[Mitral valvular disease secondary to mitral ring calcification: a clinicopathologic study].
Suzuki J,Ohkawa S,Sugiura M,Sakai M,Chida H,Watanabe C,Matsushita S,Ueda K,Kuramoto K,Takahashi T
Journal of cardiography
Fifteen cases with mitral valvular disease caused by mitral ring calcification (MRC) were observed among 2,800 consecutive autopsy patients more than 60 years of age. They consisted of one man and 14 women whose average age was 86.4 years. All had been diagnosed as having mitral valvular disease during life. For this clinicopathologic study, the cases were categorized as nine cases with mitral regurgitation (MR Group) and six with mitral stenosis (MS Group). Among the 15 cases, phonocardiograms were obtained in 14 and echocardiograms in 6. In addition, 122 cases with MRC, the length of which was 5 mm or more, were selected from 900 recent consecutive autopsies of senile patients, to evaluate the site of calcification and to analyze the ratio of calcification length to mitral valve ring circumference. The following conclusions were obtained: The prevalence of mitral valvular disease due to MRC in the aged was 15/2,800 (0.5%). MR was observed in nine cases and MS in six. Phonocardiograms of the MR Group revealed a holosystolic murmur in seven cases, a late systolic murmur in one, a third heart sound in four and a fourth heart sound in five. In the MS Group, a holosystolic murmur was found in four, a presystolic murmur in four, a diastolic rumble in one, but no opening snap in any case. A diamond-shaped systolic murmur was found in nine cases with MS or MR, suggesting an ejection systolic murmur caused by an associated calcified aortic valve. Echocardiograms showed markedly decreased DDR in five cases and increased echo intensity of the aortic valve in four. Pathologic findings revealed that the mean length of MRC was 36.6 mm in the MR Group and 58.0 mm in the MS Group. The calcification ring ratio (CRR = MRC/MVR X 100) was 50.3% in the MR Group and 69.8% in the MS Group. In the MR Group, MRC involved the anterolateral commissure in three, posteromedial commissure in five, and both in one. In five of six cases with MS, both commissures were involved by MRC. The study of 122 cases with MRC length greater than or equal to 5 mm suggested that MRC occurred first in the middle scallop of the posterior mitral leaflet, and extended to the posterior scallop, subsequently extending up to the anterior scallop, and finally involved the anterior mitral leaflet beyond the commissures.(ABSTRACT TRUNCATED AT 400 WORDS)
Cholesterol-years score is associated with development of senile degenerative aortic stenosis in heterozygous familial hypercholesterolemia.
Nozue Tsuyoshi,Kawashiri Masa-Aki,Higashikata Toshinori,Nohara Atsushi,Inazu Akihiro,Kobayashi Junji,Koizumi Junji,Yamagishi Masakazu,Mabuchi Hiroshi
Journal of atherosclerosis and thrombosis
We retrospectively evaluated the frequency and identified the factors associated with the development of aortic stenosis (AS) in 96 patients with heterozygous familial hypercholesterolemia (FH). The frequency of AS was 31% (4/13) and that of critical stenosis was 15% (2/13) in older patients over the age of 70 years. All 4 patients with AS were female aged more than 70 years who were diagnosed with FH when aged more than 60 years. There were no significant differences in conventional coronary risk factors; however, the age at cardiac catheterization, age at diagnosis of FH and the cholesterol-years score (CYS) with AS were significantly higher than those without AS (p=0.006, p=0.017, p=0.021, respectively). In multiple regression analysis, CYS was a significant independent predictor for the development of AS (p=0.037) in 13 older patients over the age of 70 years. These results suggest that physicians should be aware that AS needs attention in older patients with heterozygous FH, especially women who have been diagnosed late in life and those who have been inadequately treated.
10.5551/jat.13.323
Severe degenerative aortic stenosis: when a senile patient is a candidate for surgery.
