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Risk of Cerebral Embolization with Caseous Calcification of the Mitral Annulus: Review Article

View Article: PubMed Central - PubMed

ABSTRACT

Background:: Caseous calcification of the mitral annulus (CCMA) is believed to have a benign prognosis. Several authors have recommended conservative management in asymptomatic patients. However, the prevalence of cerebrovascular events (CVE) in patients with CCMA has never been evaluated before. The aims of this study are to investigate whether patients with CCMA are at increased risk of cerebral embolization, and to determine whether elective surgical resection of CCMA should be considered to prevent a cardioembolic stroke.

Methods:: A comprehensive literature search was obtained from MEDLINE via PubMed.gov, ScienceDirect.com, and Google Scholar using the following search queries: caseous calcification of the mitral annulus, intracardiac pseudotumor, mitral annular calcification, and cardioembolic stroke.

Results:: From our initial search that yielded 1,502 articles, we identified a total of 130 patients with CCMA reported in 86 publications. Literature review revealed that the prevalence of CVE associated with CCMA is 19.2% (25 of 130) which is significantly higher than the prevalence of CVE reported with mitral annular calcification (MAC), 11.8% (214 of 1818) (range 4.8% to 24.1%) (P = 0.01796) (odds ratio = 1.78; 0.95 confidence interval = 1.1278 – 2.8239). Only four of 25 (16.0%) patients with CCMA who suffered a CVE had history of atrial fibrillation (AF).

Conclusion:: Based on our review, it would be reasonable to consider elective surgical resection of CCMA in asymptomatic patients who are good surgical candidates, because patients with CCMA may be at increased risk of embolic strokes, which are unrelated to AF.

No MeSH data available.


Related in: MedlinePlus

Transthoracic echocardiogram in long-axis view of patient 3, showing an obstructive mass in the left ventricular outflow tract, caused by a pseudotumor attached to the anterior mitral valve annulus, with echo-lucencies within the mass. AO = aorta; LA = left atrium; LV = left ventricle; LVOT = left ventricular outflow tract; MV = mitral valve; PST = pseudotumor.
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Figure 1: Transthoracic echocardiogram in long-axis view of patient 3, showing an obstructive mass in the left ventricular outflow tract, caused by a pseudotumor attached to the anterior mitral valve annulus, with echo-lucencies within the mass. AO = aorta; LA = left atrium; LV = left ventricle; LVOT = left ventricular outflow tract; MV = mitral valve; PST = pseudotumor.

Mentions: In addition to the literature search, we report 3 patients who were diagnosed to have CCMA intraoperatively. One patient was referred to surgery with a suspected diagnosis of left atrial myxoma; another patient with diagnosis of severe MS and heavy MAC; and another patient, who presented with TIA’s, was referred for resection of a subaortic mass that was attached to the anterior mitral annulus and was causing subtotal LV outflow tract obstruction (Fig. 1). On sectioning, the encapsulated mass contained a white toothpaste-like caseous material in all 3 patients.


Risk of Cerebral Embolization with Caseous Calcification of the Mitral Annulus: Review Article
Transthoracic echocardiogram in long-axis view of patient 3, showing an obstructive mass in the left ventricular outflow tract, caused by a pseudotumor attached to the anterior mitral valve annulus, with echo-lucencies within the mass. AO = aorta; LA = left atrium; LV = left ventricle; LVOT = left ventricular outflow tract; MV = mitral valve; PST = pseudotumor.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC5120388&req=5

Figure 1: Transthoracic echocardiogram in long-axis view of patient 3, showing an obstructive mass in the left ventricular outflow tract, caused by a pseudotumor attached to the anterior mitral valve annulus, with echo-lucencies within the mass. AO = aorta; LA = left atrium; LV = left ventricle; LVOT = left ventricular outflow tract; MV = mitral valve; PST = pseudotumor.
Mentions: In addition to the literature search, we report 3 patients who were diagnosed to have CCMA intraoperatively. One patient was referred to surgery with a suspected diagnosis of left atrial myxoma; another patient with diagnosis of severe MS and heavy MAC; and another patient, who presented with TIA’s, was referred for resection of a subaortic mass that was attached to the anterior mitral annulus and was causing subtotal LV outflow tract obstruction (Fig. 1). On sectioning, the encapsulated mass contained a white toothpaste-like caseous material in all 3 patients.

View Article: PubMed Central - PubMed

ABSTRACT

Background:: Caseous calcification of the mitral annulus (CCMA) is believed to have a benign prognosis. Several authors have recommended conservative management in asymptomatic patients. However, the prevalence of cerebrovascular events (CVE) in patients with CCMA has never been evaluated before. The aims of this study are to investigate whether patients with CCMA are at increased risk of cerebral embolization, and to determine whether elective surgical resection of CCMA should be considered to prevent a cardioembolic stroke.

Methods:: A comprehensive literature search was obtained from MEDLINE via PubMed.gov, ScienceDirect.com, and Google Scholar using the following search queries: caseous calcification of the mitral annulus, intracardiac pseudotumor, mitral annular calcification, and cardioembolic stroke.

Results:: From our initial search that yielded 1,502 articles, we identified a total of 130 patients with CCMA reported in 86 publications. Literature review revealed that the prevalence of CVE associated with CCMA is 19.2% (25 of 130) which is significantly higher than the prevalence of CVE reported with mitral annular calcification (MAC), 11.8% (214 of 1818) (range 4.8% to 24.1%) (P = 0.01796) (odds ratio = 1.78; 0.95 confidence interval = 1.1278 – 2.8239). Only four of 25 (16.0%) patients with CCMA who suffered a CVE had history of atrial fibrillation (AF).

Conclusion:: Based on our review, it would be reasonable to consider elective surgical resection of CCMA in asymptomatic patients who are good surgical candidates, because patients with CCMA may be at increased risk of embolic strokes, which are unrelated to AF.

No MeSH data available.


Related in: MedlinePlus