What is the Mitral Annulus?
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The mitral annulus is a ring like structure that separates the top and bottom chambers of the left side of the heart. The left side of the heart is the main pumping side. The upper chamber is the left atrium that collects blood returning from the lungs. The lower chamber of the left side of the heart is called the left ventricle, and is the main pumping chamber that pumps blood to the body. The mitral annulus sits in between the top and bottom chamber and houses the mitral valve. It can be thought of as a support ring for the mitral valve. The mitral valve is the valve that stops blood flowing backward from the left ventricle to the left atrium, and therefore allows blood to go forward in to the body where it is needed.
What is Mitral Annular Calcification?
Mitral annular calcification is a chronic process in which there is deposition of calcium in the mitral valve annulus. The mitral annulus is typically flexible. In mitral annular calcification it becomes less flexible and thicker. The posterior annulus is most commonly affected. In the majority of people the amount of calcification is mild and therefore usually of no significance. Calcification of the mitral annulus is increased in situations where there is increased stress on the annulus and valve.
Diagnosis
Mitral Annular Calcification may be associated with a murmur that is picked up on physical examination although often there will be no murmur. The diagnosis of mitral annular calcification is most commonly by echocardiography. As in the pictures above, there is increased calcium deposition seen in the mitral annulus. Mitral annular calcification when severe can be seen on chest x-ray. It can also be picked up on CT scan and MRI scan.
Commonality
Mitral annular calcification is more common in women. 9% of woman and 3% of men over the age of 60 are found to have it on echocardiography. It is also more common in those with mitral valve prolapse. Mitral annular calcification is very common in those with chronic kidney disease, and is found in 40% of those undergoing echocardiography.
Risk Factors
Factors that increase stress on the mitral valve and its surrounding structures increase the chance of mitral valve calcification. The following conditions are associated with development of mitral annular calcification.
- Female sex
- Older Age
- Hypertension
- Mitral Valve Prolapse
- Aortic Stenosis
- Hypertrophic Cardiomyopathy
- Chronic Kidney Disease
- Atherosclerosis
Complications
Several studies have looked at the association of mitral annular calcification and the development of cardiac and other events. There is increased risk of heart attacks, stroke and death from cardiovascular causes. There is also an increased risk of development of atrial fibrillation with RVR, an irregular heart rhythm. The risk is probably explained by the fact that patients with mitral annular calcification have risk factors for cardiovascular disease. The presence of the calcium itself is unlikely dangerous.
The presence of mitral annular calcium makes it harder for surgeons to repair the mitral valve, as surgery is technically more challenging. The calcium in the annulus can make the flexible valve more rigid and predispose to a leaky valve, however that is usually not significant. Mitral annular calcification is rarely associated with obstruction to blood flow and therefore typically will not have symptoms.
Caseous Calcification of the Mitral Annulus
Caseous calcification of the mitral annulus is a rare type of mitral annular calcification where there is extensive calcification and infiltration of the annulus accompanied by a liquid center, a process known as liquefactive necrosis. As can be seen in the picture, this has a remarkable appearance. It is usually benign, however it is important it is recognized, as it can be mistaken for tumor or other more dangerous complications that can lead to unnecessary interventions such as operations. Sometimes it resolves spontaneously.
Treatment of Mitral Annular Calcification
Mitral annular calcification is usually of no clinical significance and no specific treatment such as MitraClip is required. Those with mitral annular calcification are at increased risk of cardiac events, although this is still relatively small, likely due to the presence of traditional cardiac risk factors. Therefore it is reasonable to advise those with mitral annular calcification to pay attention to blood pressure, cholesterol, lifestyle, smoking, diabetes and other common risk factors. This will serve to reduce overall cardiac risk.
Comments are purely for informational purposes and are not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Disclaimer
Very helpful.
Thank You
I read the report of a cat scan and mentioned I had this. I am Diabetic under control. my last A1C was 6. I guess my one concern is As I sit quietly I can feel a click. It is not constant only as I am still and not really often. Have been on warfarin for several years due to a pulmonary embolus no reason found. I see my PCP every 4-6 mths. I know I will be discussing this with him son. For now I am waiting to see if there is Ca in my lungs. Recently diagnosed nodules found.
for now any noncommittal advice would be appreciated.
