Mitral Annular Calcification Research Articles

Mitral Annular Calcification: The “Pack and Seal” Technique

Mitral Annular Calcification: The “Pack and Seal” Technique

Prevalence and gender distribution of mitral annular calcification and associated mitral valve dysfunction across age groups: a retrospective analysis

Abstract Background Mitral Annular Calcification (MAC) is a significant predictor of cardiovascular events and mitral valve dysfunctions (MVD), including mitral regurgitation and mitral stenosis. This study investigates the prevalence of MAC and its severity across different age groups and genders, and examines its association with MVD in a single tertiary care center. Methods A retrospective analysis was conducted on an echocardiography database of 48,912 consecutive patients. The prevalence of MAC, including both any MAC and moderate to severe MAC was assessed. Patients were categorized into different age groups: <55 years, 55-65 years, 66-75 years, and >75 years. The study also analyzed the prevalence of MVD in these patients and examined gender differences. Chi-square tests were used to evaluate statistical significance in gender and age group differences in association with MVD. Results The overall prevalence of any MAC was 12.5% (6,104), while moderate or severe MAC was observed in 2.2% (1,104) of the patients. When stratified by age, the prevalence of any MAC was 3% in patients <55 years, 15.0% in patients 55-65 years, 28.6% in patients 66-75 years, and 40.9% in patients >75 years. The prevalence of moderate or severe MAC followed a similar trend, with 0.2%, 1.9%, 5.5%, and 10.7% in the respective age groups. Gender distribution analysis revealed a significant female predominance among patients with moderate or severe MAC (59.5% vs. 40.5%), p < 0.0001. Patients with moderate or severe mitral annular calcification (MAC) had a more than four-fold increased risk of mitral valve disease (MVD) compared to those with mild MAC (57.9% vs. 13.1%, p < 0.0001).Age group was not a significant factor in MVD prevalence. Conclusion The age-related prevalence of mitral annular calcification (MAC), especially in older women, represents a significant clinical concern given its association with increased risk of mitral valve disease (MVD). This highlights the importance of vigilant MAC screening and proactive MVD management in this population. Future research should focus on identifying modifiable risk factors and developing effective screening strategies to mitigate the progression of MAC and its associated valvular complications.

Mitral annulus calcification-derived cardiac computed tomography: a marker for cardiovascular prognosis after aortic valve replacement

Abstract Introduction Calcific aortic stenosis (AS) is the most common valvular heart disease in developed countries, with incidence rising due to an aging population. Although transthoracic and transesophageal echocardiography are the primary imagistic tools for patients with AS, cardiac computed tomography (CCT) is essential in the pre-procedural planning of aortic valve replacement (AVR), crucially informing management strategies. Furthermore, CCT provides detailed imaging of cardiovascular calcification, such as mitral annular calcification (MAC) presence and extension for these patients. However, the implications of CCT-derived MAC for patient outcomes, particularly regarding major adverse cardiovascular events (MACE) remain unclear. Purpose This study aimed to determine if the presence and extent of CCT-derived MAC affect all-cause, non-cardiovascular mortality, and MACE in patients undergoing AVR. Methods Several clinical cardiovascular risk factors were collected retrospectively and CCT scans of 313 patients with AS were assessed semi-quantitatively. CCT was conducted in spiral acquisition mode with retrospectively electrocardiogram-gated reconstruction and a contrast agent was injected. This study categorizes MAC severity using Guerrero et al.'s recently validated CCT-derived MAC score. Patients were followed for 60 months post-AVR to evaluate MACE (composite of cardiovascular mortality, major arrhythmias, heart failure, and stroke), all-cause, and non-cardiovascular-related deaths. Cox univariate models were used to study the role of MAC as a predictor of the aforementioned outcomes. Results The population's median age was 81 years (78-84) and most of them were females (60.3%). Arterial hypertension was present in 85.9% of the patients, 30.6% presented diabetes mellitus, 12.1% presented chronic kidney disease, and 36% had previous myocardial revascularization. The median left ventricular ejection fraction was 58% (55-63), the mean index aortic valve area was 0.4 cm2/m2 (0.3-0.5) and most of them presented a tricuspid aortic valve (94.8%). The median STS risk score of mortality was 4.14 % (2.85-6.29), while the EuroScore II was 2.83 (1.70-4.77) points. In univariate Cox models, the lowest and intermediate MAC severity categories did not show any significant associations with MACE, all-cause, and non-cardiovascular mortality (all p values >0.05). However, the MAC score for the highest category (3 vs. 0 points) was significantly associated with MACE (HR 2.32, 95% CI [1.13-4.77], p=0.02), all-cause (HR 2.37, 95% CI [1.36-4.16], p< 0.0.001), and non-cardiovascular mortality (HR 2.09, 95% CI [1.05-4.16], p=0.03). Conclusion In the present study, severe MAC was identified as an independent predictor of cardiovascular outcomes in patients with AS undergoing AVR. These results could be translated into a more practical, largely available, clinical tool to ensure closer monitoring of this population

