Relationship of Aortic Wall Distensibility to Mitral and Aortic Valve Calcification: The Multi-Ethnic Study of Atherosclerosis.

Data are limited on whether valvular calcification is associated with aortic wall stiffness. We tested whether aortic valve calcification (AVC) and/or mitral valve calcification (MVC) is inversely associated with aortic distensibility (AD). Cross-sectional study conducted in a subset of the Multi-Ethnic Study of Atherosclerosis (MESA) included 3676 MESA participants aged 44 to 84 years with AD measured with magnetic resonance imaging and with AVC and MVC measured with noncontrast cardiac computed tomography scans. Both AVC and MVC were divided into 3 categories: zero, < median values (low), and ≥ median values (high) for patients with nonzero values. Overall, 88% (n = 3256) and 92% (n = 3365) of participants had zero AVC and MVC, while 6% (n = 211) and 4% (n = 156) had low, and 6% (n = 209) and 4% (n = 155) had high values of AVC and MVC, respectively. The AVC was independently associated with AD after adjusting for age, gender, and ethnicity ( P = .035). No association was noted between AVC groups and AD after adjustment for all covariates or MVC groups and AD in any model.

IL-10 genetic polymorphisms were associated with valvular calcification in Han, Uygur and Kazak populations in Xinjiang, China.

OBJECTIVE: Valvular calcification occurs via ongoing endothelial injury associated with inflammation. IL-10 is an anti-inflammatory cytokine and 75% of the variation in IL-10 production is genetically determined. However, the relationship between genetic polymorphisms of IL-10 and valvular calcification has not been studied. The objective of this study was to investigate the association between valvular calcification and IL-10 genetic polymorphisms in the Han, Uygur and Kazak populations in China. PATIENTS AND METHODS: All of the participants were selected from subjects participating in the Cardiovascular Risk Survey (CRS) study. The single nucleotide polymorphisms (SNPs) rs1800871 and rs1800872 of the IL-10 gene were genotyped using the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method. Three independent case-control studies involving the Han population, the Uygur population and the Kazak population were used in the analysis. RESULTS: For the Han and Kazak populations, rs1800871 was found to be associated with valvular calcification in the recessive model, and the difference remained statistically significant following multivariate adjustment (p<0.001, p=0.031, respectively). For the Han, Uygur and Kazak populations, rs1800872 was found to be associated with valvular calcification in the dominant model, and the difference remained statistically significant following multivariate adjustment (p<0.001, p=0.009, and p=0.023,respectively). CONCLUSION: Both rs1800871 and rs1800872 of the IL-10 gene are associated with valvular calcification in the Han and Kazak populations in China. Rs1800872 is also associated with valvular calcification in the Uygur population.

Rheumatic mitral stenosis in children: more accelerated course in sub-Saharan patients.

BACKGROUND: Mitral stenosis, one of the grave consequences of rheumatic heart disease, was generally considered to take decades to evolve. However, several studies from the developing countries have shown that mitral stenosis follows a different course from that seen in the developed countries. This study reports the prevalence, severity and common complications of mitral stenosis in the first and early second decades of life among children referred to a tertiary center for intervention. METHODS: Medical records of 365 patients aged less than 16 and diagnosed with rheumatic heart disease were reviewed. Mitral stenosis was graded as severe (mitral valve area < 1.0 cm2), moderate (mitral valve area 1.0-1.5 cm2) and mild (mitral valve area > 1.5 cm2). RESULTS: Mean age at diagnosis was 10.1 ± 2.5 (range 3-15) years. Of the 365 patients, 126 (34.5%) were found to have mitral stenosis by echocardiographic criteria. Among children between 6-10 years, the prevalence of mitral stenosis was 26.5%. Mean mitral valve area (n = 126) was 1.1 ± 0.5 cm2 (range 0.4-2.0 cm2). Pure mitral stenosis was present in 35 children. Overall, multi-valvular involvement was present in 330 (90.4%). NYHA functional class was II in 76% and class III or IV in 22%. Only 25% of patients remember having symptoms of acute rheumatic fever. Complications at the time of referral include 16 cases of atrial fibrillation, 8 cases of spontaneous echo contrast in the left atrium, 2 cases of left atrial thrombus, 4 cases of thrombo-embolic events, 2 cases of septic emboli and 3 cases of airway compression by a giant left atrium. CONCLUSION: Rheumatic mitral stenosis is common in the first and early second decades of life in Ethiopia. The course appeared to be accelerated resulting in complications and disability early in life. Echocardiography-based screening programs are needed to estimate the prevalence and to provide support for strengthening primary and secondary prevention programs.

