Severe Calcific Aortic Stenosis Research Articles

Procedural and clinical outcomes of patients undergoing a TAVI in TAVI procedure: Rationale and design of the multicentre, prospective, observational ReTAVI registry.

Transcatheter aortic valve implantation (TAVI) is increasingly being used in younger patients and those with lower peri-procedural risk, meaning more patients will live long enough to experience structural valve deterioration (SVD) of the bioprosthesis, indicating repeated TAVI. Experience of repeated TAVI-transcatheter heart valve (THV) implantation into an index THV is limited. This registry aims to assess the peri-procedural and short-term safety, efficacy and durability of repeated TAVI. The ReTAVI Prospective observational registry is an investigator-initiated, multicentre, international, prospective registry of patients undergoing repeated TAVI using balloon-expandable SAPIEN prosthesis to evaluate procedural and short-term safety, efficacy and durability as well as anatomical and procedural factors associated with optimal results. The registry will enrol at least 150 patients across 60 high-volume centres. Patients must be ≥18 years old, have had procedural success with their first TAVI, have index THV device failure, intend to undergo repeated TAVI and be considered suitable candidates by their local Heart Team. All patients will undergo a 30-day and 12-month follow-up. The estimated study completion is 2025. The registry will collect pre-, peri-, postoperative and 12-months data on patients undergoing repeated TAVI procedures with THVs for failure of the index THV and determine VARC-3-defined efficacy and safety at 30 days and functional outcome at 12 months. The registry will expand existing data sets and identify patient characteristics/indicators related to complications and clinical benefits for patients with symptomatic severe calcific degenerative aortic stenosis.

LIFETIME MANAGEMENT OF AORTIC STENOSIS IN EXTREME SETTING

Abstract A 51–year–old male patient returned to our attention due to symptomatic severe aortic stenosis. Despite the severity of the aortic valve disease, he had been previously turned down from aortic valve replacement by us because of lack of symptoms and very unfavorable anatomy. Indeed he had been irradiated at the age of 3 due to Hodgkin’s Lymphoma and presented with porcelain aorta, small ascending aorta and aortic annulus. The patient returned to us with a 3–month history of progressive dyspnea (NYHA class IIa) and one episode of lipothymia during physical exercise. Physical examination, hematologic and biochemical investigations at admission were normal. Our trans–thoracic echocardiogram confirmed a trileaflet aortic valve (AV) that was severely stenotic and calcified with a mean gradient of 60 mmHg and an AV area of 0.5 cm2 (0.3 cm2/m2), in presence of good left ventricular systolic function with an ejection fraction (EF) of 60%. CT excluded coronary disease but, confirmed severe calcified aortic stenosis and porcelain aorta with small calcific sino–tubular junction and ascending aorta and protruding LVOT calcium. (Ascending aorta 19 mm; STJ 19 mm). The heart–team judged the patient not suitable for AVR and decided to perform a high–risk TAVI, leaving apical conduit as the last resort. From a technical standpoint, the LVOT calcium and the short and narrow STJ were high risk features for rupture with balloon expandable devices. On the other hand the short and narrow STJ with the narrow ascending aorta would represent a serious issue for the expansion of self–expanding devices and an even more troublesome feature for future coronary access and coronary occlusion in the setting of TAVI–in–TAVI down the road. Given the patient’s young age, a balloon expandable SAPIEN ultra 23 mm was chosen to be implanted with a two–step inflation to minimize the risk of STJ rupture. The prosthesis was partially expanded until anchoring was achieved on the aortic leaflets then, on continuous pacing, the balloon was rapidly collapsed, pushed down deeper under the STJ and fully inflated to achieve prosthesis’ inflow expansion. Intra–procedural and post–procedural course were uneventful and the patient was discharged home in 5th Day. Transthoracic echocardiogram at the dismission reveal a trans–aortic mean gradient of 18 mmhg, the absence of significant paravalvular leaks and a preserved ejection fraction. Pre–discharge CT scan confirmed feasibility of future TAVI–in–TAVI in case of need.

Mitral regurgitation carries greater prognostic significance than mitral stenosis in patients undergoing transcatheter aortic valve replacement.

