Feasibility and Outcomes of Mitral Transcatheter Edge-To-Edge Repair in Patients With Variable Degrees of Mitral Annular Calcification.

Mitral annular calcification (MAC) has been an exclusion for many of the earlier pivotal trials that were instrumental in gaining device approval and indications for mitral transcatheter edge-to-edge repair (M-TEER). To evaluate the impact of MAC on the procedural durability and success of newer generation MitraClip® systems (G3 and G4 systems). Data were collected from Northwell TEER registry. Patients that underwent M-TEER with third or fourth generation MitraClip device were included. Patients were divided into -MAC (none-mild) and +MAC (moderate-severe) groups. Procedural success was defined as ≤ grade 2 + mitral regurgitation (MR) postprocedure, and durability was defined as ≤ grade 2 + MR retention at 1 month and 1 year. Univariate analysis compared outcomes between groups. Of 260 M-TEER patients, 160 were -MAC and 100 were +MAC. Procedural success was comparable; however, there were three patients who required conversion to cardiac surgery during the index hospitalization in the +MAC group versus none in the -MAC group (though this was not statistically significant). At 1-month follow-up, there were no significant differences in MR severity. At 1-year follow-up, +MAC had higher moderate-severe MR (22.1% vs. 7.5%; p = 0.002) and higher mean transmitral gradients (5.3 vs. 4.0 mmHg; p = 0.001) with no differences in mortality, New York Heart Association functional class or ejection fraction. In selective patients with high burden of MAC, contemporary M-TEER is safe, and procedural success is similar to patients with none-mild MAC. However, a loss of procedural durability was seen in +MAC group at 1-year follow-up. Further studies with longer follow-ups are required to assess newer mTEER devices and their potential clinical implications in patients with a high burden of MAC.

Mitral annular calcification (MAC) negatively influences outcomes in surgical mitral valve (MV) repair for mitral regurgitation (MR). However, there are no data on whether MAC impacts on outcomes of MitraClip percutaneous MV edge-to-edge repair. This study sought to investigate whether the presence of MAC impacts on the procedural success and durability of percutaneous transcatheter repair of MR using the MitraClip. One hundred and seventy-three patients undergoing MitraClip repair for significant MR were studied. Patients with moderate-or-severe MAC (n=28) were compared to those with no-or-mild MAC. Post-procedural MR severity was not different (p=0.642) and MR reduction to moderate-or-less was equally high in patients with moderate-or-severe MAC (100%) and those without (96.7%), p=1.000. At one year, MR severity was not different (p=0.831), and there was no difference in the repair durability when comparing patients with moderate-or-severe MAC (93.8%) to those without (90.6%), p=1.000. All patients with moderate-or-severe MAC assessed at one year were in NYHA functional Class I-II and had haemodynamic improvements with a decrease in pulmonary artery systolic pressure (-6.5±13.1 mmHg), p=0.021, and end-diastolic left ventricular internal diameter (-3.9±6.5 mm), p=0.034, not different to those achieved by patients without MAC (both p>0.100). Moderate-or-severe MAC scored by echocardiography and confirmed on fluoroscopy was not associated with decreased procedural success or durability of repair. Patients with moderate-or-severe MAC had improvements in clinical symptoms and haemodynamics, as well as decreased left ventricular dimensions.

Outcomes of mitral transcatheter edge-to-edge repair in patients with mitral annular calcification: A meta-analysis

Current and evolving strategies in the management of severe mitral annular calcification

Limited data exist regarding the impact of mitral annular calcification (MAC) on outcomes of transcatheter edge-to-edge repair for mitral regurgitation (MR). We retrospectively analyzed 968 individuals (median age, 79 [interquartile range, 70-86] years; 60.0% males; 51.8% with functional MR) who underwent an isolated, first-time intervention. Stratified by MAC extent per baseline transthoracic echocardiogram, the cohort was assessed for residual MR, functional status, all-cause mortality, heart failure hospitalizations, and mitral reinterventions post-procedure. Patients with above-mild MAC (n=101; 10.4%) were older and more likely to be female, exhibited a greater burden of comorbidities, and presented more often with severe, primary MR. Procedural aspects and technical success rate were unaffected by MAC magnitude, as was the significant improvement from baseline in MR severity and functional status along the first postprocedural year. However, the persistence of above-moderate MR or functional classes III and IV at 1 year and the cumulative incidence of reinterventions at 2 years were overall more pronounced within the above-mild MAC group (significant MR or functional impairment, 44.7% versus 29.9%, P=0.060; reinterventions, 11.9% versus 6.2%, P=0.033; log-rank P=0.035). No link was demonstrated between MAC degree and the cumulative incidence or risk of mortality and mortality or heart failure hospitalizations. Differences in outcomes frequencies were mostly confined to the primary MR subgroup, in which patients with above-mild MAC also experienced earlier, more frequent 2-year heart failure hospitalizations (20.8% versus 9.6%; P=0.016; log-rank P=0.020). Mitral transcatheter edge-to-edge repair in patients with and without above-mild MAC is equally feasible and safe; however, its postprocedural course is less favorable among those with primary MR.