Bricco G,Quaglia C,Morello M,Mangiardi L,Grasso C,Calachanis M
Minerva cardioangiologica
Senile aortic stenosis is characterized by calcific degeneration of the valve that prevents the full opening of the cusps in systole. The disease may be silent for many years despite the presence of severe flow obstruction and generally is associated with aortic regurgitation and calcification of the coronary arteries. The continuous increase of the aged population with aortic stenosis entails difficult decisions in selecting the candidates for aortic valve replacement in order to optimize the timing for surgery. Although clinical examination is still fundamental for the diagnosis of the disease and the screening of the population, noninvasive assessment by Doppler echocardiography has transformed the management of these patients. The procedure allows better identification of patients who may benefit from valve replacement in particular in the setting of a ''low output/low gradient'' state and permits a follow-up of the progression of the disease in patients who are not yet candidates for surgery. It also allows a decrease in the utilization of invasive hemodynamics becoming a cost benefit tool for the health system. When performed properly, it is relatively time consuming, needs experience but offers major anatomic and hemodynamic data. Under these circumstances, cardiac catheterization is required only in cases when there is discordance between the clinical assessment and cardiac ultrasound evaluation. In this review we summarize the prevalence and significance of the disease in the elderly population and the use of all recent echocardiographic data that may help select the true candidates for surgery.
[Progression of senile aortic valve calcification: echocardiographic and clinical assessment].
Sawada H,Takeuchi N,Aoki K,Watanabe H,Furuta S,Kato K
Journal of cardiology
Factors involved in the progression of senile aortic valve calcification were evaluated by analyzing the clinical and echocardiographic characteristics of patients older than 69 years with senile aortic valve calcification. The patients were divided into three groups; group 1: 46 male and 40 female patients with calcification of one cusp and almost normal pliability of three cusps, group 2: 48 males and 55 female patients with calcification of two or three cusps, mildly reduced pliability of calcified cusps, and aortic valve area (AVA) > or = 2.0 cm2, group 3: 26 male and 31 female patients with calcification of two or three cusps, significantly reduced pliability of calcified cusps, and AVA < or = 1.5 cm2. There were no significant differences in age, weight, height, left ventricular dimension, or left ventricular wall thickness between these three groups. For male patients, the end-diastolic maximum left ventricular outflow tract dimensions (LVOT) in groups 1, 2, and 3 were 20 +/- 2 mm, 19 +/- 2 mm (p < 0.01 vs group 1), and 17 +/- 3 mm (p < 0.001 vs group 1, p < 0.01 vs group 2), respectively. For female patients, the LVOTs of groups 1, 2, and 3 were 18 +/- 2 mm, 16 +/- 2 mm (p < 0.001 vs group 1), and 16 +/- 2 mm (p < 0.001 vs group 1), respectively. Reduction in LVOT was not associated with left ventricular hypertrophy or decrease in dimension of aortic annulus. In female patients, the frequency of mitral annular calcification of group 3 was 61% [p < 0.05 vs group 1 (35%), p < 0.01 vs group 2 (25%)].(ABSTRACT TRUNCATED AT 250 WORDS)
Unique type of isolated cardiac valvular amyloidosis.
Iqbal Shehzad,Reehana Salma,Lawrence David
Journal of cardiothoracic surgery
BACKGROUND:Amyloid deposition in heart is a common occurrence in systemic amyloidosis. But localised valvular amyloid deposits are very uncommon. It was only in 1922 that the cases of valvular amyloidosis were reported. Then in 1980, Goffin et al reported another type of valvular amyloidosis, which he called the dystrophic valvular amyloidosis. We report a case of aortic valve amyloidosis which is different from the yet described valvular amyloidosis. CASE PRESENTATION:A 72 years old gentleman underwent urgent aortic valve replacement. Intraoperatively, a lesion was found attached to the inferior surface of his bicuspid aortic valve.Histopathology examination of the valve revealed that the lesion contained amyloid deposits, identified as AL amyloidosis. The serum amyloid A protein (SAP) scan was normal and showed no evidence of systemic amyloidosis. The ECG and echocardiogram were not consistent with cardiac amyloidosis. CONCLUSION:Two major types of cardiac amyloidosis have been described in literature: primary-myelomatous type (occurs with systemic amyolidosis), and senile type(s). Recently, a localised cardiac dystrophic valvular amyloidosis has been described. In all previously reported cases, there was a strong association of localised valvular amyloidosis with calcific deposits.Ours is a unique case which differs from the previously reported cases of localised valvular amyloidosis. In this case, the lesion was not associated with any scar tissue. Also there was no calcific deposit found. This may well be a yet unknown type of isolated valvular amyloidosis.