This study assessed the outcomes of concomitant mitral valve disease and severe aortic stenosis in patients undergoing transcatheter aortic valve replacement (TAVR). Echocardiographic data of 813 patients with severe aortic stenosis undergoing transfemoral TAVR were collected, and clinical outcomes were analyzed for individuals with mitral stenosis and mitral regurgitation. The final cohort includes 788 patients with severe calcific aortic stenosis. Among single parameters of mitral stenosis, a smaller baseline mitral valve area (MVA) by the continuity equation and higher postprocedural mean mitral gradients (MMG) were associated with an increased risk of death at 1 year (P-values 0.02 and <0.01, respectively), but no correlation with outcomes was demonstrated after multivariate adjustment for major prognosticators. Mitral stenosis (based on MVA + MMG) was not associated with complications or mortality. Mitral regurgitation was present in 94.6% of the population at baseline and regressed by at least one grade post-TAVR in 28% of the patients. The improvement in mitral regurgitation was associated with a greater prosthetic effective orifice area (P-value 0.03). Significant (at least moderate) residual mitral regurgitation was correlated with short-term complications and shown to be an independent predictor of 1-year mortality (P-value 0.02, odds ratio (OR) 5.37, confidence interval 1.34-21.5). Mitral regurgitation has a greater impact on TAVR patients than mitral stenosis as assessed by functional methods.

Early Onset Severe Aortic Stenosis Presenting with Recurrent Ventricular and Supraventricular Arrhythmia and Postoperative Stroke in a 44-year-old Man with Uncontrolled Rheumatoid Arthritis

Calcific aortic stenosis is the most common aetiology of aortic stenosis and is mostly seen in older people. Systemic inflammatory diseases, such as rheumatoid arthritis (RA), are rarely associated with aortic stenosis in the literature. Uncontrolled systemic inflammation related to RA may lead to postoperative complications but this is not well documented. The patient in this case report was a 44-year-old man who had been diagnosed with RA that had been poorly controlled. He had a 7-month history of heart failure symptoms attributed to severe calcific aortic stenosis. He underwent surgical aortic valve replacement, but developed an acute cerebrovascular infarct 2 hours after surgery and recurrent unstable ventricular tachycardia on the first postoperative day warranting 15 synchronised cardioversions. RA is a rare antecedent cause of severe calcific aortic stenosis especially in younger people. Such a valvular complication associated with acute ischaemic stroke and ventricular arrhythmia warrants further study to provide optimal medical management, especially for patients with RA and early cardiovascular complications.

Optimizing Anesthetic Selection in Transcatheter Aortic Valve Replacement: Striking a Delicate Balance between Efficacy and Minimal Intervention.

Patients with severe calcific native aortic valve stenosis (AS) who require valve replacement have two options, surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR). TAVR was approved in late 2011 for extremely high-risk patients and was subsequently approved for high-risk (2012), intermediate-risk (2016), and low-risk (2019) patients. In 2019, TAVR procedures surpassed SAVR procedures for the first time in the United States. The approach to anesthesia for this procedure has also evolved. Initially, general anesthesia (GA) was preferred, but currently, conscious sedation (CS) is favored. This review aims to clarify the indications and contraindications for both approaches, as well as the advantages of one approach over the other. Recent studies show that conscious sedation has better outcomes in terms of all-cause mortality, procedure complications such as stroke, myocardial infarction, infection requiring antibiotics, acute kidney injury, and the need for inotropes or vasopressors.

Mitral annular calcification in patients with severe aortic stenosis underwent transcatheter aortic valve implantation: prevalence and association with stenosis severity

Abstract Background Patients with calcific aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) usually have calcification in other cardiac structures, especially mitral annulus. Severity of mitral annular calcification (MAC) and degree of mitral stenosis (MS) may be associated with hemodynamic effects and outcomes. Purpose We sought to investigate the prevalence of MAC in patients with severe calcific AS using mitral annular calcium score with Agatston method from cardiac computerized tomography (CT). We also aim to assess the severity grading of MAC and its association with the severity of MS evaluated by transthoracic echocardiography. Methods We conducted a retrospective cohort analysis of the TAVI registry at King Chulalongkorn Memorial Hospital between May 2013 and December 2021. Clinical information was extracted from medical records. The pre-TAVI echocardiography and cardiac CT were reviewed, as well as the mitral annular calcium score. The severity of MAC (no, mild, moderate, severe) was classified using cardiac CT per the modified Cleveland clinic classification system. The MS grading was based on the 2009 American society of echocardiography guidelines. MAC prevalence was studied. Analysis of the association between MAC and MS was conducted. Results Our cohort included a total of 188 patients (mean age of 81±8 years). 134 patients (71.3%) demonstrated evidence of MAC. 47 patients (25%) had severe MAC evaluated by cardiac CT. Among patients with severe MAC, mean age was 83±8 years, 29 patients (63%) were female, 14 patients (30%) had diabetes, and 11 (23%) of them were associated with moderate or severe MS. Patients with MAC were significantly associated with hemodynamically significant MS (moderate or severe) when compared with patients without MAC (p &amp;lt;0.001). Conclusions One-fourth of patients with severe calcific AS underwent TAVI had severe MAC. The hemodynamically significant MS was more prevalent as the severity of MAC increased. The association between MAC and long-term adverse clinical outcomes needs to be further investigated.Figure 1Figure 2

