Spontaneous perirenal hemorrhage in a patient on an anticoagulant for stroke with severe aortic valve stenosis: Is concern for renal malignancy
0
Citation
7
Reference
10
Related Paper
Abstract:
Spontaneous perirenal hemorrhage is mainly due to renal malignancy.But its presence in a patient who are on anticoagulant make it challenging for the diagnosis.We report a case of 50-year-old man who presented with brain stroke and started on an anticoagulant.Post anticoagulant treatment he presented with flank fullness.On evaluation, he found to have right perirenal hematoma suspicious of renal malignancy and severely stenosed aortic valve.We did right nephrectomy and aortic valve replacement simultaneous and on histopathologically found to have papillary renal cell carcinoma.Keywords:
Stroke
BACKGROUND: Assessment of aortic stenosis (AS) severity is critical for treatment decisions but challenging in patients with severe AS (aortic valve area, AVA <1.0 cm2) and low gradients (mean AV gradient <40 mmHg). We sough to evaluate the incremental utility of 3D multidetector computed tomography (MDCT) over TTE for assessment of AS severity in patients with either depressed (classic low-flow, low-gradient, CLFLG, LVEF <50%) or preserved LV systolic function (paradoxical low-flow, low-gradient, PLFLG, LVEF ≥50%) is unknown. METHODS: Sixteen patients who underwent TTE, invasive hemodynamics with a right heart catheterization and dual lumen pigtail catheter, and MDCT studies within 30 days were prospectively studied (10 CLFLG and 6 PLFLG). Mean age was 76±10 years with 26% females. TTE parameters included LVEF, systolic LVOT diameter (LVOT-D) and conventional AV Doppler assessment. MDCT evaluated ratio of maximal to minimal LVOT-D (eccentricity index), mean systolic LVOT-D, and AVA by planimetry. Corrected AVA was calculated by substituting the MDCT-derived mean LVOT-D into continuity equation (MDCT-AVA). RESULTS: Figure 1 shows hemodynamics and imaging parameters measured. Despite good correlation between TTE-AVA and MDCT-AVA (r=0.85, p<0.0001), AVA was underestimated in 10/16 of patients by either TTE or invasive hemodynamics, irrespective of the baseline LVEF (p < 0.0001 for both). Dimensionless index also correlated better with MDCT-AVA (r=0.71, p=0.002) then with TTE-derived AVA (r=0.58, p=0.003) or by cath-derived AVA (r=0.47, p=0.02). CONCLUSION: In patients with severe AS and low-gradients, MDCT imaging revealed eccentric LVOT in most patients, resulting in underestimation of 2D TTE-AVA. Integration of 3D imaging dataset with either 3D-transesophageal echocardiography or MDCT may improve AS severity classification of these challenging patients. Larger cohort studies will be needed to ascertain the impact on treatment decisions.
Cite
Citations (0)
Cite
Citations (220)
The finding of aortic valve calcification is of clinical relevance. Thickening and calcification of the aortic valve ('aortic sclerosis') may progress over time to calcific aortic stenosis, and calcification of the aortic valve has prognostic importance even in the absence of valve obstruction. Aortic valve calcification may also have effects on the conduction system. There is progressive awareness of the need for an imaging technique that can accurately and reproducibly quantify calcification of native and prosthetic aortic valves. Through adaptation of techniques from electron beam computed tomography (CT) coronary calcium scoring, CT has been proposed as the appropriate imaging modality. Although originally described as a method of comparing the calcification of different aortic valve bioprostheses, the major role suggested for CT aortic valve calcium quantification is now in the field of preventive medicine. This has stemmed from the recognition that traditional vascular risk factors also have a role in the etiology of calcific aortic stenosis. Subsequently, the realization that pharmacological modification of lipid profiles may result in slowing of progression or even regression of aortic valve calcification has led to a need to quantify aortic valve calcification for follow up purposes. Echocardiography has been used to estimate aortic valve calcification in studies of the natural history of aortic stenosis, but it does not accurately quantify calcium. CT appears able to fulfil this requirement, though the technique is still relatively novel. This review examines the need for aortic valve calcium quantification and the evolution of imaging to the current status. Future directions and the promise of new helical CT technologies with respect to cardiac imaging are explored.