Artificial intelligence-enhanced electrocardiogram left ventricular diastolic function assessment for prognostic assessment in mitral annulus calcification

Abstract Background Moderate-severe mitral annulus calcification (MAC) and left ventricular (LV) diastolic dysfunction are both linked to increased risks of heart failure and mortality. Assessing LV diastolic function (LVDF) in moderate-severe-MAC by echocardiography is frequently challenging and unreliable. We recently validated an AI-ECG model for LVDF. We aimed to determine if this tool can predict long-term mortality in patients with moderate-severe-MAC and whether it can help establish MAC-specific echocardiographic LVDF parameter cutoffs. Methods This retrospective study included all patients from the AI-ECG LVDF study test cohort who underwent comprehensive transthoracic echocardiography confirming moderate-severe-MAC and ECG within fourteen days of each other at Mayo Clinic between 09/2001 and 06/2022. AI-ECG LVDF was determined based on the index ECG. Patients were categorized based on AI-ECG into groups representing normal/grade-1 LVDF, grade-2 LVDF, or grade-3 LVDG (DF-1, DF-2, and DF-3, respectively). Results Of 2,506 patients with moderate-severe-MAC [mean age 77, 64.1% females], 709 (28.3%), 1,510 (60.3%), and 287 (11.5%) were classified as DF-1, DF-2, and DF-3, respectively. Worse LVDF grade was associated with older age, male sex, lower LV ejection fraction, and higher rates of noncardiovascular and cardiovascular comorbidities. Over a median follow-up of 2.8 years, 1,059 (42.3%) patients died. In multivariable survival analysis, DF-2 [adjusted hazard ratio (aHR) 1.43, 95% confidence interval (95%CI) 1.21-1.68] and DF-3 (aHR 1.54, 95%CI 1.22-1.93) were independently associated with a higher risk of death (figure). Findings were also consistent after adjusting to mitral inflow gradients. When comparing LVDF echocardiographic parameters in controls without MAC matched by age, sex, left ventricular ejection fraction, and AI-ECG DF grade, significant differences were observed. Patients with moderate to severe MAC generally exhibited lower e' velocities, higher TR velocities, elevated E/e' ratios, and increased LAVi. Interestingly, the E/A ratio between MAC patients and their matched controls across AI-ECG LVDF grades remained consistent. Conclusion AI-ECG LVDF predicts mortality risk in patients with moderate-severe-MAC, regardless of mitral inflow gradients. Utilizing AI-ECG LVDF might aid in the risk stratification of patients with significant MAC.

Increased amounts of epicardial fat tissue are not associated with mitral annular calcification in patients with severe aortic stenosis planned for transcatheter aortic valve implantation

Increased amounts of epicardial fat tissue are not associated with mitral annular calcification in patients with severe aortic stenosis planned for transcatheter aortic valve implantation

“A Bridge-over-the Bar”: A Novel Strategy to Prevent Paravalvular Regurgitation during Mitral Valve Replacement for Severe Mitral Annular Calcifications

Mitral annular calcifications have been known to increase complexity during mitral valve replacement (MVR). Standard procedure requires decalcification followed by reconstruction of the mitral annulus prior to placing the prosthesis. While this is the ideal technique, it is not feasible in every patient due to the associated risks. The mere attempt at valve replacement without proper annular decalcification has been associated with a high incidence of periprosthetic leak which complicates the postoperative course and has been associated with increased morbidity and mortality. With the advances in transcatheter therapy, postoperative periprosthetic regurgitation can be managed with devices and primary transcatheter valve implantation could be alternative to standard valve replacement; however, these alternate strategies are not without its own limitations and drawbacks. In the current report, we present a novel strategy to be used in a select group of patients with severe but non-circumferential annular calcifications to prevent/minimize periprosthetic regurgitation during MVR. This involves placing a patch over the posteriorly located calcium bar, thus minimizing tension on the posterior suture line and contain any periprosthetic regurgitation if to develop. This modification has been performed in a total of nine cases with acceptable early results.

