 consecutive patients. Clinical and echocardiographic variables were analyzed. Patients were classified into 2 groups: group 1: minimal MVC and group 2: moderate to severe MVC. Primary success was defined as post-PMV mitral valve area (MVA) ≥ 1.5 cm2 in the absence of major complications. Restenosis (RE) was defined as a decrease in MVA >50% of initial gain or a final MVA <1.5 cm2. ResultsMean age was 46.5 ± 11 years, and 86.9% (146) were women. Forty-two patients (25%) had mild MVC (group 1), and 75% of the patients had moderate to severe MVC (group 2). Procedural success was achieved in 95.2% and 76.2% for groups 1 and 2, respectively, p = 0.01. MVA after PMV was 1.82 cm2 (IQR 25–75 = 1.60–2.00) in group 1 and 1.67 cm2 (IQR 25–75 = 1.44–1.97) in group 2, p = 0.02. After 48 months, 28.2% of patients presented RE. Multivariate analysis identified the presence of MVC as an independent predictor of poor immediate results (HR = 0.12, 95% IC 0.03–0.91) and RE (HR = 1.94, 95% CI = 1.02–5.21). ConclusionOur study shows that the presence of MVC may predict immediate and long-term outcomes after PMV.

HEADACHE OF A DIAGNOSIS: A CASE OF METASTATIC PULMONARY CALCIFICATION IN A YOUNG END-STAGE RENAL DISEASE PATIENT

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Inadequate renal replacement therapy may lead to metastatic pulmonary calcification (MPC) in end stage renal disease (ESRD) patients. MPC is seldom recognized as it is usually asymptomatic. Cough and shortness of breath are uncommon manifestations of MPC. We present a case of symptomatic MPC in a young female diagnosed on CT scan. CASE PRESENTATION: 32 year old non-alcoholic, non-smoker, past history of ESRD (secondary to hypertension) and no previous drug abuse on hemodialysis (HD) for 12 years was referred for a Chest X-ray suggestive of military tuberculosis. She was started on Cefepime before transfer. She reported non-productive cough and dyspnea for 2 months. No previous history of night sweats, fever, chills, weight loss, travel, hemoptysis, exposure to tuberculous contacts, chronic infections, cancer or intake of immunosuppressive medications. She was not compliant with HD. Vitals were within normal limits except for sinus tachycardia. A left upper extremity functional AV fistula was noted and there was a firm non-tender mass in the left infraclavicular region. Her lungs were clear to auscultation with symmetric expansion. Labs showed a white cell count of 12 k/cmm, hemoglobin of 8.5 g/dl, BUN of 65 mg/dl, Cr of 12 mg/dl, phosphorus of 8 mg/dl, Ca of 9.1 mg/dl, albumin of 2.4 g/dl and an elevated PTH of 1318 pg/ml. HRCT of the chest showed multiple bilateral pulmonary micro nodules with heavy and extensive calcifications throughout upper lobes and a big soft tissue calcification in the left infraclavicular region. A 2D ECHO revealed mitral valve calcification. Vancomycin was added to cefepime. Blood cultures and TB quantiferon test were negative. HD and phosphate binders were continued throughout the hospital stay. Bronchoalveolar lavage was negative for mycobacterial, bacterial and fungal infection. During her stay the patient remained afebrile. Considering her history of ESRD and an elevated calcium phosphorus product; diagnosis of MPC was made. Antibiotics were stopped and the patient was counselled on compliance with HD and medications. Pulmonary function tests (PFTs) revealed restrictive defect with decreased diffusion capacity. DISCUSSION: MPC is most likely to develop when calcium phosphorus product exceeds 70. Mean onset of MPC from diagnosis of ESRD is 22.6 +/- 3.1 years. Most patients are asymptomatic with normal PFTs. Rarely they may have restrictive defect on PFTs. HRCT is highly sensitive. The differential diagnosis includes granulomatous infections, viral infections, pneumocystis jiroveci, silicosis, metastatic malignancy and alveolar microlithiasis. No definitive treatment is available. CONCLUSIONS: MPC is relatively common at autopsy (60-70%) in patients with ESRD, but clinical manifestations are infrequent. ESRD patients on HD who are inadequately treated and present with cough, dyspnea and lung calcification, MPC should be considered in the differential diagnosis. Reference #1: Jost, R. Gilbert, and Stuart S. Sagel. "Metastatic calcification in the lung apex.” American Journal of Roentgenology 133.6 (1979): 1188-1190. Reference #2: Belém, Luciana Camara, et al. "Metastatic pulmonary calcification: state-of-the-art review focused on imaging findings.” Respiratory medicine 108.5 (2014): 668-676. DISCLOSURES: No relevant relationships by Ghulam Aftab, source=Web Response

Vitamin D-binding protein and vitamin D receptor genotypes and 25-hydroxyvitamin D levels are associated with development of aortic and mitral valve calcification and coronary artery diseases.