Abstract P3070: Aortic Valve Calcification Is Accelerated By DNMT3A And TET2 Gene Driver Mutations Associated With Clonal Hematopoiesis

Background: Clonal hematopoiesis (CH) due to DNMT3A or TET2-driver mutations associates with heightened inflammation and a worse prognosis among patients with severe calcific aortic valve stenosis (AS). However, it is unknown what role CH plays in the pathogenesis of AS. AS is the most common age-related heart valve disease, with no medical therapy to halt progression. Methods and Results: Single-cell RNA-sequencing of immune cells of CAVD patients (n=13) with and without the most prevalent CH-mutations (DNMT3A and TET2), having a mean CH-driver gene variant allele frequency was 6.5% for DNMT3A and 17.9% for TET2. Monocytes of patients harboring DNMT3A and TET2 mutations shared 836 upregulated genes, which were associated with glycolytic, pro-inflammatory activation (CXCL10, IL38) along with paracrine pro-calcific factors (Oncostatin M (OSM), S100A9), signifying that CH might be causally involved in AS. Indeed, silencing of TET2 or DNMT3A in macrophages promotes M1-like polarization and increases release of pro-calcific mediators, particularly S100A9 and OSM. To assess whether CH-gene silenced macrophages may stimulate mesenchymal cells to secrete calcium, secreted factors from TET2 or DNMT3A-silenced macrophages were applied mesenchymal cells. Indeed, CH-gene silenced supernatants induced osteoblastic differentiation of mesenchymal cells, evidenced by increased Alizarin red calcium staining and elevated levels of ALP and RUNX2. This CH-mediated enhancement in osteoblastic transformation could be ablated by silencing of OSM. Finally, valves from atheroprone Ldlr-/- mice receiving Tet2-/- bone marrow transplants demonstrated increased total calcified area (p&lt;0.05, 1.49-fold) along with increased numbers of calcification deposits (p&lt;0.05, 2.33-fold) as shown by von Kossa staining, along with enhanced OSM and S100A9 levels. Conclusion: This is the first study to show that somatic CH-driver mutations in monocytes may accelerate AS. Moreover, calcification was ablated via silencing of OSM in CH-gene silenced macrophages. These data suggest Oncostatin M may be a therapeutically promising target in halting the development of AS in patients harboring CH mutations.

Diabetes mellitus and aortic stenosis head to head: toward personalized medicine in patients with both pathologies

Diabetes mellitus (DM) and calcific aortic stenosis (CAS) are common morbidities in the elderly, which are both chronic, progressive and often concomitant diseases. Several studies revealed that DM increases the risk of developing severe CAS, yet clear information about the relationship between both these diseases and the influence of DM on the progression of CAS is currently lacking. To evaluate the effect of DM on aortic valves and on the process of calcification, and to achieve better patient management in daily clinical practice, we analysed calcified and noncalcified valve tissue from patients with severe CAS, with or without DM. A proteomic strategy using isobaric tags was adopted and the plasma concentrations of nine proteins were studied using 3 orthogonal methods and in a separate cell model. The differentially expressed proteins identified are implicated in biological processes like endopeptidase activity, lipid metabolism, coagulation, and fibrinolysis. The results obtained provide evidence that DM provokes changes in the proteome of aortic valves, affecting valve calcification. This finding may help enhance our understanding of the pathogenesis of CAS and how DM affects the evolution of this condition, an important step in identifying targets to personalize the treatment of these patients.

Myval: A Novel Transcatheter Heart Valve for the Treatment of Severe Aortic Stenosis.