Prevalence of mitral annulus calcification in African Americans: comparison with non-Hispanic whites and Hispanics.

BACKGROUND: The association of ethnic ancestry with coronary artery calcifications suggests that mitral annulus calcification may also vary with ethnicity. We sought to compare prevalence and clinical correlates of mitral annulus calcification in non-Hispanic Whites, Hispanics, and African Americans. DESIGN: This was a retrospective study of 857 patients age 40-75 years that included 217 (25%) African Americans, 349 (41%) Hispanics, and 291 (34%) non-Hispanic Whites referred for echocardiography. Multiple logistic regression was used to determine the interrelationships between mitral annulus calcification, risk factors, and ethnicity. RESULTS: Mitral annulus calcification was detected in 181 (21.1%) patients including 35 (16.1%) African Americans, 80 (22.9%) Hispanics, and 66 (22.7%) non-Hispanic whites. In univariate analysis, patients with mitral annulus calcification were older and more likely to have hypertension, diabetes, dyslipidemia, smoking history, and two or more risk factors than were those without calcification. In multivariate analysis, age and smoking history were independent predictors of mitral annulus calcification; dyslipidemia and diabetes were borderline significant predictors; and after adjusting for the remaining variables in the model, ethnicity was not an independent significant predictor of mitral annulus calcification. CONCLUSION: In a retrospective study of middle-aged and elderly African Americans, non-Hispanic Whites, and Hispanics referred for echocardiography, mitral annulus calcification is common in all three major ethnic groups but not significantly associated with ethnic ancestry.

Percutaneous balloon mitral commissurotomy in indigenous versus non-indigenous Australians.

BACKGROUND: Rheumatic heart disease remains a serious health issue amongst the Australian indigenous population. Percutaneous balloon mitral commissurotomy (PBMC) has become the treatment of choice in patients with symptomatic pure mitral stenosis with favourable valve morphology. There is little published data on the efficacy of PBMC in indigenous Australians. AIMS: We sought to document differences between indigenous Australians (IA) and non-indigenous Australians (NIA) undergoing percutaneous balloon mitral commissurotomy (PBMC) at The Prince Charles Hospital and Holy Spirit Northside Hospital from 1990 to 2006. METHODS: PBMC was performed in 327 patients using the Inoue-balloon technique (271 female, 56 male, age +/-15 years (mean+/-S.D.), (range 13-89) between March 1990 and March 2006. RESULTS: The IA population was over represented in this cohort (11% versus an estimated 3.4% of the Queensland population) and comprised the largest non-Caucasian group. Compared with the NIA population they were younger (mean age 36 years (+/-13) versus mean 52(+/-14) years (P<0.05)). Baseline mitral valve area (MVA) was similar in the IA and NIA groups (0.96 cm(2) versus 1.08 cm(2)P=0.9). Mitral valve Echo-score was also similar between the two groups (mean score 7.36 versus 7.52 P=0.8). The IA population had higher pre-procedural mitral valve gradients (14.3 mmHg versus 11.1 mmHg, P<0.05), but less mitral valve calcification. Procedural success was achieved in 91% of both groups. Post procedural MVA (planimetry) was similar (1.98 cm(2) versus 1.84 cm(2)P=0.6), as was percent reduction in mitral valve gradient. Inadequate dilatation was seen in 1 (3%) IA and in 10 (3.6%) of the NIA group. Significant MR was seen in 2 (6%) IA patients and 11 (4%) NIA patients. There were no deaths or strokes or pericardiocenteses in either group. CONCLUSION: The indigenous population makes up a significant proportion of patients requiring PBMC in Queensland. They present younger and with higher mitral valve gradients. The procedure is safe in both the indigenous and non-indigenous Australian population. Further research is required to establish the long-term efficacy of this procedure in indigenous Australians.