10.1186/1749-8090-1-38
Etiology of valvular heart disease.
Rose A G
Current opinion in cardiology
The incidence of congenital valvular heart disease has not significantly altered in recent decades. Major factors contributing to altered profiles of acquired valvular heart disease in the past few decades include an increased elderly segment of the population and increasing recognition of nonrheumatic forms of valvular heart disease. Mitral valve prolapse, and similar involvement of other valves, together with senile calcific aortic stenosis have emerged as the most common forms of valvular heart disease in developed countries. Body leanness and hypertension are additional etiological factors for senile calcific aortic stenosis. Severe calcification of a congenital bicuspid aortic valve continues to be an important cause of aortic stenosis in the elderly. Idiopathic degeneration of the aortic and mitral valves, apparently a different condition than mitral valve prolapse, has also become recognized. Despite a recent increase in the incidence of acute rheumatic fever in North America, rheumatic heart disease remains an infrequent cause of valvular heart disease in developed nations. Its incidence has diminished in the Middle East, but it is still frequent in underdeveloped countries. Intravenous drug abuse is increasing in importance as a cause of valvular heart disease in urban centers in the United States. Syphilitic heart disease is very rare.
10.1097/00001573-199603000-00002
Influence of transcatheter aortic valve replacement on patients with severe aortic stenosis undergoing non-cardiac surgery.
Omoto Tadashi,Aoki Atsushi,Maruta Kazuto,Masuda Tomoaki,Horikawa Yui
Journal of cardiothoracic surgery
OBJECTIVES:The purpose of this study was to clarify the influence of transcatheter aortic valve replacement (TAVR) in patients with aortic stenosis (AS) undergoing non-cardiac surgery. METHODS:Thirty-four patients with severe AS diagnosed by preoperative evaluation for non-cardiac surgery were reviewed and compared in two categories. First, patient profiles and surgical risk were compared before (pre-TAVR group; n = 10) and after (post-TAVR group; n = 24) the introduction of TAVR. Second, the completion rate of non-cardiac surgery and interval between the two cardiac and non-cardiac operations were compared between surgical aortic valve replacement (AVR) patients before the introduction of TAVR (pre-AVR group (n = 10)), in AVR patients after the introduction of TAVR (post-AVR (n = 12)), and in TAVR patients (TAVR group (n = 12)). RESULTS:Age and Japan score were higher in the post-TAVR group than in the pre-TAVR group. Malignancy was the most common non-cardiac disease (80%) in the pre-TAVR group, whereas orthopedic disease was the most common (50%) in the post-TAVR group. Completion rate of non-cardiac operation in the pre-AVR, post-AVR and TAVR groups was 70, 33, and 75% (post-AVR vs. TAVR: p = 0.010), and the interval between the two operations was 129 ± 98 days, 87 ± 40 days and 27 ± 15 days, respectively (pre AVR vs. TAVR: p = 0.034 and post AVR vs. TAVR: p = 0.025). In the post-TAVR group, AVR was selected because of a lack of fitness for TAVR in 5 of 12 patients. CONCLUSIONS:After the introduction of TAVR, more senile and high-risk patients became candidates for a two-stage operation, and orthopedic conditions became the most common non-cardiac disease. Innovation in transcatheter valvular interventions and expansion of indications for patients currently evaluated as "unfit for TAVR" might be crucial issues for non-cardiac surgery with severe AS.
10.1186/s13019-020-01237-5
[Risk factors of postoperative acute kidney injury and the impact on outcome in non-senile patients undergoing cardiac valvular surgery].