Transcatheter aortic valve implantation (TAVI) performed using femoral arterial access is now a guideline recommended treatment for severe calcific aortic stenosis (AS) in elderly patients. Technological advancements and procedural refinements have focused on making TAVI simpler, safer, more effective and durable. Myval (Meril Lifesciences) is a new generation balloon-expandable transcatheter heart valve (THV) developed in India that possesses novel features to improve deliverability and aid precise deployment. Following the first-in-human study, Myval was approved in India for commercial implantation in October 2018 and was subsequently given a CE mark in April 2019. This article reviews the science, technology and up-to-date clinical evidence for the Myval THV.

TCTAP C-065 Severe Calcified Coronary Artery Disease, Aortic Stenosis and Cardiogenic Shock in an Elderly Man a 5-Step Multi-Disciplinary Solution

TCTAP C-065 Severe Calcified Coronary Artery Disease, Aortic Stenosis and Cardiogenic Shock in an Elderly Man a 5-Step Multi-Disciplinary Solution

Role of follistatin-like 1 levels and functions in calcific aortic stenosis.

Calcific aortic valve disease (CAVD) is a progressive disease resulting in severe calcific aortic stenosis (AS), and there is increasing interest in the discovery of novel biomarkers to identify patients with potential future calcific AS at an early stage. This study aimed to determine whether follistatin-like 1 (FSTL1) is associated with calcific AS events and its exact role in aortic valve calcification. A prospective observational cohort study involving 656 patients was performed to investigate the relationship between serum FSTL1 and calcific AS incidence during a follow-up of 5 years. Furthermore, we detected FSTL1 levels in valvular interstitial cells (VICs) from calcified valves and explored the effects of FSTL1 on VIC osteogenic differentiation in vitro as well as the signaling pathways involved. During a median follow-up of 5 years, lower FSTL1 levels were associated with a significantly higher risk of calcific AS events (log rank test, P = 0.007). In addition, Cox multivariable regression analyses verified the predictive value of FSTL1 after adjusting for both demographic features and laboratory confounders. Consistent with our results for serum, a lower concentration of FSTL1 was observed in calcified human valves (n = 11) and mainly colocalized with VICs. Recombinant human FSTL1 (rhFSTL1) stimulation inhibited calcium deposition, alkaline phosphatase (ALP) activity, and osteogenic gene expression partly through the downregulation of the ERK1/2 pathway. Taken together, this study provides a strong rationale to consider FSTL1 as a potential therapeutic target for calcific AS.

Rescue Balloon Aortic Valvuloplasty for Malignant Ventricular Arrhythmias and Cardiogenic Shock

Introduction: Severe Calcific Aortic Stenosis (AS) remains a major cause of morbidity and mortality in aged population. Asymptomatic with reduced LVEF has high risk of sudden death. Aim: To study the complexity of clinical course of Severe Calcific AS with LV Dysfunction. Case Report: A Seventy-Six-year-old male was admitted with ACS, NSTEMI, LVEF 35% and Severe Calcific AS. With plan of AVR, CAG was done and showed Mild CAD. Post-procedure he had sequence of catastrophic clinical events that includes, A systolic Cardiac Arrest (reverted after CPR) and Protracted Pulmonary edema (Connected to Mechanical Ventilation). Later had Malignant Ventricular Arrhythmias, treated with 34 times DC Shocks. He was not suitable for Surgical AVR or TAVI. After high-risk consent, he successfully underwent emergency Aortic Balloon Valvuloplasty (ABV) with significant drop in AV gradients. Post ABV, also had Paroxysmal AF. Arrhythmias were also treated with Beta blocker, Antiarrhythmics, Digoxin and Potassium supplementation. Gradually stabilized, discharged and followed up. Discussion: Aortic stenosis, a disease of elderly age group. Symptomatology varies widely. It has limited management options. In our case, Post CAG critical illness was probably due to “Pre -CAG” LV dysfunction with subclinical symptoms. ABV used as bail out the procedure in high-risk patients. Conclusion: ABV is considered as a viable palliative option, with the introduction of smaller profile balloons, rapid pacing and vascular closure devices. ABV can safely used as bridging procedure before Surgical AVR or TAVI in high-risk patients

Abstract 12982: Between a Rock and a Hard Place: Stiff Left Atrial Syndrome in a Patient With Hereditary Rickets