Ethnic differences between extra-coronary measures on cardiac computed tomography: multi-ethnic study of atherosclerosis (MESA).

BACKGROUND: Emerging evidence indicates that calcifications in valvular and thoracic aorta are manifestations of generalized atherosclerosis. Assessing the presence and extent of extra-coronary atherosclerosis may further improve prognostic information in subjects who are at risk for cardiovascular disease. The aim of the study is to determine the relative prevalence and quantity of extra-coronary calcifications across ethnic groups in a multi-ethnic population based cohort of asymptomatic individuals. METHODS AND RESULTS: The ethnic differences associated with aortic valve calcification (AVC), mitral valve calcification (MVC), aortic valve root calcification (AVRC) and thoracic aortic wall calcification (TAC) were assessed in 6814 asymptomatic individuals in the multi-ethnic study of atherosclerosis (MESA) study. The overall prevalence of AVC, MVC, AVRC and TAC was 13, 10, 34 and 28%, respectively). As far as the valvular calcifications (AVC, MVC, AVRC) are concerned, the highest prevalence was observed in the Whites, followed by Hispanics and African-Americans with the lowest levels of calcification among the Chinese (all p<0.001). On the other hand, the Chinese along with Whites had the highest prevalence of TAC (p<0.001). After adjustment for traditional CVD risk factors and coronary artery calcification, the relative risk of AVC compared with Whites was 0.72 in Blacks (95% CI 0.59-0.90), 1.03 in Hispanics (95% CI 0.82-1.28) and 0.56 in Chinese (95% CI 0.40-0.80). Similar associations were observed for the presence of MVC and AVRC. However, as compared to Whites, the relative risk for presence of TAC was not significantly lower among Hispanics (RR: 0.83, 95% CI: 0.68-1.01) and Chinese Americans (RR: 1.24, 95% CI: 0.95-0.1.62); however Blacks had a significantly lower risk of TAC (RR: 0.50, 95% CI: 0.41-0.60), respectively. CONCLUSIONS: Racial differences exist in the prevalence of extra-coronary calcification in a large multi-ethnic population of asymptomatic individuals, thus underscoring the need for developing population specific nomograms to identify overall atherosclerotic burden in a more accurate manner in different ethnic groups. Further studies are needed to assess prognostic potential of each of these new measures of extra-coronary calcification in predicting subsequent cardiovascular events, independently and incrementally above known cardiovascular risk factors and the amount of calcified coronary plaque.

Mitral valve disease presentation and surgical outcome in African-American patients compared with white patients.

BACKGROUND: Disparities associated with race, particularly African-American race, in access to medical and surgical care for patients with cardiac disease have previously been documented. The purpose of this study was to determine the presentation, etiology, and hospital outcome differences between African-American patients and white patients with regard to surgically corrected mitral valve disease. METHODS: All 1,425 adult patients who underwent first time, isolated mitral valvuloplasty or mitral valve replacement by the same group of surgeons at New York University Medical Center and Bellevue Hospital Center between 1993 and 2003 were studied. RESULTS: African Americans (n = 123, 8.6%) were significantly younger (45.6 +/- 14.4 versus 60.5 +/- 15.3 years) and had significantly higher incidences of diabetes mellitus, renal failure, congestive heart failure, endocarditis, and rheumatic mitral disease; whereas whites (n = 1,302, 91.4%) more commonly had degenerative mitral disease. African Americans were less likely to undergo mitral valvuloplasty. There were no significant differences in the incidences of postoperative complications or hospital mortality (2.4% African American versus 5.1% white, p = 0.19). CONCLUSIONS: African Americans present for mitral valve surgery at a significantly younger age than whites and with higher incidences of many risk factors. Whether presentation at a significantly earlier age in African Americans is a result of failures in primary care or an enhanced susceptibility to the process of mitral disease and comorbidities remains to be determined. African Americans were less likely to undergo mitral valvuloplasty, which may have an effect on long-term outcome. Improved screening in this racial group will facilitate earlier referral, increasing the potential for mitral valvuloplasty.