Xie Z Y,Chen Y H,Li Z L,Chen S X,Wu Y H,Zhang K C,He Y N,Huang J S,Chen J M,Shi W,Liang X L
Zhonghua xin xue guan bing za zhi
To investigate the risk factors of postoperative acute kidney injury (AKI) in patients aged between 40 and 50 years old undergoing cardiac valvular surgery and the impact on outcome. The clinical data of 286 patients aged between 40 and 50 years old undergoing cardiac valve surgery in Guangdong Provincial People's Hospital from January 2012 to December 2016 were analyzed retrospectively. Preoperative coronary angiography was performed in all patients. All patients enrolled were divided into AKI group and non-AKI group according to the existence or not of postoperative AKI. Patients with AKI were further divided into AKI stage 1, stage 2, and stage 3 groups according to KDIGO guideline. Demographic characteristics, preoperative clinical data including serum creatinine, estimated glomerular filtration rate, hemoglobin, uric acid, urinary protein, presence or absence of chronic kidney disease, left ventricular ejection fraction, pulmonary artery pressure, New York Heart Association (NYHA) functional classification, preoperative co-morbidity (hypertension, diabetes, anemia, cerebrovascular disease, peripheral artery disease), preoperative medication(vasoactive drugs, diuretic, renin-angiotensin system inhibitor (RASI), surgical data (contrast dosage in coronary angiography, type of cardiac valve surgery) were recorded and analyzed in this retrospective study. The risk factors for postoperative AKI and its impact on clinical outcomes (mortality, hospitalization expenses and Intensive Care Unit stay duration) were evaluated. Logistic regression analysis was used to determine the risk factors for postoperative AKI and the adjusted variables with 0.2 were selected for the multivariate logistic regression analysis to define the independent determinants for AKI. AKI was defined in 106 out of 286 enrolled patients, including 96 patients with AKI stage 1, 10 patients with AKI stage 2 and no patients with AKI stage 3. The proportion of coexisting cerebrovascular diseases was higher in AKI group than in non-AKI group (9(8.49%) and 5(2.78%), χ(2)=4.677, 0.031), while there was no difference among other baseline data between the two groups. Multivariate logistic regression analysis showed that preoperative complications of cerebral vascular disease was an independent risk factor of postoperative AKI (3.578, 95 1.139-11.242, 0.029). Five out of 106 AKI patients died during hospitalization while there was only 1 patient died among 180 patients without AKI. Patients with AKI after cardiac valve operation experienced higher mortality than patients without AKI (χ(2)=5.625, 0.028). Further analysis showed that there was no difference in hospitalization mortality between patients with AKI stage 2 and stage (χ(2)=0.686, 0.408) while the hospitalization mortality in patients with AKI stage 2 was higher than those without AKI (χ(2)=8.113, 0.004). The hospitalization expenses in patients with AKI were 10.38(8.59,12.54) ×10(4) RMB, significantly higher than that in patients without AKI (9.72(8.03,11.93) ×10(4) RMB)(0.043). There was no difference in hospitalization expenses between patients with AKI stage 1 and without AKI (0.635). The hospitalization expenses in patients with AKI stage 2 was higher than those without AKI (0.023). Intensive Care Unit stay duration in patients with AKI was 3(1,4) days, significantly higher than those without AKI (0.044). There was no difference in Intensive Care Unit stay duration in patients with AKI stage 1 and without AKI (0.978), while Intensive Care Unit stay duration in patients with AKI stage 2 was significantly longer than those without AKI (0.006). Preoperative complications of cerebral vascular disease is an independent risk factor of postoperative AKI. Non-senile patients with AKI after cardiac valvular surgery is associated with a higher proportion of mortality, hospitalization expenses and Intensive Care Unit stay duration as compared patients without postoperative AKI.
10.3760/cma.j.issn.0253-3758.2019.07.006
Preoperative left atrial minimum volume as a surrogate marker of postoperative symptoms in senile patients with aortic stenosis who underwent surgical aortic valve replacement.