Introduction: Stiff left atrial syndrome (SLAS) is an uncommon cause of pulmonary hypertension (PH) that has been described as a complication of ablation for atrial fibrillation; here we describe a unique case of SLAS in the setting of extensive left atrial calcification from the treatment of hereditary hypophosphatemia (HH). Case Presentation: A 44-year-old woman with a history of HH presented for evaluation of progressive exertional dyspnea. Previous treatment with calcitriol and phosphate had been complicated by severe calcific mitral and aortic stenosis requiring aortic and mitral valve replacement eight years prior. She reported initial improvement in her symptoms after surgery, but more recently had noted worsening dyspnea and edema despite escalating her home diuretic dose. TTE was notable for moderately severe PH with no evidence of valvular or ventricular dysfunction. Chest CT showed extensive left atrial mural calcification (Figure A) with corresponding calcium visible in the wall of the left atrium on TTE (Figure B). The patient was admitted and underwent IV diuresis followed by RHC confirming mPAP of 41mmHg with a PCWP of 20mmHg and prominent V waves to 33mmHg (Figure C-D). PCWP was confirmed by wedge oxyhemoglobin saturation. Symptoms were improved but not resolved with additional diuresis. Discussion: In this patient with metastatic calcinosis related to the treatment of her HH, we believe her PH is most likely secondary to SLAS due to marked circumferential left atrial calcification. SLAS is characterized by decreased left atrial compliance, leading to large V waves in the absence of mitral regurgitation or an elevated LVEDP. Beyond diuresis, there are no proven treatments for PH due to SLAS.

Reconsidered surgical aortic valve replacement after declined transcatheter valve implantation.

Outcomes for high surgical risk patients who declined transcatheter aortic valve implantation (TAVI) and then reconsidered for conventional aortic valve replacement (rSAVR) for severe calcific aortic stenosis are not well known. This single-centre, case-control study (rSAVR vs Conservative group) retrospectively analysed patients for rSAVR (2009-2019). Multivariable logistic regression was used to identify independent predictors of composite of neurological sequelae/renal failure/deep sternal wound infection/re-exploration and death. Survival was compared using Kaplan-Meier curves and log-rank test. A Cox proportional hazards model was used to determine predictors of survival. TAVI was denied in 519/1095 patients, 114(10.4%) had rSAVR (cases) and 405 (37%) were managed conservatively (controls). Mean age for rSAVR was 80 years (IQR: 73.5-85 years). The commonest reason for declining TAVI was prohibitive high risk due to multiple comorbidities. Among rSAVR, hospital mortality was 2.2% and stroke was 4.4%. Median follow-up was conservative; 14.4 months versus rSAVR; 34.8 months. Five-year survival was conservative; 12.6% versus rSAVR; and 59.5% (overall conservative; 38.0% vs. rSAVR; 60.5%, p < 0.001). rSAVR was protective (hazard ratio [HR]: 0.37, 95% confidence interval [CI]: 0.26, 0.51, p < 0.001) and high comorbidities had high hazard (HR: 1.57, 95% CI: 1.19, 2.07, p = 0.001). rSAVR had fewer hospital readmission episodes (Conservative; 13.6/patient-year vs. rSAVR; 6.9/patient-year, p = 0.002). rSAVR may be considered in high surgical risk elderly patients who have been declined TAVI in centres with low operative mortality. rSAVR may be superior to conservative management in carefully selected patients.

It’s Never too Late: Late-Stage Aortic Stenosis Treated With Transcatheter Aortic Valve In A Patient With Significant Aortic Root Enlargement With Measurements Beyond Those Recommended By The Valve Manufacturers

A patient with severe calcific bicuspid aortic valve stenosis, revealed by Transthoracic Echocardiogram (TEE), was markedly symptomatic with recurrent decompensation of diastolic heart failure. TEE also revealed moderate insufficiency with large annulus measurements beyond the parameters of currently available valve prostheses. Most valve companies initially declined to provide their device due to the size mismatch, raising concern about valve embolization and potential residual paravalvular leak (PVL). Ultimately, we decided that the calcification in both leaflets may be able to hold onto a 29 mm Edwards-SAPIEN valve, and after a prolonged informed consent the patient was considered for TAVR.