Prevalence and clinical correlates of mitral annulus calcification in Hispanics and non-Hispanic whites.

BACKGROUND: Data about mitral annulus calcification (MAC) are sparse in Hispanics. We compare prevalence and clinical correlates of MAC in Hispanics and non-Hispanic whites. METHODS: We reviewed echocardiograms and clinical data of 337 Hispanics and 279 non-Hispanic whites, age 45 to 75 years. In cross-sectional data, prevalence and interrelationships of MAC, coronary heart disease (CHD), and risk factors were compared using multivariable logistic regression. RESULTS: In Hispanics, MAC was significantly associated with CHD (odds ratio [OR] = 2.06, confidence interval [CI] = 1.09-3.87), age (OR = 1.73, CI = 1.21-2.49), female sex (OR = 1.87, CI = 1.01-3.47), smoking (OR = 1.80, CI = 1.01-3.24), and having multiple (>2) risk factors (OR = 3.43, CI = 2.66-4.43). In non-Hispanic whites, MAC was associated with CHD (OR = 4.24, CI = 2.00-8.98), age (OR = 2.87, CI = 1.82-4.50), and having multiple risk factors (OR = 3.59, CI = 2.7-4.77). There were no significant ethnic differences in prevalence of MAC. CONCLUSIONS: Among Hispanics referred for echocardiography, MAC is associated with CHD and risk factors.

Reproducibility of CT measurements of aortic valve calcification, mitral annulus calcification, and aortic wall calcification in the multi-ethnic study of atherosclerosis.

RATIONALE AND OBJECTIVES: Extracoronary calcifications may have clinical significance. The error in extracoronary calcification measurements is still unknown. Accurate quantification of calcifications of the aortic valve (AVC), mitral annulus (MAC), and aortic wall (AWC) may be possible by using cardiac computed tomography (CT). We sought to establish the interscan, interobserver, and intraobserver reproducibility of these measures in all cardiac CT scans in the Multi-Ethnic Study of Atherosclerosis. MATERIALS AND METHODS: We measured extracoronary calcifications in 100 randomly selected participants to assess interobserver, interscan, and intraobserver variability. Two scans were available for analysis in 99 of these participants, and we quantified thoracic aorta and valvular calcifications. RESULTS: Mean interscan variability of AVC was 9.7% +/- 11.4% and 8% +/- 10.3% for Agatston and volume scores, with variability of the median at 6.4% and 5.5%, respectively (P > .05). MAC inter-reader variability was 8.2% and 8.9%, with interscan variability of 28% and 33% and intrareader variability of 4% and 4.1%, respectively. For AWC, inter-reader variability was 3%-7.1%, interscan variability was 17%-18%, and intrareader variability was 0.4%-1.4%. CONCLUSION: AVC, MAC, and AWC measurements are sufficiently reproducible to allow serial investigations over a time suitable for clinical studies.

[Dyspnoea in pregnant female immigrants due to unexpected mitral valve stenosis]. / Dyspnoe bij allochtone zwangeren door onverwachte mitralisklepstenose.

Three female patients, a 22-year-old Moroccan woman, a 25-year-old Turkish woman and a 35-year-old Iraqi woman, became increasingly dyspnoeic during their pregnancy; this was a symptom of congestive heart failure due to mitral valve stenosis. Since all patients were refractory to medical treatment, they underwent invasive therapy by percutaneous transvenous mitral balloon valvotomy (PTMV). In two patients this therapy was successful, but in one patient a closed mitral valvotomy was needed. All three women delivered healthy infants, two immediately following the PTMV; at follow-up 2-4 years later, the women and infants were all doing well. The prevalence of mitral valve stenosis in the western world is increasing because of changing immigration patterns. When pregnant patients start complaining about dyspnoea, especially if they are immigrants, one should be aware of the possibility of mitral valve stenosis. PTMV is a safe and successful treatment for these patients and is preferred above surgical therapy because of its low morbidity and mortality for both mother and foetus. PTMV must be performed in a thoracic surgery centre by an experienced team and the X-ray exposure should be minimised.

