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Mitral Annulus Calcification

Mitral annulus calcification is a degenerative process involving the mitral valve ring, that sometimes extends to the whole valvular apparatus. It has the same risk factors as atherosclerosis and is more often found in chronic kidney disease, radiation therapy, and elderly patients. This condition sometimes causes mitral stenosis and more often mitral regurgitation and is associated with atrial fibrillation, atrioventricular block, stroke and cardiovascular mortality, being a good indicator of global atherosclerotic burden.


Presentation

Mitral annulus calcification is usually asymptomatic unless it is severe enough to impair forward blood flow or cause severe mitral regurgitation, leading to left atrial enlargement and atrial fibrillation [1] or is associated with significant degenerative disease of the aortic valve [2]. Severe calcification may cause mitral stenosis [3] and is associated with multiple coronary artery disease with an unstable plaque and high myocardial infarction risk and increased likelihood of stroke [4]. However, it is unclear whether the mitral calcification causes stroke by embolization or the cerebral disease is due to cerebrovascular atherosclerosis because patients with this mitral abnormality also have significant aortic and carotid plaque. Also, affected individuals develop endocarditis more often [5]. Heart rhythm can also be impaired by mitral annulus calcification, that is associated with atrial fibrillation and conduction abnormalities: atrioventricular block and bundle branch block [6]. Aortic valve calcification and stenosis may also be present, sometimes causing symptoms [7].

Pseudotumor
  • AO aorta; LA left atrium; LV left ventricle; LVOT left ventricular outflow tract; MV mitral valve; PST pseudotumor.[benthamopen.com]
Intermittent Claudication
Heart Disease
  • Abstract M-mode and two-dimensional echocardiograms of 3,254 patients without evidence of rheumatic heart disease were evaluated retrospectively for evidence of aortic cusp calcification and mitral annulus calcification.[ncbi.nlm.nih.gov]
  • , Valvular Heart Disease, EP Basic Science, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Congenital[acc.org]
  • Posted in cardiology -Therapeutics, Cardiology -unresolved questions, cardiology women, Cardiology-Coronary artery disese, echocardiography, MVPS, valvular heart disease, tagged annular vt, mac, mitral annular calcifcation, mitral valve calcification[drsvenkatesan.com]
  • Clinical diagnosis included rheumatic heart disease (32%), noninflammatory calcific disease (34%), and chronic renal failure (32%).[archinte.jamanetwork.com]
Osteoporosis
  • Her past medical history was significant for osteoporosis and spine surgery. Initial physical examination revealed no abnormalities. Her heartbeat was regular, and no cardiac murmurs were audible.[synapse.koreamed.org]
  • It has been suggested that MAC in elderly women can be attributed to ectopic calcium deposits related to the severe bone loss caused by post-menopausal osteoporosis (37) .[onlinejacc.org]
Ulcer
  • 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.[ncbi.nlm.nih.gov]
Renal Insufficiency
  • Comorbidities noted included chronic renal insufficiency/dialysis (n 8), cancer (n 6), coronary disease (n 6), and obstructive cardiomyopathy (n 1).[ncbi.nlm.nih.gov]
  • Insufficiency, Chronic, Risk Factors, Stroke, Tomography Scanners, X-Ray Computed, Transcatheter Aortic Valve Replacement, Vascular Calcification Back to Listings[acc.org]
Confusion
  • Factors which may lead to diagnostic confusion are: (a) failure to identify the posterior mitral leaflet (7/21); (b) diminished anterior leaflet mobility (mean 15 mm); (c) accoustic shadowing of the left ventricular wall (18/21); (d) pseudosystolic anterior[ncbi.nlm.nih.gov]
  • In these cases it may be heard well at the cardiac base, and could be confused with the murmur of aortic stenosis (AS), but it does not radiate to the carotid arteries.[cardiologyforyou.blogspot.com]
Dysarthria
  • On the fourth day, her orientation and consciousness were restored to normal, but there was residual dysarthria and difficulty swallowing.[synapse.koreamed.org]

Workup

Blood workup has no specific findings in mitral annulus calcification, but it may reveal high cholesterol and glycemia levels, high inflammation markers, as well as indicators of impaired renal function: increased creatinine, potassium, and low glomerular filtration rate.

The diagnosis is made using various imaging methods. The plain thoracic radiography is sometimes able to describe it if calcification is important. Calcium deposits take the shape of the mitral annulus, being observed as "J", "C" or "O" letters. Echocardiography is a much more reliable diagnostic method, describing calcification as a hyperechoic mass or band attached to the anterior or posterior mitral leaflets [8]. More importantly, echocardiography evaluates the degree to which calcification impairs leaflet mobility and causes stenosis or regurgitation, by measuring gradients and determining mitral valve area. Also, this method evaluates the presence of aortic calcification, chamber dilatation, left ventricular hypertrophy and wall kinetics, diastolic mitral flow reversal, this being especially important in individuals that have atrial fibrillation or angina patients. The degree of severity is evaluated in parasternal short axis view: mild (focal), moderate (involving one-third to one-half of the annulus) or severe (more than one-half of the ring is implicated). The mitral valve per se may be difficult to evaluate if calcification is severe because calcium is echo-dense and prevents posterior structures visualization.