To assess the association between vitamin D-Binding Protein (VDBP rs7041T>G) and vitamin D receptor (VDR rs1544410G>A) gene polymorphisms with susceptibility to cardiovascular diseases in population from west of Iran. Two hundred forty-nine individuals with cardiovascular disease (92 with aortic and Mitral Valves Calcification (AMVC) and 157 with Coronary Artery Diseases (CAD) that their diseases were confirmed by echocardiography and angiography and unrelated 182 healthy controls (gender and age-matched) were selected for this case-control study. The VDR 1544410G>A, and VDBP 7041T>G genotyping were detected by PCR-RFLP, serum vitamin D and lipid concentrations were measured by ELISA and enzyme assay, respectively. The VDR rs1544410G>A gene is a strong risk factor for CAD (OR = 1.28, p = 0.002) and the dominant genotype (T/G+G/G) of VDBP 7041 T>G SNP plays a protective role (OR = 0.67, p = 0.003) in AMVC development in studied population. In addition, lower level of vitamin D strongly increased the risk of CAD (15 ± 11.02 vs. 21.3 ± 18μg/L, p = 0.043) and AMVC (12.1 ± 13.1 vs.21.3 ± 18μg/L, p = 0.014) development in individuals carrying T/T genotype of VDBP 7041 T>G gene polymorphism. There was a strong interaction between A allele VDR rs1544410 and G allele of VDBP rs7041 genes in a protective role (OR = 0.74, p = 0.044) in AMVC patients). CAD and AMVC patients were deficient in vitamin D, i.e. their level of vitamin D was strongly lower than that in the control group. Our findings for the first time indicated that there is a strong association between vitamin D deficiency, lipid profile and the VDR rs1544410G>A and rs7T41>G VDBP genes polymorphisms. These interactions may be one of the important factors for CAD and AMVC incidence.

The association between cardiac valvular calcification and fetuin-A levels in kidney transplant recipients.

Low fetuin-A levels in hemodialysis patients can be associated with development of vascular and valvular calcifications. The mechanisms underlying vascular and valvular calcifications are multifactorial. There are a few studies showing the relationship between low fetuin-A levels and valvular calcification after kidney transplantation. We aimed to evaluate the association between serum fetuin-A levels and valvular calcification in kidney transplant recipients. The cardiac valvular calcification was assessed by echocardiography in 56 recipients. Patients were divided into two groups as those with (n = 11) and without (n = 45) aortic and/or mitral valve calcification. The extent of valvular calcification was visually assessed according to the standard visual score method: moderately (multiple larger spots) and heavily calcified (extensive thickening and calcification) of all cusps. Serum fetuin-A levels were measured. The demographic features of both groups were comparable. There was no significant difference between regular physical exercise (63.6% vs. 55.6%), obesity (18.2% vs. 17.8%), abdominal obesity (54.5% vs. 46.7%), smoking (0% vs. 13.3%), hypertension (63.6% vs. 68.9%), left ventricular hypertrophy (45.5% vs. 33.3%) and diabetes mellitus (9.1% vs. 20%) ratios in groups with or without valvular calcification, respectively (p > 0.05). Fetuin-A levels of both groups did not differ. Fetuin-A levels positively correlated with serum creatinine (r 0.326, p = 0.014), and negatively correlated with estimated glomerular filtration rate (r -0.297, p = 0.026). We could not find a relationship between serum fetuin-A levels and valvular calcification in kidney recipients. In this population, further studies are needed to assess the role of serum fetuin-A in valvular calcification.

Heart-brain interactions

Heart-brain interactions are represented by the association of cerebral ischemia with coronary artery disease, cardioembolic cerebral ischemia, and cardiovascular complications due to brain damage. As atherosclerosis is a systemic inflammatory disease, in patients with transient ischemic attack, stroke or asymptomatic carotid artery disease, a previous myocardial infarction, angina or an asymptomatic coronary artery disease are often associated and a correlation between the carotid atherosclerosis and coronary artery disease severity has been reported. Furthermore, the long-term prognosis of patients with stroke is strongly affected by coronary events. At the same time, the prevalence of concomitant cerebrovascular disease is common in patients with coronary artery disease. Other cardiovascular diseases, including left atrial and left atrial appendage thrombosis in atrial fibrillation, thrombi in the left ventricle in acute and chronic coronary artery disease and dilated cardiomyopathies, infective endocarditis with vegetations, cardiac valve prosthesis thrombosis, cardiac tumors, mitral and aortic valve calcifications, aortic plaques and patent foramen ovale, are associated with cardioembolic events. Finally, acute ischemic or hemorrhagic cerebral events, epileptic seizures, cerebral traumas, and brain tumors can be associated with electrocardiographic abnormalities, catecholaminergic myocardial damage, or arrhythmias.

