Relation Between Mitral Annular Calcium and Complex Aortic Atheroma in Patients With Cerebral Ischemia Referred for Transesophageal Echocardiography

doi:10.1016/j.amjcard.2006.12.053

The American Journal of Cardiology

Volume 99, Issue 9, 1 May 2007, Pages 1306-1311

https://doi.org/10.1016/j.amjcard.2006.12.053 Get rights and content

Mitral annular calcium (MAC) has been shown to be an independent predictor of stroke, but the basis for this association remains incompletely defined. This study was conducted to investigate the extent to which aortogenic embolism may mediate the MAC-stroke relation. In a cross-sectional study of patients referred for transesophageal echocardiography for the evaluation of cerebral ischemia, the relation between MAC and proximal and distal complex aortic atheroma (CAA) was assessed. In 419 patients composing the study cohort, MAC was associated with atherosclerosis risk factors, previous cardiovascular disease, atrial fibrillation, ipsilateral large-artery stenosis, left-sided cardiac abnormalities, and aortic valve calcium. MAC was associated with CAA of the proximal and distal thoracic aorta in unadjusted analyses, and these associations became stronger with increasing MAC severity. After adjustment for clinical and echocardiographic covariates, MAC exhibited a significant association with proximal and distal CAA in the entire cohort. In patients without alternative potential mechanisms for cerebral ischemia, however, the relation with proximal CAA became more pronounced (adjusted odds ratio 2.74, 95% confidence interval 1.22 to 6.16), but that for distal CAA changed little and became nonsignificant (adjusted odds ratio 1.97, 95% confidence interval 0.87 to 4.45). In conclusion, MAC was significantly associated with proximal and distal CAA independent of clinical and echocardiographic covariates in this cohort with cerebral ischemia, but in subjects without identifiable alternative mechanisms, the magnitude of the relation increased only for proximal CAA. These findings support the role of proximal CAA as a direct mediator of the increased stroke risk associated with MAC.

Section snippets

Methods

We conducted a retrospective, cross-sectional study of patients with cerebral ischemia referred for TEE at Weill-Cornell Medical Center (New York, New York) for the evaluation of a source of cardioembolism. The Echocardiography Laboratory’s electronic database was queried to select consecutive patients referred with cerebrovascular events from January 1998 to September 2004. Subjects with infective endocarditis, congenital heart disease (excepting isolated atrial septal defect), rheumatic valve

Results

Four hundred nineteen patients met the inclusion criteria. Their clinical and demographic characteristics are listed in Table 1. Slightly >1/5 of the cohort had MAC of at least mild severity. Patients with MAC were older and generally had greater prevalences of traditional atherosclerotic risk factors than those without MAC. The presence of MAC was also more frequently associated with previous coronary or cerebrovascular disease and with previous or newly diagnosed atrial fibrillation. Subjects

Discussion

In this study of consecutive patients referred for the transesophageal echocardiographic evaluation of cerebral ischemia, MAC was significantly associated with complex atheroma of the proximal thoracic aorta after adjustment for clinical and echocardiographic predictors, and the magnitude of this relation increased in subjects in whom no alternative stroke mechanisms were identified. Moreover, MAC and CAA exhibited a dose-response relation, such that increasing levels of MAC severity were