When echocardiography raises suspicion of endocarditis, thrombosis or cardiac tumors, cardiac magnetic resonance imaging and computed tomography scanning are useful in establishing the correct diagnosis [9]. Still, these methods are bound by motion artifacts. Multislice (spiral) and electron-beam computed tomography are more effective diagnostic techniques that also apply to the aortic valve. Another visualization method is fluoroscopy performed during coronarography, but this is only used if coronary artery disease is suspected.

Calcified Aortic Valve
  • aortic valve, of whom 515 (6.3%) had stenosis with a minimal aortic valve gradient of 16 mm Hg.[heart.bmj.com]
Prolonged PR Interval
  • This case of WPW syndrome type A presented the following conduction abnormalities: (1) right bundle-branch block; (2) transient second-degree AV block with prolonged PR interval of the conducted beats; (3) during electrophysiological study, induction[ncbi.nlm.nih.gov]
Bifascicular Block
  • The electrocardiogram (ECG) showed a new bifascicular block. No episodes of advanced atrioventricular blocks or significant pauses were observed in the 24-h Holter-ECG monitoring.[revespcardiol.org]
Complete Left Bundle Branch Block
  • This occurs particularly in cases in which CMA extends to the anterior annulus and more medial segments of the posterior annulus and mainly in the form of complete left bundle branch blocks and bifascicular blocks. 7 Nevertheless, the frequency of this[revespcardiol.org]

Treatment

  • Therefore, in our opinion, mitral annulus calcification requires treatment of cardiovascular risk factors, but generally no specific measures such as surgery or oral anticoagulants are required to lower the risk of stroke.[ncbi.nlm.nih.gov]
  • Because it is similar in appearance to lesions such as a cyst, a thrombus, a tumor, or an abscess, misdiagnoses and unnecessary surgical treatments have been reported.[cdt.amegroups.com]
  • The most common indication for surgical treatment was the association of CCMA with severe mitral regurgitation in 22 patients and severe mitral stenosis in 5.[benthamopen.com]
  • Treatment and prognosis Annular calcification per se does not require any treatment. Instead, patients are managed according to the presence of heart block, mitral regurgitation (usually minimal) and other cardiovascular signs and symptoms.[radiopaedia.org]
  • Treatment of Mitral Annular Calcification Mitral annular calcification is usually of no clinical significance and no specific treatment such as MitraClip is required.[myheart.net]

Prognosis

  • Usually located on the posterior mitral leaflet Contains putty-like, “toothpaste-like” material surrounded by a calcified shell Differential Diagnosis Benign prognosis not to be mistaken for tumor which is in the differential diagnosis Prognosis There[learningradiology.com]
  • CONCLUSION: Bacterial endocarditis complicating mitral annulus calcification has a poor prognosis due to the frequent comorbidity and severity of the infectious complications.[ncbi.nlm.nih.gov]
  • Most case reports have shown good prognosis with no cerebrovascular events.[synapse.koreamed.org]
  • 059071, 外科術, ゲカジュツ, operative surgery, 045593, 治療法, チリョウホウ, therapy, 040918, 心臓外科, シンゾウゲカ, heart surgery, 054763, 胸部外科, キョウブゲカ, thoracic surgery, 055808, 心臓血管外科, シンゾウケッカンゲカ, cardiovascular surgery, 055961, 補綴, ホテツ, prosthesis, 054779, 予後, ヨゴ, prognosis[togodb.biosciencedbc.jp]
  • Treatment and prognosis Annular calcification per se does not require any treatment. Instead, patients are managed according to the presence of heart block, mitral regurgitation (usually minimal) and other cardiovascular signs and symptoms.[radiopaedia.org]

Etiology

  • […] prevalence of left atrial and left ventricular enlargement, hypertrophic cardiomyopathy, atrial fibrillation, aortic valve calcification and stenosis, various cardiac conduction defects, bacterial endocarditis, cardiovascular events and stroke, though the etiological[ncbi.nlm.nih.gov]
  • The lesion can be readily distinguished macroscopically from mitral stenosis of rheumatic etiology. Lippincott-Raven Publishers.[journals.lww.com]
  • Echocardiography appears to be a sensitive method of detecting mitral annular calcification and may be helpful in differentiating rheumatic and nonrheumatic etiologies. ( Arch Intern Med 137:1143-1150, 1977)[archinte.jamanetwork.com]
  • Although pleural thickening of any etiology may later develop calcification, it is commonly due to infections, hemorrhage, or asbestos exposure.[pulmonarychronicles.com]
  • Apply the latest knowledge on hot topics such as the value of physical examination in taking care of the ICU patient, accurately diagnosing the etiology of systolic murmurs, diagnosing osteoarthritis and acute vertigo in the dizzy patient, diagnosing[books.google.ro]