The possibility of using osteopontin as a marker of calcification of the heart valve apparatus in patients with chronic kidney disease on replacement therapy by hemodialysis

Aim of research. To identify a possible relationship between the degree of violation of phosphorus-calcium metabolism and the intensity of the processes of calcification of heart valves in patients with chronic kidney disease on hemodialysis. Materials and methods. 51 patients with CKD stage 5 were examined. The level of calcium, serum phosphorus, calcium-phosphorus product was estimated, the level of parathyroid hormone, osteopontin was determined. Echocardiographically, the presence or absence of aortic and mitral valve calcification was assessed. Results. We revealed calcinosis of heart valves in 39.2% of patients: combined mitral-aortic calcinosis was observed in 21.5% of patients, isolated calcinosis of mitral valve – in 13.7%, isolated calcinosis of aortic valve was observed in 3.9%. Hyperphosphatemia (PЈ0.033) and an increase in the product of CaxP concentration above 5.0 (PЈ0.002) were statistically significant in the development of calcification of cardiac structures. Parathyroid hormone levels were statistically higher in the groups of patients with calcinosis and heart valve compaction (pЈ0.001) than in patients without calcinosis. Osteopontin indices were higher in the group of patients with calcinosis than in patients with compaction of heart valves (PЈ0.001) and significantly higher than in patients without calcification of heart structures (PЈ0.05). Summary. Calcification of heart valves in hemodialysis patients is associated with an increase in plasma concentrations of osteopontin, parathyroid hormone, calcium-phosphorus metabolism. Positive correlation between the level of osteopontin and the degree of heart valve damage allows to use it as a marker of cardiovascular calcification.

Long-Term All-Cause and Cause-Specific Mortality in Asymptomatic Patients With CAC ≥1,000: Results From the CAC Consortium

ObjectivesThis study thoroughly explored the demographic and imaging characteristics, as well as the all-cause and cause-specific mortality risks of patients with a coronary artery calcium (CAC) score ≥1,000 in the largest dataset of this population to date. BackgroundCAC is commonly used to quantify cardiovascular risk. Current guidelines classify a CAC score of >300 or 400 as the highest risk group, yet little is known about the potentially unique imaging characteristics and mortality risk in individuals with a CAC score ≥1,000. MethodsA total of 66,636 asymptomatic adults were included from the CAC consortium, a large retrospective multicenter clinical cohort. Mean patient follow-up was 12.3 ± 3.9 years for patients with cardiovascular disease (CVD), coronary heart disease (CHD), cancer, and all-cause mortality. Multivariate Cox proportional hazards regression models adjusted for age, sex, and conventional risk factors were used to assess the relative mortality hazard of individuals with CAC ≥1,000 compared with, first, a CAC reference of 0, and second, with patients with a CAC score of 400 to 999. ResultsThere were 2,869 patients with CAC ≥1,000 (86.3% male, mean 66.3 ± 9.7 years of age). Most patients with CAC ≥1,000 had 4-vessel CAC (mean: 3.5 ± 0.6 vessels) and had greater total CAC area, higher mean CAC density, and more extracoronary calcium (79% with thoracic artery calcium, 46% with aortic valve calcium, and 21% with mitral valve calcium) than those with CAC scores of 400 to 999. After full adjustment, those with CAC ≥1,000 had a 5.04- (95% confidence interval [CI]: 3.92 to 6.48), 6.79- (95% CI: 4.74 to 9.73), 1.55- (95% CI:1.23 to 1.95), and 2.89-fold (95% CI: 2.53 to 3.31) risk of CVD, CHD, cancer, and all-cause mortality, respectively, compared to those with CAC score of 0. The CAC ≥1,000 group had a 1.71- (95% CI: 1.41 to 2.08), 1.84- (95% CI: 1.43 to 2.36), 1.36- (95% CI:1.07 to 1.73), and 1.51-fold (95% CI: 1.33 to 1.70) increased risk of CVD, CHD, cancer, and all-cause mortality compared to those with CAC scores 400 to 999. Graphic analysis of CAC ≥1,000 patients revealed continued logarithmic increase in risk, with no clear evidence of a risk plateau. ConclusionsPatients with extensive CAC (CAC ≥1,000) represent a unique very high-risk phenotype with mortality outcomes commensurate with high-risk secondary prevention patients. Future guidelines should consider CAC ≥1,000 patients to be a distinct risk group who may benefit from the most aggressive preventive therapy.