Cite
Citations (29)
Aims To determine whether low-flow/low-gradient (LF/LG) aortic stenosis affects survival after transcatheter aortic valve implantation (TAVI), we performed a meta-analysis of currently available studies. Methods MEDLINE and EMBASE were searched through January 2019 using PubMed and OVID. Observational studies comparing all-cause mortality after TAVI for patients with classical LF/LG (C/LF/LG) aortic stenosis versus normal-flow/high-gradient (NF/HG) aortic stenosis, paradoxical LF/LG (P/LF/LG) aortic stenosis versus NF/HG aortic stenosis, and (3) C/LF/LG aortic stenosis versus P/LF/LG aortic stenosis were included. Study-specific estimates, risk and hazard ratios of mortality, were combined in the random-effects model. Results Our search identified nine eligible studies including a total of 5512 TAVI patients. Pooled analysis demonstrated significantly higher early mortality in C/LF/LG aortic stenosis than NF/HG aortic stenosis (risk ratio, 1.72; P = 0.02) and no statistically significant difference in early mortality between P/LF/LG aortic stenosis and NF/HG aortic stenosis ( P = 0.67) and between C/LF/LG aortic stenosis and P/LF/LG aortic stenosis ( P = 0.51). Midterm mortality in C/LF/LG (risk ratio/hazard ratio, 1.73; P = 0.0003) and P/LF/LG aortic stenosis (risk ratio/hazard ratio, 1.48; P < 0.0001) was significantly higher than that in NF/HG aortic stenosis. There was no statistically significant difference in midterm mortality between C/LF/LG aortic stenosis and P/LF/LG aortic stenosis ( P = 0.63). Conclusion After TAVI, C/LF/LG aortic stenosis is associated with increased early mortality compared with NF/HG, and C/LF/LG and P/LF/LG aortic stenosis is associated with increased midterm mortality compared with NF/HG aortic stenosis despite no difference in early mortality between P/LF/LG aortic stenosis and NF/HG aortic stenosis. There is no difference in early and midterm mortality between C/LF/LG aortic stenosis and P/LF/LG aortic stenosis.
Cite
Citations (7)
Calcific aortic valve disease (CAVD), an active disease process ranging from mild thickening of the valve to severe calcification, is associated with high mortality, despite new therapeutic options such as transcatheter aortic valve replacement (TAVR). The complete pathways that start with valve calcification and lead to severe aortic stenosis remain only partly understood. By providing a close representation of the aortic valve cells in vivo, the assaying of T lymphocytes from stenotic valve tissue could be an efficient way to clarify their role in the development of calcification. After surgical excision, the fresh aortic valve sample is dissected in small pieces and the T lymphocytes are cultured, cloned then analyzed using fluorescence activated cell sorting (FACS). The staining procedure is simple and the stained tubes can also be fixed using 0.5% of paraformaldehyde and analyzed up to 15 days later. The results generated from the staining panel can be used to track changes in T cell concentrations over time in relation to intervention and could easily be further developed to assess activation states of specific T cell subtypes of interest. In this study, we show the isolation of T cells, performed on fresh calcified aortic valve samples and the steps of analyzing T cell clones using flow cytometry to further understand the role of adaptive immunity in CAVD pathophysiology.
Paraformaldehyde
Cite
Citations (2)
Objective: Short telomere length (TL) is associated with atherosclerosis development. Aortic valve stenosis, an age-related disease characterized by narrowing of the aortic opening, is mainly caused by aortic valve calcification. Development of aortic valve calcifications shares many similarities with atherogenesis. In this study, the relation between telomere length dynamics in valve tissue and the aortic valve calcification process will be determined. Methods: Aortic valves were obtained from 11 patients undergoing valve replacement surgery. Each valve cusp was macroscopically dissected into healthy, intermediate and calcified regions. DNA was extracted using the phenol/chloroform method and TL measured by Southern blot of the terminal restriction fragments. Results: TL from healthy and intermediate valve regions were similar and then merged into a non-calcified group. In all subjects, TL of calcified regions were shorter than TL in non-calcified regions. The gap between TL in non-calcified and calcified regions was 0.53kb (p<0.007). Conclusions: Calcified aortic valve regions have shorter telomere length than non-calcified. The directionality of the relation between telomere dynamics and aortic valve calcification will be elucidated in an in vitro study.
Klotho
Cite
Citations (0)
Current mouse models still have limitations in studying aortic valve stenosis (AVS). A suitable animal model bearing a close resemblance to the pathophysiological processes of humans needs to be developed. Here, we combined two risk factors to create a mouse model that mimics the pathological features of human AVS.We combined WI and hyperlipidemia in ApoE-/- mice to explore the synergistic effect on the stenosis of the aortic valve. Transthoracic echocardiography revealed progressively increased peak velocity with age in ApoE-/- mice to velocities above C57 mice when fed a high-fat diet after wire injury. Moreover, ApoE-/- mice demonstrated lower cusp separation and lower aortic valve area after 8 weeks vs. C57 mice. Gross morphology and MRI showed advanced thickening, sclerosis aortic valve, narrowing of the orifice area, and micro-CT showed obvious calcification in the aortic valves in the hyperlipidemia group after wire injury. Histopathology studies showed thickening and fibrosis of aortic valve leaflets in the hyperlipidemia group after wire injury. Notably, lipid deposition was observed in ApoE-/- mice 8 weeks after wire injury, accompanied by overexpressed apoB and apoA proteins. After wire injury, the hyperlipidemia group exhibited augmented inflammation, ROS production, and apoptosis in the leaflets. Moreover, the combination group exhibited advanced fibro-calcific aortic valves after wire injury.Overall, we present the synergistic effect of wire injury and hyperlipidemia on lipoproteins deposition in the development of AVS in ApoE-/- mice, this model bear close resemblance to human AVS pathology.