Double Envelope Through The Aortic Valve: More than Range Ambiguity to Continuous Wave Doppler

A 70-YEAR-OLD MAN (99 kg, 185 cm) presented for aortic valve replacement owing to severe calcific aortic valve stenosis (AS). His AS was diagnosed recently after an investigation for presyncopal symptoms. Transthoracic echocardiogram demonstrated severe AS with peak and mean gradients of 84 and 48 mmHg, respectively. Asymmetric basal hypertrophy with mild left ventricular outflow tract (LVOT) obstruction also were noted. A peak LVOT gradient of 20 mmHg was measured with Valsalva maneuver, and mild mitral regurgitation was observed.

The Influence of Coronary Artery Disease in the Development of Aortic Stenosis and the Importance of the Albumin Redox State.

Calcific aortic valve and coronary artery diseases are related cardiovascular pathologies in which common processes lead to the calcification of the corresponding affected tissue. Among the mechanisms involved in calcification, the oxidative stress that drives the oxidation of sulfur-containing amino acids such ascysteines is of particular interest. However, there are important differences between calcific aortic valve disease and coronary artery disease, particularly in terms of the reactive oxygen substances and enzymes involved. To evaluate what effect coronary artery disease has on aortic valves, we analyzed valve tissue from patients with severe calcific aortic stenosis with and without coronary artery disease. Proteins and peptides with oxidized cysteines sites were quantified, leading to the identification of 16 proteins with different levels of expression between the two conditions studied, as well as differences in the redox state of the tissue. We also identified two specific sites of cysteine oxidation in albumin that have not been described previously. These results provide evidence that coronary artery disease affects valve calcification, modifying the molecular profile of aortic valve tissue. In addition, the redox proteome is also altered when these conditions coincide, notably affecting human serum albumin.

Transcatheter aortic valve replacement in the developing world: Lessons learnt and its implications for practice

BackrgroundTranscatheter aortic valve replacement (TAVR) has become an accepted modality of treatment in intermediate and high surgical risk patients of symptomatic severe calcific aortic stenosis (AS). We herein report Indian data of 84 intermediate and high-risk patients who underwent TAVR at two Armed Forces cardiac centres. MethodsMost of the patients underwent TAVR in cardiac catheterization lab by percutaneous transfemoral approach, under conscious sedation. Patients were followed up and echocardiographic parameters were assessed after six months of procedure. ResultsTotal of 84 intermediate and high-risk patients underwent TAVR between Jan 2017 and June 2021. Mean age of population was 71.5 ± 8.4 years; 28.5% of patients had bicuspid aortic valve and Mean STS score was 6.34 ± 2.08. Majority (92.8%) patients underwent the procedure under conscious sedation. Self-expanding valves were used in 72.6% and balloon expandable in 27.4% of patients. Predilatation was done in 64% patients while 13% cases underwent post dilatation. Procedural mortality was 2.3%. Rate of permanent pacemaker implantation was 4.9%. Ischemic stroke occurred in 1.1% of patents. There was no case of severe paravalvular leak. Emergency surgical aortic valve replacement was done in 2.4% patients. Procedural success in this study was 97.6%. All-cause mortality was 9.5% at 6 months. ConclusionsTAVR is an effective treatment modality in intermediate and high-risk Indian patients with severe aortic stenosis. Patients with bicuspid or previous bio prosthetic aortic valves also have a good outcome post TAVR.

Mitral annular calcification leading to severe mitral stenosis in a patient with severe calcific aortic stenosis and complete heart block: Different shades of calcium in heart

Calcium deposition in the heart can present in various ways. Mitral annular calcification (MAC) can cause mitral regurgitation but severe mitral stenosis has been reported very rarely. Mitral stenosis in the Indian subcontinent is mostly caused by rheumatic heart disease; however, here, we present a case of severe mitral stenosis due to MAC in a hypertensive and diabetic female that also had severe calcific aortic stenosis and conduction defect. Clinicians need to be aware of other causes of acquired mitral stenosis that include systemic lupus erythematosus, antiphospholipid antibody syndrome, carcinoid syndrome, mucopolysaccharidosis, Whipple disease, radiation, and MAC. Although MAC usually causes mitral regurgitation, severe mitral stenosis has been reported very rarely. However, when MAC is the cause of severe mitral stenosis, those patients are poor candidates for mitral valve replacement. Differentiating the etiology of mitral stenosis is of therapeutic and prognostic significance.

D-Transposition of great arteries with severe calcific aortic stenosis in an adult patient: a rare presentation.

D-Transposition of great arteries with severe calcific aortic stenosis in an adult patient: a rare presentation.