I wouldn’t worry about the mitral annular calcification for now. At some point an echocardiogram would be advised.
Thank you for responding. The cancer was ruled out. Thank God! Do you recommend anything further for now?
My brother in law passed away 5 months ago at the age of 31 from mitral valve prolapse with severe calcification of the annular ring. It was a shock to everyone because he always had a good BP and HR and never have chest pains. The only medical problem he had was severe stomach pains on and off for the past few years. The doctors could never figure it out and passed it off as pancreatitis. The last time he went to the ED, 2 years ago, a doctor said he had dangerously low vitamin D (although the drank milk all the time and was outside most of the day), but everything else seemed to be within normal limits. He did smoke cigarettes for about 12 years but had recently stopped. I was wondering if you had any insight on this? We were told his condition was hereditary and that’s why it was so advanced at such a young age.
I forgot to mention it was sudden cardiac death.
What was the stated cause of death, the valve disease in this setting is very unlikely to have contributed.
The stated cause of death said “mitral valve prolapse with severe calcification of the annular ring”, which caused him to go into sudden cardiac arrest. All of his other organs looked good according to the doctor who did his autopsy and she said she couldn’t even tell he was a smoker because his lungs looked good.
My echocardiography says mild posterior mitral annular calcification with unrestricted valve opening
What is this?
It means there is some calcium in the valve as can be seen with age-ing or other processed, but it is not affecting valve function.
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Disclaimer: The comment response is opinion and in no way affiliated with my employer. It is a vague response that is not to be used as direct medical advice and in no way should replace the opinion of a medical provider.
Hello sir I have rheumatic heart decease from last 20 yes I am 37 year old right now without operation I have AR grade II MR grade I & This week when I did 2D echo first time for tricuspid valve showing trivial TR . I have concered about it. Pulmonary valve is normal For last 20 years I have done 16 2D echoes but except this for every checking there was nil regurgitation for tricuspid. Positive thing is the all dimensions are same as before LVEF is 62% I don’t have any problems for doing daily activities. Dr only concerned about my heart beat & found sound .very high gradients due to tachycardia. No pulmonary hypertension. He prescribed me 1 tablet Ivabrid 5 half half daily. I am fine but I am concerned. I took nuril 2.5 2 tab daily & penicillin 12 lakhs monthly for last 20 years please give me suggestion
The valvular heart disease appears to be relatively mild in this case and if you have no symptoms then no specific therapy would be advised.
I missed one thing that mitral valve is thincked & heavily calcific & difficult to doctor to assess the severity of the stenosis due to merging of theAR & MS jets & due heavy calcification. Please reply sir. Is it time of surgery
I’ve had 2 stents, D.C.’s with A-fib, and now a CT this week shows calcification of the mitral annulus. I’m diabetic also with many health issues. My PCP has increased my beta blocker to help with the afib. How concerned should I be?
With regard to the mitral annular calcification i would suggest obtaining an echocardiogram to evaluate the structure and function of the mitral valve. If it is an isolated finding that does not affect the function of the valve you don’t have much cause for concern.
Hi. Is dense MAC with mild to moderate mitral regurgitation something to be worried about?
The valve is of course not normal but the MAC and moderate MR in isolation can often be well tolerated and not a large cause for concern. Surveillance would typically be recommended. If symptoms were to develop then further testing may be required. I would have to see the images to comment accurately.
I missed one thing that mitral valve is thincked & heavily calcific & difficult to doctor to assess the severity of the stenosis due to merging of theAR & MS jets & due heavy calcification. Please reply sir. Is it time of surgery
If i were seeing a similar case, i would do a TEE as the next step with 3D to characterize the valve more accurately.
I appreciate this article very much. I had a mitral valve repair (open heart) that couldn’t be completely done in August 2015 due to “giant bar of calcium posteriorly that precluded placing the valve sutures including the ring sutures.” I had MVP for decades, and severe regurgitation caused me to see the surgeon. After doing the partial repair, the post-op echo showed minor regurgitation. I had none of the palpitations that had plagued me for years for 14 glorious months but they started again. Heart rate goes to 160-170 for 90 minutes and finally settles down to 85 or so. Echo 17 months post-op shows SEVERE REGURGITATION again. Back to square one. Pre- and post-op diagnoses from operative report: “Mitral Annular Calcification, Severe Mitral Annular Calcification, Posterior Leaflet Prolapse; Paroxysmal Atrial Fibrillation.” Seeing surgeon in May for stress echo and consultation. He said maybe not surgery. I’m thin, eat super healthy, good BP, never smoked, no diabetes, 1 drink a month, a few cups of coffee a month. Why do I have these calcifications? Anything I should do? Are the palpitations related to the regurgitation? I get an “attack” about once a month.