Background: Mitral annular calcification (MAC) is a chronic inflammatory condition that is associated with future cardiovascular events. There is limited data that explores how MAC impacts outcomes in patients with pre-existing mitral regurgitation (MR). Methods: This is a retrospective analysis using the TriNetX US Collaborative Network database. A database of hospitalized patients ≥50 years was queried using ICD-10 and TriNetX curated codes. We identified those given a discharge diagnosis of MR between 2020-2023, excluding patients with rheumatic mitral valve disease or ESRD. We then stratified by presence/absence of a new diagnosis of MAC (occurring after MR diagnosis). Cohorts were balanced for socio-demographics, body mass index, and common comorbidities including hypertension, hyperlipidemia, diabetes, and tobacco use, with a standard difference of <0.1 considered to indicate adequate balancing. Hazard ratios were calculated for outcomes, with a P<0.05 considered significant. Results: Our query yielded 11,462 patients in the MAC group and 450,474 patients in the no MAC group. Following propensity matching, each group had 11,462 patients. All targeted variables were adequately balanced. Average age was similar in both the MAC and no MAC groups (76 years vs 75.8 years). The populations were majority white (80.3% vs 81.2%) and female (56.8% vs 57.0%). BMI was also similar (29.2 vs 28.7). Among patients with pre-existing MR, subsequently diagnosed MAC was associated with increased 1-year risk of hospitalization (HR 1.22, 95%CI 1.180-1.262, p<0.0001), ICU admission (HR 1.38, 95%CI 1.250-1.524, p<0.0001), ischemic heart disease (HR 1.446, 95%CI 1.289-1.622, p<0.0001), new onset HFpEF (HR 1.286, 95%CI 1.160-1.425, p<0.0001), cerebrovascular disease (HR 1.341, 95%CI 1.190-1.512, p<0.0001), prosthetic valve replacement (HR 2.126, 95%CI 1.786-2.530, p<0.0001), and mitral stenosis (HR 3.16, 95%CI 2.490-5.234, p<0.0001). There was not a significant difference between groups for HFrEF (HR 0.955, p=0.4377), cardiogenic shock (HR 1.188, p=0.1098), or cardiac arrest (HR 1.155, p=0.1979). Conclusions: In patients with previously diagnosed MR, a subsequent diagnosis of MAC was associated with increased 1-year risk of hospitalization, new onset ischemic heart disease or HFpEF, and a variety of other adverse cardiovascular outcomes.

Background: Mitral annular calcification (MAC) is degenerative, fibrous calcification of the mitral valve annulus. It is more common in people over 70 years old. It is a marker of increased cardiovascular risk which occurs in a graded fashion by MAC severity. The aim of this study was to evaluate the association of Mitral annular calcification with severity of coronary artery disease (CAD) in patients under 65 years old. Methods: A total of 140 patients with IHD were enrolled by purposive sampling. Study populations were divided into MAC group and non MAC group. MAC was detected by Trans-thoracic echocardiography as an intense echo-producing structure located at the junction of the atrio-ventricular groove and posterior mitral leaflet in parasternal long axis view. MAC is measured in millimeters from the leading anterior to the trailing posterior edge and quantified as mild to moderate (1 to 4 mm) and severe (>4 mm) considering its thickness. Assessment of angiographic severity of CAD was done in the same hospital stay by Vessel score, Friesinger score and Leaman score. Results: Patients of MAC and non MAC groups were similar in terms of age and sex. Smoking (p=0.001) and family history of IHD (p=0.03) were significantly higher in MAC group. Anterior MI was significantly higher in MAC group (p=0.03). Left main and TVD were significantly higher in MAC group (p=0.001, p=0.01) whereas normal vessels were more in non MAC group (p=0.001). Intermediate and high Friesinger score (e”5) were significantly higher in MAC group whereas low Friesinger score (<5) were more in non MAC group. There was significant (p=0.01) positive correlation between MAC and CAD severity in terms of vessel score (r=0.76) Friesinger score (r=0.75) and Leaman score(r=0.42). Multivariate logistic regression analysis showed that MAC was independent predictors of significant CAD (p=0.02, OR= 2.84). Conclusion: Echocardiographically detected mitral annual calcification (MAC) can be an independent predictor of significant coronary artery disease. There is positive correlation between severity of MAC and severity of CAD. Cheap, available and radiation free nature of the echocardiographic detection of MAC may be a marker of significant CAD. Cardiovascular Journal Volume 6, No. 1, 2013, Page 10-16 DOI: http://dx.doi.org/10.3329/cardio.v6i1.16109

