Daniel Weisenberg

Association between mitral annulus calcification and aortic atheroma: a prospective transesophageal echocardiographic study

BACKGROUND AND PURPOSE Although mitral annulus calcification (MAC) has been reported to be a significant independent predictor of stroke, no causative relationship was proven. It is also known that aortic atheroma (AA), especially those >/=5 mm thick and/or protruding and/or mobile are associated with stroke. This study was designed to determine whether an association exists between MAC and AA. METHODS We prospectively evaluated the records of 279 consecutive patients who underwent transesophageal echocardiography (TEE) for various indications to measure the presence and characteristics of AA. The 105 patients in whom a diagnosis of MAC was made on transthoracic echocardiography (TTE) immediately preceding the TEE, were compared with 174 age-matched patients without MAC. MAC was defined as a dense, localized, highly reflective area at the base of the posterior mitral leaflet. We measured MAC thickness with two-dimensional-TTE in four-chamber view and AA thickness, protrusion and mobility with TEE. AA was defined as localized intimal thickening of >/=3 mm. A lesion was considered complex if there was plaque extending >/=5 mm into the aortic lumen and/or if it was protruding, mobile or ulcerated. RESULTS No differences were found between the groups in risk factors for atherosclerosis or in indications for referral for TEE. Significantly higher rates were found in the MAC group for prevalence of AA (91 vs. 44%, P<0.001), atheromas >/=5 mm thick (68 vs. 19%, P<0.001), protruding atheromas (44 vs. 15%, P<0.001), ulcerated atheromas (10 vs. 1%, P<0.001) and complex atheroma (74 vs. 22%, P<0.001). Sixty patients had MAC thickness >/=6 mm and 45<6 mm. AA thickness was significantly greater in the patients with a MAC thickness of >/=6 mm (6.1+/-2.8 vs. 5.0+/-2.6 mm, P=0.03). On multivariate analysis MAC, hypertension and age were the only independent predictors of AA (P=0.0001, 0.005 and 0.007, respectively). CONCLUSIONS There is a significant association between the presence and severity of MAC and AA. MAC may be an important marker for atherosclerosis of the aorta. This association may explain in part the high prevalence of systemic emboli and stroke in patients with MAC.

Right ventricular pacing increases tricuspid regurgitation grade regardless of the mechanical interference to the valve by the electrode

AIMS The effect of right ventricular (RV) pacing on tricuspid regurgitation (TR) is debatable and is presumed to be related to an interference with valve closure by the electrode. The aim of the study was to determine the impact of pacing per se on TR grade. METHODS AND RESULTS The study group included 23 clinically stable patients (13 males; mean age 78 +/- 12 years) with a permanent pacemaker at the RV apex (83% DDD mode) and normal left ventricular function. They were all non-dependent on pacing and were otherwise in sinus rhythm. None had a primary dysfunction of the tricuspid valve. TR grade and RV size were assessed in two consecutive echo studies with and without active RV pacing. Results showed that active RV pacing was associated with an increase in TR severity (TR vena contracta: 0.4 +/- 0.2 vs. 0.2 +/- 0.2 cm, P < 0.001; TR jet area: 4.1 +/- 2.3 vs. 2.3 +/- 1.8 cm(2), P < 0.001). This was also reflected in a significant decrease in the number of patients with mild TR (P = 0.003) and increase in the number with moderate regurgitation (P = 0.02). There was no change in RV areas with pacing. CONCLUSION Active RV pacing is associated with a significant increase in TR grade. This effect is not induced by acute changes in the RV area and is unrelated to an interference with leaflet closure by the electrode.

Association Between Mitral Annular Calcium and Flail Mitral Leaflet in Degenerative Mitral Valve Disease

The aim of this study was to assess the association between mitral annular calcium (MAC) and flail mitral leaflets in a cohort of patients with degenerative mitral valve disease. A retrospective study was conducted of consecutive patients with degenerative mitral valve disease who underwent echocardiography at Rabin Medical Center from 2003 to 2012. Special focus was attended to the presence and grade of MAC and characterization of valve pathology (myxomatous vs nonmyxomatous, prolapse vs flail). Patients were excluded if they had undergone previous mitral valve surgery and/or had infective endocarditis. Multivariate logistic regressions were used to control for confounders. The study included 1,912 patients (60.8% men, mean age 63.8 ± 17.4 years) divided into 3 groups: 1,627 (86%) without MAC, 183 (10%) with either mild or moderate MAC, and 94 (5%) with severe MAC. The presence of flail leaflet was 27%, 30%, and 46% in these groups, respectively (p <0.001). After adjustment for age, gender, and co-morbidities, the odd ratio for flail mitral leaflet with severe MAC versus no MAC was 1.76 (95% confidence interval 1.10 to 2.83, p = 0.019). In conclusion, this study demonstrates that degenerative mitral valve disease with severe MAC is significantly associated with flail mitral leaflet.

902 Bileaflet mitral valve orientation — is it associated with obstructive valve thrombosis? A transesophageal echocardiographic study

2 , 2 Institute for Cardiovascular Diseases, Belgrade, Yugoslavia Objective: Preservation of the posterior leaflet during mitral valve replacement in patients (pts) with mitral regurgitation has been proven beneficial for postoperative left ventricular performance. Some authors have been stating that posterior leaflet preservation during every mitral valve replacement was highly beneficial both post- operatively as well as long-term. The aim of our study was to investigate long-term effect of this technique in pts with rheumatic mitral stenosis. Patients and Methods: We studied 20 pts with mitral valve replacement for rheumatic mitral stenosis operated from 1989-1990. In all pts a Carbomedics valve was inserted. In group A (10 pts) the posterior leaflet was preserved, while group B (10 pts) underwent excision of both leaflets with corresponding chordas. In both groups hemodynamic characteristic of the valve and the left ventricle, based on echocardiographic findings 12 years later, were compared. We determined maxi- mal (PG) and mean (MG) transmitral valvular gradients, as well as the effective area of inserted valvular opening (AREA), telediastolic (TDV) and telesystolic (TSV) left ventricular volume, stroke volume (SV), ejection fraction (EF), fractional shortening (FS) and segmental left ventricular motion. Results: The mean size of inserted valve was 27.4 in group A and 26.6 in group B. We found no difference between the two groups according to hemodynamic data: PG (10.4 vs 11.1mmHg), MG (4.0 vs 3.5 mmHg), AREA (2.3 vs 2.37cm2), TDV (114.5 vs 133.7ccm), TSV (36.6 vs 46.2ccm), SV (53.7 vs 83.7ccm), EF (67.1 vs 63.7%), FS (38.2 vs 33.7%). Dyskinesis of the corresponding segments was found in 3 patiens in group A and in one patient in group B. Conclusion: In pts with rheumatic mitral stenosis and valve replacement, posterior leaflet preservation has not been shown beneficial for left ventricular function during long-term follow-up. Adequate preservation of the posterior mitral leaflet did not change the properties of the inserted valve in long-term follow-up.