Given the severe calcification it is likely that the next operation you have would be a mitral valve replacement and not a repair, particularly if a repair fails. Mitral valve repair is an art form and a lot depends on the ability of the surgeon. If you have truly severe regurgitation and are symptomatic or show other signs of strain, surgery may be advised. The palpitations are likely related to the leaky valve. https://myheart.net/articles/mitral-valve-repair-surgery-what-you-need-to-know/ https://myheart.net/articles/mitral-valve-replacement-surgery/ https://myheart.net/articles/mitral-regurgitation/
respected doctor, my 47 years old mother’s echocardiography result came and it said mitral valve is calcified, but other three valves are normal. she is obese too. should i consider valve replacement surgery? a suggestion will be appreciated.
Respected doctor, my 47 years old mother is diagnosed with rheumatic heart disease with severe mitral stenosis and mild mitral recurgitation. The mitral valve is calcified. Also there is mild recurgitation in tricuspid valve. What would be the advised steps to treat this? She is obese and does have hyperthyroid. Also she has been asthamatic for about 16 years. A suggestion would be appreciated. Thank you.
She has severe mitral stenosis and will likely require treatment. If the disease is symptomatic the question is, whether she is a candidate for balloon mitral valvuloplasty, or if the calcification means that she will require surgery instead.
Respected doctor, How will i know if she needs valvuloplasty or valve replacement surgery? thanks for replying.
I’m a 34 year old female today I went to the e.r for sever back pain. I was convinced it was my kidneys, after ordering a CT Scan the Dr said my kidneys were fine but the seen 7mm calcification on left atrium. My bP was 140/102 I still have no answers on the sever back pain but now extremely worried about my heart. In suppose to follow up with my primary Dr. Next for an Echo. What could of caused this. Im to young to have heart problems
I would start by clarifying things and seeing what the echo shows before you worry. If the TTE isnt enough an echo known as a TEE may be required.
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Tests I have had, and Angiogram, say my Mitral Valve is calcified, and my heart would Explode
would valve replacement be tried. Am wondering if the new TAVI valve replacement could be
considered for my cause? I am on Oxygen 24/7 as I have no air capacity to do much, without stress! My B/P is fairly normal, I have a highstress # like 83, am 74 years old. Using feurosimide , but no heart medications as of yet! What do you think?
There are many options available even for heavily calcified valves, however i would need to know a lot more about your situation and see the images to comment.
Ridiculonodular opacity middle lobe & mitral valve calcification. Could they be related?
very good information. Thank you.
is mitral and aortic annular calcification progressive? Are there risks involved during surgery with the presence of calcifications?
Which surgery are you referring to?
In general it is felt to be a chronic, somewhat progressive process.
Thank you for the article, it explains the calcification very well. I’m told I have significant mitral regurgitation and I was hoping to have the valve repaired, but have now been told that due to calcification it will probably have to be replaced. I’ve no real symptoms of valve trouble, a little short of breath occasionally but nothing else, but they tell me it’s best to have the operation now while I’m still relatively young and my general health is good.
In many instances calcification does not preclude valve repair, make sure you are seeing an expert reference mitral surgeon.
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Thank you for the article, helped me to understand my condition.
I am 73 suffering from high blood pressure and mild type 2 diabetes. I was recently diagnoised to have very high calcification. I have sofar never been diagonised to have any cardiac disorder. I am now advised to go through Cardio Cath and Echo. I need to know, is there a high probability of me having a cardiac arrest at any time.
Assalamualikum wrwb
My mom 51 years old got 2D echocardiogram and detected
Mitral valve: MAC +
Doctors told normal ..but asked to see the doctor if symptoms persists.
How can we leave it and wait for symptoms.
We are very worried.plz suggest what to do now
If the dr is not worried and there is no tightening or leak of the valve then there is likely no concern.
