Faculty Bibliography

OBJECTIVE: The inflammatory process of aortic stenosis involves the differentiation of aortic valve myofibroblasts into osteoblasts. Osteopontin, a proinflammatory glycoprotein, both stimulates differentiation of myofibroblasts and regulates the deposition of calcium by osteoblasts. Osteopontin levels are increased in patients with such conditions as end-stage renal disease, ectopic calcification, and autoimmune disease. We hypothesized that increased plasma osteopontin levels might be associated with the presence of aortic valve calcification and stenosis. METHODS: Venous blood from volunteers older than 65 years undergoing routine echocardiographic analysis or aortic valve surgery for aortic stenosis was collected. Plasma osteopontin levels were measured by means of enzyme-linked immunosorbent assay. The presence of aortic stenosis was defined as an aortic valve area of less than 2.0 cm(2). Aortic valve calcification was assessed by using a validated echocardiographic grading system (1, none; 2, mild; 3, moderate; 4, severe). Comparisons were performed with nonpaired t tests. RESULTS: Aortic stenosis was present in 23 patients (mean age, 78 years) and was absent in 7 patients (mean age, 72 years). Aortic valve calcification scores were 3.5 +/- 0.6 and 1.3 +/- 0.5 in patients with and without aortic stenosis, respectively (P < .001). Patients with no or mild aortic valve calcification had lower osteopontin levels compared with patients with moderate or severe aortic valve calcification (406.1 +/- 165.8 vs 629.5 +/- 227.5 ng/mL, P = .01). Similarly, patients with aortic stenosis had higher osteopontin levels compared with patients without aortic stenosis (652.2 +/- 218.7 vs 379.7 +/- 159.9 ng/mL, P < .01). CONCLUSION: Increased levels of plasma osteopontin are associated with the presence of aortic valve calcification and stenosis. These findings suggest that osteopontin might play a functional role in the pathogenesis of calcific aortic stenosis

Posterior mitral valve (MV) leaflet aneurysms are extremely rare complications of infective endocarditis (IE). When MV aneurysms occur, they usually involve the anterior leaflet. Real time three-dimensional transesophageal echocardiography (RT3D TEE) has been recently developed and provides views of unparalleled quality by optimizing visualization of spatial relationships. We present a rare case of a posterior MV leaflet aneurysm due to IE in a 64-year-old woman, best visualized by RT3D TEE

A 74-year-old woman presented with an acute cerebrovascular infarct involving multiple vascular territories, suggestive of an embolic event. The initial transesophageal images create the impression of an echogenic mass in the left atrial appendage. A small pericardial effusion was also seen surrounding the left atrial appendage. After further views were obtained, the echogenic mass appeared to be in this fluid-filled space rather than in the appendage itself. To confirm this finding, echo contrast (Definity) was administered. After contrast injection, the left atrial appendage was opacified, while the effusion around the appendage and the echodensity within this space were not opacified. Our case highlights the utility of contrast-enhanced echocardiography in clearly delineating the boundaries of the endocardium in cases, when a pericardial effusion surrounds the left atrial appendage

Thirty percent of acute pancreatitis occurs in older adults. Morbidity and mortality are increased in this population as compared with younger cohorts. Acute pancreatitis is more often caused by biliary obstruction and less often caused by alcohol in older patients. Elevations of serum amylase and lipase are nonspecific, occurring in a variety of nonpancreatic disorders, many of which have overlapping clinical signs and symptoms. The diagnosis may be more challenging in geriatric patients due to normal aging changes of pancreatic parenchyma and ducts, which may mimic findings in pancreatic inflammatory or neoplastic disease. Identification of adverse prognostic factors permits risk stratification leading to early contrast-enhanced computed tomography scan, prophylactic antibiotics, or transfer to an intensive care unit. To avoid misdiagnosis and improve outcomes, clinicians must be aware of the diverse spectrum of acute pancreatitis in older patients in ambulatory as well as long-term care settings

OBJECTIVES: The goal of this work was to explore the treatment and outcomes of patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) age > or =90 years. BACKGROUND: The elderly are often excluded from clinical trials of NSTE-ACS and are underrepresented in clinical registries. METHODS: We used data from the CRUSADE registry to study 5,557 patients with NSTE-ACS age > or =90 years and compared their baseline characteristics, treatment patterns, and in-hospital outcomes with a cohort age 75 to 89 years (n = 46,270). RESULTS: Although both groups had much in common, compared with the younger elderly, the older elderly were less likely to be diabetic, smokers, or obese. Among patients without contraindications, the older elderly were less likely to receive glycoprotein IIb/IIIa inhibitors and statins during the first 24 h and were less likely to undergo cardiac catheterization within 48 h. The older elderly were more likely to die (12.0% vs. 7.8%) and experienced more frequent adverse events (26.8% vs. 21.3%) during the hospitalization-differences that persisted after adjustment for baseline patient and hospital characteristics. Increasing adherence to guideline-recommended therapies was associated with both increased bleeding and a graded reduction in risk-adjusted in-hospital mortality across both age groups. CONCLUSIONS: In this large population of nonagenarians and centenarians with NSTE-ACS, increasing adherence to guideline-recommended therapies was associated with decreased mortality. These findings reinforce the importance of optimizing care patterns for even the oldest patients with NSTE-ACS, while examining novel approaches to reduce the risk of bleeding in this rapidly expanding patient population