Association between transforming growth factor-beta1 gene C-509T and T869C polymorphisms and rheumatic heart disease.

BACKGROUND: Scarring and collagen deposition in the valves and destruction of myocytes may result from the combined effects of a smoldering rheumatic process and a constant trauma to the mitral valve or aortic valve by the turbulent flow in rheumatic heart disease (RHD). Transforming growth factor-beta1 (TGF-beta1) may be responsible for the increased valvular fibrosis and calcification in the pathogenesis of RHD. However, the role of TGF-beta1 genetic variant in RHD has not been studied. This case-controlled study was carried out to investigate the possible relationship between the TGF-beta1 gene C-509T and T869C polymorphisms and RHD among the Chinese population in Taiwan. METHODS: A group of 115 patients with RHD documented by using echocardiography and 100 age- and sex-matched healthy control patients were studied. TGF-beta1 gene C-509T and T869C polymorphisms were identified with polymerase chain reaction-based restriction analysis. RESULTS: A significant difference was seen in the distribution of genotypes between patients with RHD and control patients for either TGF-beta1 C-509T polymorphism (P <.0001) or T869C polymorphism (P <.0001). The frequency of TGF-beta1 C-509T CC genotype was lower in the RHD group than in the control group (chi2 = 19.05, P <.0001), which suggests that this genotype may confer protective effects against RHD. A significant difference was seen in the distribution of allelic frequency between patients with RHD and control patients for TGF-beta1 T869C polymorphism (P =.04). The odds ratio (OR) for risk of RHD associated with TGF-beta1 T869C T allele was 1.49 (95% CI, 1.02-2.19). Further categorization of patients with RHD into mitral valve disease and combined valve disease subgroups revealed no statistical difference in these gene polymorphisms when compared with the 2 subgroups. CONCLUSIONS: Patients with RHD have a lower frequency of TGF-beta1 C-509T CC genotype and a higher frequency of T869C T allele, which supports a role for the TGF-beta1 gene C-509T and T869C polymorphisms in determining the risk/protection of RHD in Taiwan Chinese patients.

Natural history of moderate mitral valve stenosis.

BACKGROUND: With the introduction of surgery and percutaneous balloon valvuloplasty for relieving severe mitral stenosis the natural history of the disease has markedly altered. OBJECTIVES: To determine the natural history of the disease in patients with moderate mitral valve stenosis. METHODS: Demographic, clinical and echocardiographic data were evaluated in 36 patients with moderate mitral stenosis during a follow-up of 71 +/- 15 months. RESULTS: The 36 patients comprised 32 women and 4 men with a mean age of 43.7 +/- 12.2 years; 28 were Jewish and 8 were of Arab origin. During follow-up, there was a significant decrease in mitral valve area, with an increase in mean mitral valve gradient and score. Mean loss of mitral valve area was 0.04 +/- 0.11 cm 2/year. No correlation was found between disease progression and age, past mitral valve commissurotomy, baseline mean gradient or mitral valve score. Larger baseline mitral valve area (P = 0.007) and Arab origin (P = 0.03) had an independent correlation to loss of mitral valve area. Fifteen patients (42%) did not demonstrate any loss in mitral valve area during the follow-up period. CONCLUSIONS: The rate of mitral valve narrowing in patients with moderate mitral stenosis is variable and cannot be predicted by patient's age, past commissurotomy, valve score or gradient. Secondly, larger baseline mitral valve area and Arab origin showed an independent correlation to loss of mitral valve area; and finally, in many patients valve area did not change over a long observation period.