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Dr. Ahmed
My wife just turned 77. She has a severly calcified mitral valve that her Dr. says needs
replacement. He will not do the surgery because she is too high a risk due to past
problems having major difficulty coming outof antithesia. Surely this issue has came
up in the past. Can’t a lower level be used?
What would you reccomend?
Please excuse the spelling.
In our center, if the patient is high risk for surgery we use different methods such as transcatheter methods that can successfully treat even calcified valves.
https://myheart.net/articles/tmvr-transcatheter-mitral-valve-replacement/
I have been diagnosed with Bicuspid Aortic Valve and mild to moderate Aortic Insufficiency and mild Aortic Stenosis. Age 54.
I have been monitoring progression with echocardiograms every si months. It has been stable.
But in the last echo, there was a finding of moderate Mitral Valve regurgitation and Mitral Annular calcification. Previously, the Mitral Valve was normal.
I don’t know if Mitral Calcification it is related to kidney. My kidney had been normal last year but latest blood report kidney function r has dropped below normal. EGFR=49. Normal=60. Creatinine=1.76. Normal=1.33.
Symptoms: My cardiologist said my November 2017 Treadmill was okay. I had reached the target Heart Rate. I am normal weight but have been feeling tired on exertion but Dr says that is likely caused by aging and fitness rather than valve issues.
Will exxercising and improving my cardiovasculaar fitness improve the symptoms of Aortic and Mitral regurgitation?
Images:
https://drive.google.com/drive/folders/14YnG28n-i1b6qkHQcHDsv0of21iBcGRl?usp=sharing
When you say you get tired do you get overwhelming tired where if you had the opportunity you would fall asleep ? whereas usually you felt just minor fatigue?
Chances are if your lower body (upper thighs and lower legs) feel heavy your heart is working overtime and you should be considered for mitral valve replacement/repair.
You know your body best. Don’t just go with what the doctor feels. Get a second opinion.
My opinion…good luck with that.
Thank you very much.
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I had tricuspid valve repair and mild mitral leak for years. Now I have mild mitral valve annular calcification. My tricuspid repair is now at a moderate leak. My repair was done 14 years ago. My first question is, do they really have to wait for my leak to be severe to replace my valve? my other concern is my body seems to like to grow extra stuff like calcium deposits and scar tissue. I am currently going through a situation with my shoulder having a 3.2cm calcium deposit and a small one right beside that. My second question is should I be concerned about this calcification in my heart
I forgot to ask if you could please Email me your answer. I also have heart palpitations that started like 2 years ago. [email protected]
Dr. I have had numerous chronic health issues, worsening since age 17yrs. I now an a just turned 50 yr old woman who 13months ago had a major open heart,(using the heart lung bypass due to inability to do the Davinci robotic, full sternectomy) to repair mitral valve, Goretex neo-cords x 2 sets to P2,#33 (Medtronic) Duran AnCore annuloplasty Band implanted, left atrial appendage exclusion with #40 Atricure clip. I did have complications that kept me in hospital for close to 3wks.I came from N.C to the Cleveland hospital, where I knew they had a great reputation for what needed to be done. But now with my EDS,& other disorders causing more issues, for I do have dysautanomia (umbrella term for the many other issues, most rare, so far at least 14 documented diagnoses,) my issue is now: my Heart rate is higher than ever, staying even at rest between 110-150. BP averages 130/100- 180/110 when in past it would from my POTS go back and forth between very high to very low. Worsening Pulmonary Hypertension and pulmonary fibrosis, I could go on, but my new concern is , why do I now have calcification on the repaired MV.? this discovered after a contrast CT for abdomen, which was done as emergency 2 wks ago,from chronic GI issues, that have begun again. Do I need to worry about the Valves & go back for a follow up to Cleveland or is this par for the course and I need to just live to my best ability til ???. For I do know that time isn’t my best friend. But if there is something that can prolong and help I want to,just dont want to keep chasing for hope that only is a short time til the inevitable. And yes, I was a healthy, thin build woman, because of my health,I have always took extra care, eating healthy, exercising ( til now cannot) so I am doing my part. But with pain, and deterioration, I am at my wits end, any advise on how normal it is / or do I need to do anything to help myself in regards to the valves ,before I go across country again, would be most helpful and appropriated. Thank you.
Sincerely, TF
Its unlikely the annular calcification is new, rather it was likely there prior to the operations. The symptoms are likely unrelated to the annular calcium.