Morimoto Junko,Hozumi Takeshi,Takemoto Kazushi,Wada Teruaki,Maniwa Naoki,Kashiwagi Manabu,Shimamura Kunihiro,Shiono Yasutsugu,Kuroi Akio,Yamano Takashi,Yamaguchi Tomoyuki,Matsuo Yoshiki,Kitabata Hironori,Ino Yasushi,Kubo Takashi,Tanaka Atsushi,Nishimura Yoshiharu,Akasaka Takashi
Journal of cardiology
BACKGROUND:Previous reports have shown that postoperative symptoms despite successful surgical aortic valve replacement (AVR) are not uncommon depending on severity of myocardial fibrosis in patients with aortic stenosis (AS). Left atrial minimum volume (LAV) at end-diastole determined by direct exposure of left ventricular end-diastolic pressure may be useful as a surrogate marker of postoperative symptoms in patients with AS undergoing AVR. METHODS AND RESULTS:We studied 75 patients with AS who underwent AVR and were followed up to 600 days after AVR. We examined the postoperative symptomatic status which occurred between 60 days to 600 days after AVR. The study patients were divided into 2 groups: 19 patients (25%) with postoperative symptoms (symptomatic group) and 56 without symptoms (asymptomatic group). There were no significant differences in preoperative left ventricular volumes and ejection fraction and AS severity by echocardiography between the two groups. There were significant differences in preoperative echocardiographic LAV index (LAVI) between symptomatic group and asymptomatic group (45±15 vs. 28±11ml/m). Using receiver operating characteristic curve analysis, LAVI≥30ml/m detected postoperative symptoms with the large area under the curve (0.84) (sensitivity 94% and specificity 68%). In the multivariate analysis, preoperative LAVI was the independent predictor of the postoperative symptomatic status after AVR (odds ratio: 1.11; 95% CI: 1.04-1.18). CONCLUSIONS:The preoperative echocardiographic LAVI measurement is useful as a surrogate marker of symptomatic status after AVR in patients with AS.
10.1016/j.jjcc.2019.04.003
Non-Rheumatic Mitral Annular Calcification as a Cause of Late-Onset Mitral Stenosis.
Desai Chirag K,Orvarsson Jon,Stys Adam
South Dakota medicine : the journal of the South Dakota State Medical Association
While 'senile' calcific mitral stenosis is a rare cause of mitral stenosis as compared with rheumatic heart disease worldwide, it is thought to be more common in developed nations. Due to differences in the mechanism of dysfunction compared to rheumatic mitral stenosis, treatment options for senile calcific mitral stenosis are more limited and technically challenging. We describe a case of symptomatic severe mitral stenosis that was managed by surgical bioprosthetic valve replacement.
Endothelium and valvular diseases of the heart.
Leask Richard L,Jain Neelesh,Butany Jagdish
Microscopy research and technique
It has become increasingly evident that the endothelium plays a critical role in the pathogenesis of valvular heart disease. The endothelium helps regulate vascular tone, inflammation, thrombosis, and vascular remodeling. Dysfunction of the endothelial cells has been linked to many vascular disorders including atherosclerosis. Common valvular diseases such as senile degenerative valve disease, myxomatous (or floppy) valves, rheumatic valves, and infective endocarditis valves show changes in the synthetic, morphologic, and metabolic functions of the valvular endothelial cells. These diseases are active processes related to endothelial cell dysfunction. Endothelial cell dysfunction is caused by mechanical forces, bacterial infection, autoantibodies, and circulating modulators of endothelial cell function. This study reviews the role of endothelial cell dysfunction in the more common valvular diseases. Continued research on endothelial cell dysfunction is crucial to our understanding of valvular heart diseases and may elucidate novel treatment and prevention strategies.
10.1002/jemt.10251
Use of antiarrhythmic drugs in elderly patients.
Lee Hon-Chi,Tl Huang Kristin,Shen Win-Kuang
Journal of geriatric cardiology : JGC
Human aging is a global issue with important implications for current and future incidence and prevalence of health conditions and disability. Cardiac arrhythmias, including atrial fibrillation, sudden cardiac death, and bradycardia requiring pacemaker placement, all increase exponentially after the age of 60. It is important to distinguish between the normal, physiological consequences of aging on cardiac electrophysiology and the abnormal, pathological alterations. The age-related cardiac changes include ventricular hypertrophy, senile amyloidosis, cardiac valvular degenerative changes and annular calcification, fibrous infiltration of the conduction system, and loss of natural pacemaker cells and these changes could have a profound effect on the development of arrhythmias. The age-related cardiac electrophysiological changes include up- and down-regulation of specific ion channel expression and intracellular Ca(2+) overload which promote the development of cardiac arrhythmias. As ion channels are the substrates of antiarrhythmic drugs, it follows that the pharmacokinetics and pharmacodynamics of these drugs will also change with age. Aging alters the absorption, distribution, metabolism, and elimination of antiarrhythmic drugs, so liver and kidney function must be monitored to avoid potential adverse drug effects, and antiarrhythmic dosing may need to be adjusted for age. Elderly patients are also more susceptible to the side effects of many antiarrhythmics, including bradycardia, orthostatic hypotension, urinary retention, and falls. Moreover, the choice of antiarrhythmic drugs in the elderly patient is frequently complicated by the presence of co-morbid conditions and by polypharmacy, and the astute physician must pay careful attention to potential drug-drug interactions. Finally, it is important to remember that the use of antiarrhythmic drugs in elderly patients must be individualized and tailored to each patient's physiology, disease processes, and medication regimen.