To compare all-cause mortality in patients with mitral annulus calcification (MAC) and severe mitral valve dysfunction (MVD) who received standard mitral intervention versus no intervention. Patients with MAC often have high surgical risk due to advanced age, comorbidities, and technical challenges related to calcium. The impact of a mitral intervention on outcomes of patients with MAC and severe MVD is not well known. Retrospective review of patients with MAC by transthoracic echocardiography (TTE) in 2015 at a single institution. Patients with severe mitral stenosis (MS) or regurgitation (MR) were analyzed and stratified into two groups: surgical or transcatheter intervention performed <1 year after the index TTE, and no or later intervention. The primary endpoint was all-cause mortality. Of 5502 patients with MAC, 357 had severe MVD (MS = 27%, MR = 73%). Of those, 108 underwent mitral intervention (surgery = 87; transcatheter = 21). They were younger (73 ± 11 vs. 76 ± 11 years, p < 0.01) and less frequently had cardiovascular diseases compared with no-intervention. Frequency in women was similar (45% vs. 50%, p = 0.44). During median follow-up of 3.2 years, the intervention group had higher estimated survival than those without intervention (80% vs. 72% at 1 year and 55% vs. 35% at 4 year, p < 0.01). Adjusted for age, eGFR, LVEF < 50%, and pulmonary hypertension, mitral intervention was an independent predictor of lower mortality (hazard ratio = 0.66, 95% confidence interval 0.43-0.99, p = 0.046). Patients with MAC and severe MVD who underwent mitral intervention <1 year from index TTE had lower mortality than those without intervention. Mitral intervention was independently associated with lower mortality.

Introduction: Mitral annular calcification (MAC) has been associated with age, hemodialysis (HD) status, coronary disease, and mortality. While MAC is seen frequently in pts undergoing percutaneous edge-to-edge repair of mitral regurgitation (MR) its impact on survival is unknown. Hypothesis: MAC is not associated with mortality after percutaneous MR repair. Methods: Pts who underwent MitraClip repair of MR between Apr 2009 and May 2014 were included. Kaplan-Meier survival was plotted between pts with no MAC and pts with MAC. A multivariate Cox regression of all-cause mortality was performed simultaneously adjusting for MAC, age, HD status, and prior myocardial infarction (MI). Results: 173 pts were included. Mean age at percutaneous repair was 76.9 ± 12.6 yrs and 40.8% were females. MAC was present in 86/173 (49.7%) of pts, and was mild in 61/86 (70.9%) cases and moderate or severe in the remaining cases. In pts with MAC prevalence of prior MI was higher 28/86 (32.6%) vs. 16/87 (18.4%) p=0.037 but ejection fraction was similar 51.8 ± 17.1 vs. 50.4 ± 18.6 % p=0.603. Age was increased in pts with MAC 79.9 ± 10.1 vs. 74.3 ± 14.0 yrs p=0.003. MR was moderate-to-severe in 35/173 (20.2%) of pts and severe in 138/173 (79.8%) of pts. MR improved by 2 grades or more in 165/173 (95.4%) of pts after repair. Survival was decreased in pts with MAC as compared to pts with no MAC by Log Rank p=0.049 (Figure 1A). However, in a multivariate Cox regression model of all-cause mortality, MAC, after adjusting for age, HD status, and prior MI, was not associated with mortality with a hazard ratio of 1.166 (95% CI 0.707 - 1.922) p=0.548 (Figure 1B). In this model age and prior MI were associated with mortality with hazard ratios of 1.048 (95% CI 1.021 - 1.077) p=0.001 and 1.798 (95% CI 1.052 - 3.075) p=0.032, respectively. Conclusions: The presence of MAC was not associated with mortality after adjusting for age, HD status, and prior MI and should not preclude the MitraClip procedure. Procedural success was equally high.