Thank you, the preoperative Echocardiogram said no seen calcification on any valves, could the fact I have EDS’ or layman’s term. Connective tissue disorder, I did years before have a LINQ put in then after only 3months removed, it had migrated to bottom of breast& no longer worked. I’ve since questioning you, have had more issues arise.. had bloodwork come back at it’s worse, & had upper Endoscopy/lower colonoscopy,& unexpectedly had entire esophagus stretched twice with Savary Dilator to get to 16mm. They also saw need for 4 biopsies of middle &lower 3rd of esophagus, spoke of possible eosinophilic esophagus? But history in family of cancer of esophagus,lung ect.. I now am on disability & told my Cardi.& Surgeon Ohio state Dr.(I’m in NC) is not covered, but have had no Drs.in NC even agree to see me for this issue, saying ,”I’m to high risk& I need to see my Drs.who took care of me originally,& did the surgery. I had BCBSNC then, not Medicaid, I do not know what or how to get help, meanwhile..I hurt, cannot breath comfortably, am homebound more each day, Hypertension worse, tachycardia & Afib. Any suggestions are acceptable, it’s hard even more for they do not deny health deteriorating, just to help me attempt to have a better quality of life, better than nothing, discouraged & disgusted at the fact that who pays,Medicaid or private insurance takes precedence over life. I’m only 50, I have beautiful grandbabies I want to live to see, longer preferred, but though a awesome group “Angels of Mercy”will fly me free (as they did in past to Ohio,every time,God bless them) I cant afford self pay Dr visit, newly separated,I live on the lowest poverty level I never thought even possible.Ready to just wait and if death is my only option, I’ve tried, even attempted medical trials,to no avail. Whether I had calcification before or after, I’m quickly worsening daily, so without care for heart. Again, any suggestions are welcomed.Thank you for taking time to read.Sincerely
T.Filer”
I am 71 yo female, symptom free. I have dyslipidemia: total chol.210-240, LDL 130-160. HDL around 60. Likely genetic, I’m not overweight and have no DM. On recent card.echo mild calcification was found on posterior mitral leaflet, wo significant regurge.Would you recommend cholesterol lowering drug, like Crestor, since high cholesterol maybe associated w valve calcification?
Although theoretically that would make sense to some degree, its not known whether cholesterol meds prevent rate of annular calcification.
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Disclaimer: The comment response is opinion and in no way affiliated with my employer. It is a vague response that is not to be used as direct medical advice and in no way should replace the opinion of a medical provider.
Dear Dr Ahmed,
My father is 82 yrs old, had a TAVR procedure done 7-18 and at that time was aware that he had a leaky Mitral valve. The TAVR procedure was done in Missoula MT and was very successful. We have been watching his health and he is now experiencing a lot of shortness of breath, very low energy, no strength in legs and we just had an Echocardiogram done that showed his Mitral valve has been deteriorating and the Echo results revealed a rather large calcification leading to the surgeons having a concern that if a clip is put on the valve it may cause the valve to be way to tight and cause more problem with the leakage. Our surgeon also mentioned challenges with a complete Mitral valve replacement cause of the challenges with stitching the new valve to an overly calcified area, as well as my fathers current health conditions. My question……is there anything else that can be done? We are waiting to hear tomorrow if the surgeons team believe they can do the clip procedure without causing overdue tightness of the valve. Thank you for taking to reply….Mike
There are a few options (not available in most centers). These include valve in MAC, TMVR replacement, or a hybrid approach. These should only be entertained in the most experienced hands but in the correct patients may be of great use.
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Disclaimer: The comment response is opinion and in no way affiliated with my employer. It is a vague response that is not to be used as direct medical advice and in no way should replace the opinion of a medical provider.
This is regarding my father Mr Surinder Kumar who is 76 years old and has been diagnosed with severe MS/MR. He was advised mitral valve replacement surgery but after admission, it was discovered that he suffers from extensive MAC and therefore the surgery would be high risk. Now we have been advised to go for transcatheter mitral valve replacement, which as per our understanding is a new technique.
We want to seek your opinion in this case and would be grateful if you can spare some time and advise us as per the reports below.