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2020, Trends in Cardiovascular Medicine
The mitral annulus is a fibrous structure that surrounds the mitral valve leaflets and is prone to calcification. Despite its common occurrence, association with cardiovascular morbidity and mortality and relationship with dysfunction of the mitral valve, the pathobiology of mitral annular calcification is incompletely understood. Mitral annular calcification is no longer regarded as a local, chronic and degenerative process resulting in precipitation of calcium and phosphate, but as an active and regulated molecular process that is related to lipid metabolism, hemodynamic stress, chronic kidney disease, bone and mineral metabolism and inflammation. This review summarizes the current evidence examining the pathophysiologic determinants of mitral annular calcification.
Associations of Mitral and Aortic Valve Calcifications with Complex Aortic Atheroma in Patients with Embolic Stroke of Undetermined Source
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Citation Excerpt :
Pujadas et al demonstrated that MAC was associated with a high prevalence of CAA in 121 patients with stroke of uncertain etiology, with positive and negative predictive values of 84.0% and 57.7%, respectively.25 Karas et al also reported significant associations between MAC and CAA among patients with stroke.26 Our results are in agreement with existing histopathological and clinical evidence that cardiac valve calcification is highly associated with the atherosclerotic process.
This study investigated the associations of mitral and aortic valve calcification with complex aortic atheroma among patients with embolic stroke of undetermined source.
We included 52 consecutive patients (mean age 58.1 years; 75.0% male) with embolic stroke of undetermined source. Mitral annular calcification, aortic annular calcification, and aortic valve sclerosis were assessed by transthoracic echocardiography. Complex aortic atheroma was assessed by transesophageal echocardiography and was defined as plaque protruding greater than or equal to 4 mm into the lumen or with ulcerated or mobile components.
Ten patients (19.2%) had complex aortic atheroma. Patients with and without complex aortic atheroma showed significant differences in terms of hypertension (80.0% versus 38.1%, P = .017), dyslipidemia (90.0% versus 31.0%, P <.01), chronic kidney disease (60.0% versus 14.3%, P <.01), previous coronary artery disease (30.0% versus 4.8%, P = .013), prior stroke (40.0% versus 7.1%, P <.01), left atrial dimension (4.0 cm versus 3.6 cm, P = .023), aortic valve sclerosis (80.0% versus 26.2%, P <.01), aortic valve calcification (aortic annular calcification or aortic valve sclerosis) (80.0% versus 26.0%, P <.01), and left-sided valve calcification (mitral annular calcification or aortic annular calcification or aortic valve sclerosis) (80.0% versus 28.6%, P <.01). In multivariate analysis, left-sided valve calcification was independently associated with complex aortic atheroma (odds ratio 4.1, 95% confidence interval 1.3-26.1, P = .049).
Mitral or aortic valve calcification detected by transthoracic echocardiography can be a useful marker for predicting complex aortic atheroma in patients with embolic stroke of undetermined source.
Contributing Mechanisms of Aortic Atheroma in Ischemic Cerebrovascular Disease
2015, Journal of Stroke and Cerebrovascular Diseases
Citation Excerpt :
Thus, when ICVD patients present with hypoperfusion characteristics, the possibility of AA should be considered. AA also accompanies other stroke risk factors, such as nonvalvular atrial fibrillation,51 mitral annular calcification,52-55 aortic stenosis,56,57 and so on (Table 1). Therefore, other potential sources of emboli still need to be evaluated even after AA is found.
In recent years, the correlation between aortic atheroma (AA) and the occurrence and recurrence of ischemic cerebrovascular disease (ICVD) has attracted much attention, but the contributory mechanisms remain controversial. This review analyzes related research on the roles of AA in ICVD, and demonstrates the correlation between the formation and development of AA and abnormal metabolism, inflammation, hemodynamic changes, and other contributory factors. The presence of complex aortic plaque (CAP) in the ascending aorta and aortic arch increases the risk of cerebral embolism and degree of injury, while the association between CAP in the descending aorta and cerebral embolism remains ambiguous. AA also functions as an indicator of atherosclerosis burden as well as hypercoagulability, which may further increase the risk of ICVD. Further study on the relationship of AA to ICVD will improve diagnosis and treatment in clinical practice.
The role of cardiac imaging in stroke prevention
2014, Cardiac Electrophysiology Clinics
Citation Excerpt :
In a variant of MAC known as caseous calcification, the rate of stroke events was 7% (Fig. 7).87 Karas and colleagues88 found that on TEE, MAC was significantly associated with proximal and distal complex aortic atheroma for evaluation of cerebral ischemia. These data confirm that MAC could be a predictor of stroke.