10.3724/SP.J.1263.2011.00184
[Biopsy of the heart valves. 872 cases].
Steiner I,Dominik J
Ceskoslovenska patologie
In this study, 872 heart valves surgically excised from 810 patients during a period of 5 years (1994 through 1998) were examined pathologically. There was a predominance of aortic (506 patients) versus mitral valves (246 pts.). While aortic valves came more often from men (364) than from women (142), in mitral valves the M:F ratio is 82/164. Isolated calcific aortic stenosis appeared as the most frequent valvular disease (418 pts.), with predominance of its sclerotic-senile type (238 pts.). Mitral stenosis (185 pts.) remains the classical post-rheumatic disease. The relative frequency of a subvalvular stenosing mitral lesion is stressed. The "pure" incompetence of both aortic (70 pts.) and mitral (56 pts.) valve was usually based on valvular myxoid degeneration. An aorto-mitral disease requiring replacement of both valves (51 pts.) presented typically as a post-rheumatic lesion, however, a combination of a post-rheumatic mitral with a degenerative-sclerotic aortic valve disease may be possible. In 30 patients, the valvular replacement was performed for infective endocarditis or a post-IE lesion, mostly of the aortic valve. With the almost non-existence of acute rheumatic fever and with the increasing average age of population in this country, we may expect a long-term decline in mitral valve disease and an increase in aortic valve disease, particularly in the sclerotic type of aortic stenosis.
[Hemodynamic evaluations of patients with small aortic annulus with St. Jude Medical prosthetic heart valve].
Shimabukuro T,Takeuchi Y,Gomi A,Nakatani H,Suda Y,Kono K,Nagano N
The Japanese journal of thoracic and cardiovascular surgery : official publication of the Japanese Association for Thoracic Surgery = Nihon Kyobu Geka Gakkai zasshi
As the elderly population in Japan increases, senile degenerative aortic valvular disease also tends to increase. These patients often have a small aortic annulus. The problem of "valve-patient-mismatch" occurs when a small prosthesis is inserted into a patient with a small aortic annulus. To avoid annular enlargement after aortic valve replacement (AVR), we tried to use a small-sized St. Jude Medical (SJM) valve. From September 1988 through November 1996, 110 AVR were performed in our institution. In these cases, 30 underwent AVR with a small sized SJM valve (male < or = 21 mm, female < or = 19 mm). Dobutamine stress echocardiography was performed in 19 patients who had undergone AVR with a small-sized SJM valve. Surgical results were also compared between patients with small aortic annulus and those with normal-sized aortic annulus. Using Doppler echocardiography, pressure gradients (PG), cardiac index (CI), effective orifice area (EOA), and performance index (PI) were calculated at rest and during stress. The mean body surface area (BSA) of patient who had undergone AVR with SJM19A, 19HP and 21A was 1.40, 1.42 and 1.56 m2, respectively. With dobutamine stress, heart rates, PG and CI increased significantly. Mean and maximum PG of patients with 19HP (8.0 and 15.4 mmHg at rest, 12.9 and 28.0 mmHg under stress, respectively) and 21A (9.5 and 19.1 mmHg at rest, 16.5 and 35.3 mmHg under stress, respectively) were relatively low. EOA index (EOAI) of patient with 19HP showed the highest values mean 0.93 cm2/m2. PIs tended to be higher with HP models than with standard models. The tests were completed without significant side effects such as frequent ventricular arrhythmias. Among the cases with small aortic annulus, there were no operative deaths or hospital deaths. There were also no late deaths, episodes of hemorrhage or thrombosis. Conclusions. In our institution, AVR was performed safely without any aortic annular enlargement with a small aortic anulus in small BSA patients. Postoperative hemodynamic data obtained by echocardiography were satisfactory for all patients at rest and even during maximum dobutamine stress test.
10.1007/bf03217917