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 Table of Contents  
Year : 2019  |  Volume : 8  |  Issue : 4  |  Page : 186-187

Self-Assessment Quiz

1Department of Respiratory Medicine, AJ Institute of Medical Sciences, Mangalore, India

Date of Web Publication6-Jan-2020

Correspondence Address:
Dr. Vishnu Sharma Moleyar
1Department of Respiratory Medicine, AJ Institute of Medical Sciences, Mangalore
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JCPC.JCPC_26_19

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How to cite this article:
Moleyar VS. Self-Assessment Quiz. J Clin Prev Cardiol 2019;8:186-7

How to cite this URL:
Moleyar VS. Self-Assessment Quiz. J Clin Prev Cardiol [serial online] 2019 [cited 2022 Nov 28];8:186-7. Available from: https://www.jcpconline.org/text.asp?2019/8/4/186/275163

Question 1: What is the most likely diagnosis from the figures? [Figure 1], [Figure 2], [Figure 3]
Figure 1: Chest X-ray posteroanterior view showing permanent cardiac pacemaker and mitral annular calcification

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Figure 2: Chest X-ray lateral view showing permanent cardiac pacemaker and mitral annular calcification

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Figure 3: Echocardiography image showing mitral annular calcification

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Answer: Chest X-ray shows permanent pacemaker with mitral annular calcification (MAC). Echocardiography image confirms MAC.

Mitral valve lies below the imaginary line passing from the right cardiophrenic angle to the inferior aspect of the left hilum in chest X-ray.[1] MAC is a degenerative process and is associated with cardiovascular diseases. MAC is associated with conduction defects, including atrioventricular block, bundle branch block, and intraventricular conduction delay. This is more so in patients with severe MAC.[2] MAC is also associated with symptomatic bradyarrhythmias which may require pacemaker implantation.[3] Bradyarrhythmia is due to infiltration of calcium into the conduction system.

Question 2: Which of the following is NOT a risk factor for development of MAC?

  1. Chronic renal failure
  2. Hypercholesterolemia
  3. Chronic liver disease
  4. Systemic hypertension
  5. Turbulent blood flow.

Answer: C. Chronic liver disease does not increase the risk of development of MAC.

MAC is accelerated by advanced age, turbulent blood flow across mitral valve (as in systemic hypertension, aortic stenosis, hypertrophic cardiomyopathy), hypercholesterolemia, diabetes mellitus, chronic renal failure with secondary hyperparathyroidism, conditions that increase annular stress (e.g. mitral valve prolapse), and genetic abnormalities of the fibrous skeleton[4] (Marfan's and Hurler syndromes). Any patient diagnosed to have MAC should be evaluated for the presence of above predisposing conditions.

Question 3: Which of the following complication is NOT a complication of MAC?

  1. Myocardial infarction
  2. Mitral regurgitation
  3. Mitral stenosis
  4. Arrhythmias
  5. Infective endocarditis.

Answer: A. Myocardial infarction, stroke, and atherosclerosis are associated with MAC but probably not directly caused by it.[5] All the other can occur as a complication of MAC. MAC is an inflammatory process which serves as a nidus for infective endocarditis.

Question 4: Which of the following is NOT a differential diagnosis for MAC?

  1. Atrial myxoma
  2. Benign cardiac tumors
  3. Thrombus
  4. Vegetations due to infective endocarditis
  5. Rupture of chordae tendineae.

Answer: E. On echocardiography, MAC is identified as an echo-dense band or mass in the atrioventricular groove. MAC is seen throughout systole and diastole and can be distinguished separately from the posterior mitral valve leaflet.[6] Hence, MAC can be easily distinguished form ruptured chordae tendineae by echocardiography.

Question 5. Which is a WRONG statement regarding MAC?

  1. MAC is most often an incidental finding
  2. MAC is associated with an increased risk of incident cardiovascular disease
  3. MAC should treated surgically
  4. MAC commonly affects posterior annulus
  5. Computed tomography is useful to estimate the extent and location of MAC.

Answer: C. Surgical treatment is not indicated for uncomplicated MAC.[7] There is no specific treatment for MAC. Underlying predisposing factors should be identified and treated. MAC may produce significant mitral stenosis and in that case mitral valve replacement (MVR) may be needed.[8] However, MVR in a patient with severe MAC is technically very challenging and is associated with high likelihood of unfavorable surgical outcomes. Hence, surgical correction is generally not recommended and most surgeons avoid it. Recently, percutaneous mitral valve implantation has been tried for treating MAC-related mitral valve dysfunction.[8] The results have been mixed and more work is currently underway.

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There are no conflicts of interest.

  References Top

Gross BH, Shirazi KK, Slater AD. Differentiation of aortic and mitral valve prostheses based on postoperative frontal chest radiographs. Radiology 1983;149:389-91.  Back to cited text no. 1
Mellino M, Salcedo EE, Lever HM, Vasudevan G, Kramer JR. Echographic-quantified severity of mitral anulus calcification: Prognostic correlation to related hemodynamic, valvular, rhythm, and conduction abnormalities. Am Heart J 1982;103:222-5.  Back to cited text no. 2
Nair CK, Sketch MH, Desai R, Mohiuddin SM, Runco V. High prevalence of symptomatic bradyarrhythmias due to atrioventricular node-fascicular and sinus node-atrial disease in patients with mitral anular calcification. Am Heart J 1982;103:226-9.  Back to cited text no. 3
Johnson RC, Leopold JA, Loscalzo J. Vascular calcification: Pathobiological mechanisms and clinical implications. Circ Res 2006;99:1044-59.  Back to cited text no. 4
Nair CK, Thomson W, Ryschon K, Cook C, Hee TT, Sketch MH. Long-term follow-up of patients with echocardiographically detected mitral anular calcium and comparison with age- and sex-matched control subjects. Am J Cardiol 1989;63:465-70.  Back to cited text no. 5
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;89:161-4.  Back to cited text no. 6
Abramowitz Y, Jilaihawi H, Chakravarty T, Mack MJ, Makkar RR. Mitral annulus calcification. J Am Coll Cardiol 2015;66:1934-41.  Back to cited text no. 7
Eleid MF, Foley TA, Said SM, Pislaru SV, Rihal CS. Severe mitral annular calcification: Multimodality imaging for therapeutic strategies and interventions. JACC Cardiovasc Imaging 2016;9:1318-37.  Back to cited text no. 8


  [Figure 1], [Figure 2], [Figure 3]


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