Guidelines for the preventive treatment of ischaemic stroke and TIA (I). Update on risk factors and life style
2012, Neurologia
Actualizar las guías terapéuticas del Comité ad hoc del Grupo de Estudio de Enfermedades Cerebrovasculares de la SEN en el tratamiento preventivo de ictus isquémico (II) y ataque isquémico transitorio (AIT).
Revisión de evidencias disponibles sobre los factores de riesgo y la oportunidad de su modificación para prevenir el ictus isquémico y AIT. Los niveles de evidencia y grados de recomendación se han basado en la clasificación del Centro de Medicina Basada en la Evidencia.
En esta primera parte se resumen las recomendaciones sobre la actuación sobre los siguientes factores: presión arterial, DM, lípidos plasmáticos, consumo de tabaco y alcohol, dieta y actividad física, cardiopatías embolígenas, estenosis carotídea asintomática, terapia hormonal sustitutiva y anticonceptivos, hiperhomocisteinemía, estados protrombóticos y síndrome de apnea del sueño.
La modificación de los estilos de vida y el tratamiento farmacológico de la hipertensión arterial, diabetes méllitus y dislipemia según criterios de prevención primaria y secundaria se recomiendan en la prevención de ictus isquémico.
To update the ad hoc Committee of the Cerebrovascular Diseases Study Group of The Spanish Neurological Society guidelines on prevention of ischaemic stroke (IS) and transient ischaemic attack (TIA).
We reviewed available evidence on risk factors and means of modifying them to prevent ischaemic stroke and TIA. Levels of evidence and recommendation grades are based on the classification of the Centre for Evidence-Based Medicine.
This first section summarises the recommendations for action on the following factors: blood pressure, diabetes, lipids, tobacco and alcohol consumption, diet and physical activity, cardio-embolic diseases, asymptomatic carotid stenosis, hormone replacement therapy and contraceptives, hyperhomocysteinemia, prothrombotic states and sleep apnea syndrome.
Changes in lifestyle and pharmacological treatment for hypertension, diabetes mellitus and dyslipidemia, according to criteria of primary and secondary prevention, are recommended for preventing ischemic stroke.
LV thrombus detection by routine echocardiography: Insights into performance characteristics using delayed enhancement CMR
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This study sought to evaluate performance characteristics of routine echo for left ventricular thrombus (LVT).
Although the utility of dedicated echocardiography (echo) for LVT is established, echo is widely used as a general test for which LVT is rarely the primary indication. We used delayed-enhancement cardiac magnetic resonance (DE-CMR) as a reference to evaluate LVT detection by routine echo.
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In this study, 243 patients had routine clinical echo and dedicated CMR within 1 week without intervening events. Follow-up supported DE-CMR as a reference standard, with >5-fold difference in endpoints between patients with versus without LVT by DE-CMR (p = 0.02). LVT prevalence was 10% by DE-CMR. Echo contrast was used in 4% of patients. Echo sensitivity and specificity were 33% and 91%, with positive and negative predictive values of 29% and 93%. Among patients with possible LVT as the clinical indication for echo, sensitivity and positive predictive value were markedly higher (60%, 75%). Regarding sensitivity, echo performance related to LVT morphology and mirrored cine-CMR, with protuberant thrombus typically missed when small (p ≤ 0.02). There was also a strong trend to miss mural thrombus irrespective of size (p = 0.06). Concerning positive predictive value, echo performance related to image quality, with lower diagnostic confidence scores for echoes read positive for LVT in discordance with DE-CMR compared with echoes concordant with DE-CMR (p < 0.02).
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¹: Dr. Kizer was supported in part by Grant K23 HL070854 from the National Heart, Lung, and Blood Institute, Bethesda, Maryland.

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MiscellaneousRelation Between Mitral Annular Calcium and Complex Aortic Atheroma in Patients With Cerebral Ischemia Referred for Transesophageal Echocardiography

Section snippets

Methods

Results

Discussion

Am J Cardiol

Am J Cardiol

Atherosclerosis

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

Aging changes in the aortic and mitral valvesHistologic and histochemical studies, with observations on the pathogenesis of calcific aortic stenosis and calcification of the mitral annulus

Am J Pathol

Mitral annular calcification and the risk of stroke in an elderly cohort

N Engl J Med

Miscellaneous
Relation Between Mitral Annular Calcium and Complex Aortic Atheroma in Patients With Cerebral Ischemia Referred for Transesophageal Echocardiography