Abstract
Introduction: Mitral Annular Calcification (MAC) is present in 25-40% of people ≥ 60 years old and has associations with atrial fibrillation, stroke, endocarditis, mitral regurgitation, and mitral stenosis. MAC poses major challenges to surgical or transcatheter mitral valve interventions. Current echocardiographic methods for assessing MAC are limited. Goals: To assess transthoracic echocardiographic (TTE) approaches for quantifying MAC severity compared to a gold standard of MAC calcium score by gated computed tomography (CT). Methods: 75 patients undergoing evaluation for TAVR had TTE and CT in close proximity. MAC area and circumference were measured in parasternal long-axis (PLAX), parasternal short-axis (PSAX), and apical 2, 3, and 4-chamber views on TTE. Mitral valve gradients and left atrial volume were recorded. The curvilinear length of MAC in the PSAX view on TTE and cardiac CT were also measured. Associations between various TTE measures and MAC calcium score were assessed using linear regression. Results: Median age was 75.3, 50.4% female, 85.3% Caucasian. MAC area and circumference in PSAX on TTE showed moderate correlations (R 2 =0.32-0.37) with MAC calcium score. Curvilinear MAC length measures on SAX TTE and CT had improved correlation with MAC score (R 2 =0.41 & 0.78, Figure). Combined circumference of MAC from PLAX+PSAX had the strongest association (R 2 = 0.48). Interobserver variability on CT and TTE had coefficients of variation ranging 17-37%. Left atrial volume and mitral valve gradients had weak associations with MAC severity (R 2 =0.03-0.12). Tertiles of MAC calcium scores were 2650, 5150 and 7750. Conclusions: MAC length in the PSAX view showed the strongest association with MAC severity. Dedicated PSAX views of the mitral annulus may improve the ability to reproducibly grade MAC severity by echo.
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