Here’s the link to Echo, TEE images https://drive.google.com/open?id=1EmiT3fgn2ALwNiWfDauCtVAMT4W5UO8z
Angiography images: https://drive.google.com/open?id=16OmRhvYRzIvTOEi9nk2oynvjLlI1m_ug
CT Chest plain https://drive.google.com/open?id=1YavFmfx6HkdwxCzFfjOqQcE5H9nfmgWk
CT Chest Contrast https://drive.google.com/open?id=1jyCeI_5iCkveem5oNiwk3U3g9fTO2IQg
The images show severe MS and moderate MR, severe mixed mitral valve disease. If severely symptomatic and felt to have a good prognosis then TMVR in MAC can be considered. We have done these and they can have good results, sometimes a hybrid surgical/catheter approach is preferred. This is a high risk procedure and should only be done in a place experience with this and with good results.
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Disclaimer: The comment response is opinion and in no way affiliated with my employer. It is a vague response that is not to be used as direct medical advice and in no way should replace the opinion of a medical provider.
I am a 59 year old women and found out that I have Mitral annular and aortic root calcifications. Also, evidence of calcific atherosclerosis in the following arteries; LAD: 152, Left Circumflex: 24.3, RCA: 35.3 The first echo showed moderate aortic stenosis.
I have been experiencing chest tightness and off and on heart palpitations. Fatigue. I am very sensitive to salt and caffeine, as well as many medications. The salt will make my BP spike if I get to much salt. I watch what I eat to help keep my BP normal. Most of the time it runs 117 to 130/ 65-81. Then if to much salt it will spike to 178-180/ 90-95 and stay there for about 15.The dr wnts me to take statins but I have very bad reactions to all that I have tried. The statin causes dizziness, nausea, joint pain or more fatigue. I am also taking 1 aspirin a day.
What my question is; I am worried since I can not take the statin which is supposed to help decrease the risk. What are my risks and with my symptoms of having the stroke or heart attack sooner rather than later. Would surgery be something I should be considering now. I do not want to wait till there is too much calcification and it can not be fixed.
his is regarding my father who is 76 years old and has been diagnosed with severe MS/MR. He was advised mitral valve replacement surgery but after admission, it was discovered that he suffers from extensive MAC and therefore the surgery would be high risk. Now we have been advised to consider transcatheter mitral valve replacement, which as per our understanding is a new technique.
We want to seek your opinion in this case, We are willing to officially consult you so you can look at the scans and reports and advise if surgery is an option and if so, which type should we go for- open heart, minimally invasive or transluminal. Many thanks.
Where is he based?
Do you have details of the echo report?
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Disclaimer: The comment response is opinion and in no way affiliated with my employer. It is a vague response that is not to be used as direct medical advice and in no way should replace the opinion of a medical provider.
I am 31 years old, female
my 2 d echo result is
Grade 1 diastolic dysfunction
Mitral annular calcification with mild MR
What should i do doc…
Thank you
What will be the first heart sound intensity in mitral annular or valvular calcification in elderly female patients without any mitral stenosis
Hi Dr Ahmed. I’m a 61 yr old female with Lupus, APS, heart disease (score 801) and I have a mechanical mitral valve with a severely calcified annulus. I take warfarin, prednisone and plaquinal daily. I have normal cholesterol, trygliceryides, BP, oxygen saturation (99-100) heart rate @ 60-62 BPM. Is my situation fixable and is there an operation to fix the annulus being that it is heavily calcified?
Thank you!
In general, the calcified annulus wouldn’t need fixing if the mechanical valve is working well.
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Disclaimer: The comment response is opinion and in no way affiliated with my employer. It is a vague response that is not to be used as direct medical advice and in no way should replace the opinion of a medical provider.
I am 62 Yo and just had my 2D echo 2 days ago.
2D Echo Conclusion:
1. Grade 1 diastolic Dysfunction
2. Mitral Annular Calcification with mild mitral regurgitation
Questions: Any immediate precautions and treatment for these two findings?
Thank you.
It depends on the presence of associated regurgitation and stenosis. The presence of cardiac risk factors should be identified and treated. The annular calcification alone without significant other associated issues is typically watched over time and not specifically treated. Did you discuss these things with the ordering Dr?
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Disclaimer: The comment response is opinion and in no way affiliated with my employer. It is a vague response that is not to be used as direct medical advice and in no way should replace the opinion of a medical provider.