Atrial Embolization after a Transcatheter Mitral Valve Replacement

Mitral annular calcification (MAC) is increasingly observed in elderly population. The purpose of this study was to investigate incidence of MAC and its association with mitral valvular disease (MVD). A total of 13,483 consecutive patients who underwent echocardiography were enrolled. MAC was defined as an echo-dense, shelf-like structure with an irregular, lumpy appearance involving the mitral valve annulus, with acoustic shadowing. Prevalence of MAC and its association with significant mitral stenosis (MS) or mitral regurgitation (MR) were studied. Significant (≥moderate) MS was defined as mean transmitral valvular pressure gradient>5mm Hg and significant MR was defined as ≥moderate MR based on quantitative or semi-quantitative Doppler methods. MAC was present in 1881 of 13,483 patients (14%). Patients with MAC (MAC group) was older and more female gender than those without MAC (non-MAC group). Significant MS was present in 2.2% of MAC and in .6% of the non-MAC group (p<0.0001). Significant MR was present in 11.9% of MAC and in 5.0% of the non-MAC group (p<0.0001). Co-existence of MAC and aortic valve replacement (AVR) was associated with increased prevalence of MVD (MS:11.4%, MR:17.2%, respectively). MAC was present in 14% of the patients and was associated with significant MVD. Co-existence of MAC and AVR may increase the risk of MVD.

Clinical Significance of Circumferential Mitral Annular Calcification in Mitral Valve Replacement

The aim of the present study was to study time indices of heart rate variability (HRV) in patients with mitral annular calcification (MAC). A cross-sectional observational study was performed. Fifty patients with echocardiographic evidence of MAC and 50 age- and gender-matched control subjects without echocardiographic evidence of MAC were included. All the study participants underwent 2-dimensional echocardiographic examinations and 24-hour Holter monitoring for HRV analysis. Student-t, Mann-Whitney U and Chi-square tests were used for statistical analysis. Hypertension and coronary artery disease were more common in the MAC group than in the control group. All HRV parameters including mean RR interval, SDNN, SDANN, SDNN index, pNN50 and RMSSD were reduced in the MAC group when compared with the control group (p<0.05 for all). In hypertensive subgroup, all HRV parameters except mean RR interval were diminished in patients with MAC when compared with those without MAC (p<0.05 for all). In non-hypertensive subgroup, all HRV parameters were also diminished in patients with MAC when compared with those without MAC. In the subgroup of patients with coronary artery disease, patients had lower HRV parameters except mean RR interval, pNN50 and RMSSD in comparison to those without MAC (p<0.05 for all). In the subgroup of patients without coronary artery disease, all HRV parameters were depressed in patients with MAC in comparison to those without MAC (p<0.05 for all). Our findings indicate that MAC was associated with reduced heart rate variability which possibly reflects decreased parasympathetic tone with a predominant activity of the sympathetic tone.

Background: Percutaneous Transvenous Mitral Commissurotomy (PTMC) is the preferred treatment for severe mitral stenosis (MS) in patients with favorable valve morphology. Mitral Annular Calcification (MAC) may adversely affect procedural success and increase post-procedural mitral regurgitation (MR). Objective: To evaluate the impact of Mitral Annular Calcification on post-PTMC outcomes. Methodology: This mixed retrospective and prospective study was conducted at Peshawar Institute of Cardiology from April 2021 to December 2024. A total of 303 patients with severe MS (MVA ≤1.0 cm², mean gradient &gt;10 mmHg) were included. Echocardiographic parameters including Wilkins and commissural scores were assessed. Procedural success was defined as post-PTMC MVA &gt;1.5 cm², ≥50% increase in MVA, and absence of severe MR or major complications. Data were analyzed using SPSS 26. Results: Mean age was 38.88±11.38 years; 80.9% were females. Wilkins score ≤8 was observed in 82.8%, and 63% had no commissural calcium. Mean MVA increased from 0.92±0.16 cm² to 1.8±0.31 cm²; 91.7% achieved procedural success. Severe MR occurred in 11.2%, with one mortality. Commissural score correlated positively with MR (r=0.475, p&lt;0.001) and negatively with MVA (r=–0.398, p&lt;0.001). Patients with commissural score 2 had a 5.24-fold higher risk of severe MR (p=0.027). Conclusion: PTMC is a safe and effective intervention for severe MS; however, Mitral Annular Calcification significantly reduces procedural success and increases MR risk. Pre-procedural commissural scoring enhances patient selection and outcome prediction. Keywords: Commissural Score, Mitral Annular Calcification, Mitral Regurgitation, Mitral Valve Area, PTMC.

Outcomes of transcatheter aortic valve replacement in patients with mitral annular calcification and concomitant mitral valve dysfunction: A systematic review and meta-analysis