Epidemiology

  • Emile Cheriex b , Jan Lodder c , Fons Kessels d a St Anna Hospital, Geldrop, Netherlands, b Department of Cardiology, University Hospital Maastricht, Netherlands, c Department of Neurology, University Hospital Maastricht, Netherlands, d Department of Epidemiology[heart.bmj.com]
  • Considerations in the use of echocardiography in epidemiology: the Framingham Study . Hypertension 1987 ;9:Suppl II: II-40 —II-44. Citing Articles (221) Letters Article Figures/Media[nejm.org]
  • Epidemiology of mitral annular calcification and its predictive value for coronary events in African Americans: the Jackson Cohort of the Atherosclerotic Risk in Communities Study. Am Heart J . 2004 Dec. 148 (6):979-84. [Medline] .[emedicine.medscape.com]
  • However, AVS shows epidemiologic and histopathologic similarities to coronary atherosclerosis ( 2 , 3 ).[care.diabetesjournals.org]
Sex distribution
Age distribution

Pathophysiology

  • Mitral annulus calcification has been associated with embolic events, but the precise pathophysiology has not been elucidated.[ncbi.nlm.nih.gov]
  • This review describes MAC, and reviews pathophysiological mechanisms contributing to its formation and clinical implications of its presence.[acc.org]
  • We describe the pathophysiological mechanisms contributing to the formation of MAC and the clinical implications of this disease entity.[onlinejacc.org]
  • Nestico PF, Depace NL, Morganroth J, Kotler MN, Ross J: Mitral annular calcification: Clinical, pathophysiology and echocardiographic review. Am Heart J 1984;107:989–996.[karger.com]

Prevention

  • The mitral valve per se may be difficult to evaluate if calcification is severe because calcium is echo-dense and prevents posterior structures visualization.[symptoma.com]
  • Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention[acc.org]
  • Anticoagulation and antiplatelet therapy are ineffective to prevent a cardioembolic stroke in patients with CCMA, because the mechanism of embolization from CCMA lesions is unlikely to be related to thrombi.[benthamopen.com]
  • […] incidental and are usually unrelated to the symptoms. 2) Because caseous MAC is known to be indolent and benign, most patients are treated conservatively. 2) However, in some cases, surgery 4 - 8) is performed based on suspicion of an intracardiac tumor, for prevention[synapse.koreamed.org]
  • In conclusion, CCMA is a rare variant of CMA, but should be considered in the differential diagnosis with other cardiac masses to prevent unnecessary surgery.[revespcardiol.org]

References

Article

  1. Fox CS, Parise H, Vasan RS, et al. Mitral annular calcification is a predictor for incident atrial fibrillation. Atherosclerosis. 2004;173(2):291-94.
  2. Allison M, Cheung P, Criqui M, et al. Mitral and aortic annular calcification are highly associated with systemic calcified atherosclerosis. Circulation. 2006;113:861–866.
  3. Labovitz A, Nelson J, Windhorst D, et al. Frequency of mitral valve dysfunction from mitral anular calcium as detected by Doppler echocardiography. Am J Cardiol. 1985;55:133–137.
  4. Kizer JR, Wiebers DO, Whisnant JP, et al. Mitral annular calcification, aortic valve sclerosis, and incident stroke in adults free of clinical cardiovascular disease: the Strong Heart Study. Stroke. 2005;36(12):2533-2537.
  5. Vistarini N, d’Alessandro C, Aubert S, et al. Surgery for infective endocarditis on mitral annulus calcification J Heart Valve Dis. 2007;16:611–616.
  6. Nair C, Runco V, Everson G, et al. Conduction defects and mitral annulus calcification Br Heart J. 1980; 44:162–167.
  7. Jassal DS, Tam JW, Bhagirath KM, et al. Association of mitral annular calcification and aortic valve morphology: a substudy of the aortic stenosis progression observation measuring effects of rosuvastatin (ASTRONOMER) study. Eur Heart J. 2008;29 (12):1542-1547.
  8. Atar S, Jeon DS, Luo H, Siegel RJ. Mitral annular calcification: a marker of severe coronary artery disease in patients under 65 years old. Heart. 2003;89(2):161-164.
  9. Shah BN, Babu-Narayan S, Li W, Rubens M, Wong T. Severe mitral annular calcification: insights from multimodality imaging. Tex Heart Inst J. 2014;41(2):245-247.

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Last updated: 2019-07-11 20:18