Hyperlipidemia
Apolipoprotein E
Cite
Citations (1)
Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Fondazione Gigi e Pupa Ferrari ONLUS Background Aortic stenosis (AS) is the most common valve disorder characterized by fibro-calcific remodeling of valve leaflets. Recent evidence indicated that there is a sex-related difference in AS development and progression. Fibrotic remodeling is peculiar of women's aortic valve, while men's aortic leaflets are more calcified than in women. Purpose To assess aortic valve fibrosis (AVF) in a severe AS cohort using non-invasive diagnostic tools and determine whether sex-specific pathological pathways and cell types are associated with severe AS. Methods We have included 28 men and 28 women matched for age with severe AS who underwent Doppler echocardiography and cardiac contrast-enhanced computed tomography (CT) before intervention. The calcium and fibrosis volumes were assessed and quantified using the ImageJ thresholding method, indexed calcium and fibrosis volume were calculated by dividing the volume by the aortic annular area. Differentially expressed genes and functional inferences between women and men's aortic valves were carried out on a publicly available microarray-based gene expression dataset (GSE102249). Cell types enrichment analysis in stenotic aortic valve tissues was used to reconstruct the sex-specific cellular composition of stenotic aortic valves. Results We confirmed that women had significantly lower aortic valve calcium content compared to men, while fibrotic tissue composition was significantly higher in women than men. We identified that the expression profile of human stenotic aortic valves is sex-dependent. Pro-fibrotic processes were prevalent in women, while pro-inflammatory ones, linked to the immune response system, were enhanced in men. Cell-type enrichment analysis showed that mesenchymal cells were over-represented in AS valves of women, whereas signatures for monocytes, macrophages, T and B cells were enriched men ones. Conclusions Our data provide the basis that the fibro-calcific process of the aortic valve is sex-specific, both at gene expression and cell type level. The quantification of aortic valve fibrosis by CT could make it possible to perform population-based studies and non-invasive assessment of novel therapies to reduce or halt sex-related calcific aortic valve stenosis (CAVS) progression, acting in an optimal window of opportunity early in the course of the disease.
Cite
Citations (0)
Abstract Background Recently, we established an experimental model of moderate aortic valve stenosis (AS) aiming to mimic human disease progression closely. Functional and structural MRI of a mouse model in experimental aortic valve stenosis has not been accomplished so far. Purpose Here, we aimed at developing comprehensive MRI approach for simultaneous assessment of changes in valvular, left ventricular and aortic morphology and function. Methods Male 12-week-old wildtype mice (C57Bl/6) were subjected to wire injury of the aortic valve to induce aortic valve stenosis. High resolution MRI at 9.4T was used to monitor subsequent functional and structural changes in the aortic valve, the ascending aorta, the left ventricle and aortic flow patterns. Results MRI permits accurate planimetry of the orifice and the thickness of the aortic valve, allows a reliable three-dimensional mapping of transvalvular aortic flow, simultaneously depicts aortic regurgitation in 3D fashion and permits assessment of left ventricular changes due to AS. In our model we observed a reduced valve orifice and an increase in valve thickness. Homogenous flow pattern under control converted to heterogenous and turbulent flow with progression of AS associated with increased aortic strain, aortic wall and left ventricular wall thickness. Conclusions In a murine model of aortic valve stenosis MRI is capable to reliably display a three-dimensional transvalvular aortic flow profile with concomitant quantification of structural and functional changes in aortic valve, left ventricle, and ascending aorta. This comprehensive functional imaging at high resolution and distinct reproducibility offers for the first time serial assessment of disease progression in an experimental model of aortic valve stenosis.
Ventricular pressure
Cite
Citations (1)
Calcific Aortic Valve Disease (CAVD) is a fibrocalcific disease. Lipoproteins and oxidized phospholipids play a substantial role in CAVD; the level of Lp(a) has been shown to accelerate the progression of valve calcification. Indeed, oxidized phospholipids carried by Lp(a) into the aortic valve stimulate endothelial dysfunction and promote inflammation. Inflammation and growth factors actively promote the synthesis of the extracellular matrix (ECM) and trigger an osteogenic program. The accumulation of ECM proteins promotes lipid adhesion to valve tissue, which could initiate the osteogenic program in interstitial valve cells. Statin treatment has been shown to have the ability to diminish the death rate in subjects with atherosclerotic impediments by decreasing the serum LDL cholesterol levels. However, the use of HMG-CoA inhibitors (statins) as cholesterol-lowering therapy did not significantly reduce the progression or the severity of aortic valve calcification. However, new clinical trials targeting Lp(a) or PCSK9 are showing promising results in reducing the severity of aortic stenosis. In this review, we discuss the implication of lipids in aortic valve calcification and the current findings on the effect of lipid-lowering therapy in aortic stenosis.
Fibrous cap
Endothelial Dysfunction
Cite
Citations (12)