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Morphologic features and pathology of the elderly heart
Published in Wilbert S. Aronow, Jerome L. Fleg, Michael W. Rich, Tresch and Aronow’s Cardiovascular Disease in the Elderly, 2019
Atsuko Seki, Gregory A. Fishbein, Michael C. Fishbein
The mitral valve apparatus consists of the atrial wall, mitral valve annulus, leaflets, chordae tendineae, papillary muscles, and underlying left ventricular wall. The leaflets may display thickening with degeneration of collagen fibers, lipid accumulation, and focal calcification (59). Nodular thickening of the free edge of the anterior leaflet, referred to by some as “atheromatosis,” is seen in all adults. Severity of the lipid deposition on the leaflet also correlates with age, but there are no gender differences (60). In addition, mitral annular calcification, small scars, diffuse opacity, or hooding of leaflets (myxomatous degeneration) are often seen in the elderly (59). Mitral annular calcification may be associated with mild, usually insignificant, mitral insufficiency. Age-related changes in the pulmonary valve and tricuspid valve are minor. Nodules of Aranti and fenestrations of the cusps are sometimes present in the pulmonary valve (60).
The etiology of mitral stenosis
Published in Neeraj Parakh, Ravi S. Math, Vivek Chaturvedi, Mitral Stenosis, 2018
Mitral annular calcification (MAC) is a chronic, progressive, and degenerative process causing dystrophic calcification in the mitral valve annulus. Usually, it is detected as an incidental finding in the elderly age group. Rarely, it becomes clinically significant due to the impairment of normal diastolic annular dilation along with restricted mitral valve leaflet motion causing left-ventricular inflow obstruction. The prevalence of this condition is increasing due to a better life expectancy, a higher population of elderly individuals, and an increasing number of patients having risk factors such as hypertension. According to the European Heart Survey, degenerated MS accounted for approximately 10%, 30%, and 60% of all cases of MS in the age groups of 60–70, 70–80, and more than 80 years, respectively.4 This condition is also known as senile MS. Degeneration becomes accelerated and can occur even in younger age groups in patients with chronic kidney disease, hypertension, diabetes mellitus, hypercalcemia, hypercholesterolemia, and congenital abnormalities like Marfan and Hurler syndromes. Diagnosis of rheumatic mitral stenosis should be considered if commissural calcium and fusion is seen. In fewer than 1% of cases, the calcified mass may contain a radiolucent core. This finding has been termed “caseous” calcification of the mitral valve annulus, or mitral annular calcification with central softening. In a study of 100 patients of more than 62 years of age with MAC, only 6% had a mean gradient of more than 5 mmHg and mitral valve area of less than 1.8 cm2.5 It is hypothesized that due to the presence of concurrent diastolic abnormalities during relaxation, mitral valve area calculated by pressure half-time on echocardiography may be underestimated. MAC can be associated with conduction system diseases, atrial fibrillation, and an increased risk of coronary and vascular disease. It can serve as a nidus for secondary infective endocarditis.
Mitral annular calcification predicted major cardiovascular events in patients presented with acute coronary syndrome and underwent percutaneous coronary intervention
Published in Acta Cardiologica, 2020
Mustafa Çetin, Hakan Duman, Savaş Özer, Tuncay Kırış, Göksel Çinier, Ece Usta, Seçkin Satılmış, Turan Erdoğan
Mitral annular calcification (MAC) is described as the chronic degenerative calcification of fibrous tissue mostly at the posterior leaflet of mitral valve and less often at the anterior leaflet of the same valve [1]. It is usually asymtptomatic and detected incidentally during cardiac evaluation with transthoracic echocardiography (TTE) that is performed for other reasons. The incidence of MAC increases with ageing but other comorbidities including chronic kidney disease, hypertension, hyperlipidaemia, electrolyte disorders and conditions associated with increased mechanical shear stress contribute to the development of MAC. Several epidemiologic studies reported the prevalence of MAC between 8% and 15% [2,3]. Pathophysiology is not well understood yet but it is suggested that complex process that is involved in atherosclerosis also accompany the development of MAC [4]. Observational studies found that MAC was associated with incident coronary artery disease (CAD), cardiovascular (CV) mortality, stroke, new-onset AF and severity of atherosclerosis [5–7].
Device profile of the AltaValve system for transcatheter mitral valve replacement: overview of its safety and efficacy
Published in Expert Review of Medical Devices, 2020
Alberto Alperi, David del Val, Alfredo Nunes Ferreira-Neto, Mathieu Bernier, Afonso B Freitas-Ferraz, François Dagenais, Josep Rodés-Cabau
Patients with severe MR in the presence of severe and circumferential mitral annular calcification (MAC), as well as those with previous mitral valve ring annuloplasty or bioprosthetic surgical replacement, represent a particularly challenging population. Lately, the compassionate off-label use of transcatheter valve prosthesis intended for the aortic or pulmonary position, mainly with balloon-expandable systems, has gained popularity and the results of several studies in this field have been reported. In the presence of MAC, the results of a multicentre international registry including 116 patients showed a technical success rate of 76.7%, with procedural failures mainly driven by the need of a second valve in 15% of patients [10]. The rates of significant residual MR and all cause 30-day death were 4.9% and 25%, respectively. The results of mitral valve-in-valve procedures for degenerated mitral biological prosthesis or failed mitral surgical rings have also been reported using both trans-apical [11] and venous trans-septal [12] approaches. In this setting, high 30-day survival rates and a low incidence of significant residual MR, particularly in valve-in-valve (vs. valve-in-ring) cases, were observed.
Interventional therapies for relief of obstruction in hypertrophic cardiomyopathy: discussion and proposed clinical algorithm
Published in Hospital Practice, 2018
Srihari S Naidu, Jason Jacobson, Sei Iwai, Tanya Dutta, Wilbert S Aronow, Angelica Poniros, Ramin Malekan, David Spielvogel, Julio A Panza
Indications for this approach currently include patients in whom the basal septum is thin, less than 1.5 cm thick, where risk of ventricular septal defect is high with either alcohol septal ablation or surgical myectomy. Such patients typically have either a very narrow outflow tract, or excessive redundancy of the mitral leaflets or chordal apparatus as the dominant contributor to obstruction. Severe narrowing of the outflow tract can occur in elderly patients due to posterior mitral annular calcification, for example, a phenomenon increasingly seen in clinical practice as an etiology of late-onset obstruction. While those with basal septal hypertrophy would benefit from alcohol septal ablation or surgical myectomy, the remainder may benefit from MitraClip, assuming there is no concomitant mitral stenosis.