Prognostic value of mitral annular calcification in patients with severe aortic stenosis

Prognostic value of mitral annular calcification in patients with severe aortic stenosis

Surgical implantation of transcatheter balloon expandable prosthesis in mitral position: a case with severe calcified mitral annulus

We present the case of a female patient with mitral valve disease with severe stenosis and moderate insufficiency but with a calcified mitral annulus that compromised the anterior leaflet and mitral valve apparatus and multiple comorbidities. An inverted balloon expandable bioprosthesis was implanted in the mitral position without complications. The patient was discharged on the fifth postoperative day. The clinical and echocardiographic control performed one month later was satisfactory.

Sex-related differences in outcomes and prognosis of severe calcific mitral stenosis due to mitral annular calcification: A propensity-score matched cohort study.

The prevalence of severe calcific mitral stenosis (MS) is higher in female patients. The aim of the study was to assess the sex-related differences in clinical characteristics and prognosis in patients with severe calcific MS. Among 7154 adult patients with MS due to mitral annular calcification who underwent echocardiography between October 2010 and August 2020, 287 patients with severe MS were retrospectively analyzed. The endpoint was all-cause mortality. We calculated a propensity score matched analysis with 22 potential confounding covariates including clinical characteristics and medication usage. In the entire cohort, there was a predominance of female patients (66%), and the mean age was 72±11years. While 97 patients (34%) underwent MV intervention, 190 patients (66%) were conservatively managed. During a median follow-up of 12months (25th -75th percentile: 3-29months), 102 patients (36%) died. The cumulative survival rate of female patients was lower compared with male patients in conservative treatment group (p=0.012), while the cumulative survival rate was comparable between the sexes in MV intervention group (p=0.63). Even after propensity score matching in 170 patients (85 females and 85 males), similar results were obtained (p=0.012 for conservative treatment group, p=0.61 for MV intervention group). Female sex predominated in patients with severe calcific MS. Female patients with severe calcific MS had worse prognosis than male patients when treated conservatively, while in patients undergoing MV intervention, prognosis was similar between the sexes.

Diagnosis and Management of Mitral Valve Disease in the Elderly

AbstractCalcific mitral stenosis, commonly seen in the elderly in developed countries, occurs primarily due to mitral annular calcification, and its prevalence is increasing secondary to an aging population. Mitral regurgitation, commonly seen across all age groups, occurs primarily due to anatomical or functional impairment of one or more components of the mitral apparatus or the left ventricle that are necessary for normal valve function, and its prevalence is increasing secondary to an increasing number of patients with heart failure. The current review discusses the diagnosis of and treatment options (medical, surgical, and transcatheter) for mitral valve disease, including the associated challenges, specifically in the elderly.

Invasive hemodynamic characteristics in patients with mitral annular calcification related mitral stenosis and chest radiation.

Quantification of invasive hemodynamics and mitral annular calcification-related mitral stenosis remains underexplored in patients exposed to chest radiation. We sought to explore invasive hemodynamic parameters via transseptal catheterization in patients with and without chest radiation who had a diagnosis of mitral annular calcification-related mitral stenosis. After excluding patients with more than moderate mitral regurgitation, we found that there was no difference in mitral valve area on hemodynamic testing in patients with and without radiation with an elevated baseline transmitral gradient on transthoracic echocardiography in the setting of mitral annular calcification-related mitral stenosis. There was a higher transmitral gradient and left atrial pressure in patients with prior radiation consistent with left atrial noncompliance, suggesting that treatment mitral valve stenosis may not relieve symptoms in this cohort of patients.

The impact of intravenous agitated saline contrast echocardiography on subclinical neuronal injury determined by neuron-specific enolase

Abstract Introduction Patent foramen ovale (PFO) is a congenital defect in interatrial septum with 25-30% prevelance. Diagnostic methods include transesophageal echocardiography (TEE), magnetic resonance imaging (MRI), and computed tomography (CT), but transthoracic echocardiography (TTE) is the primary diagnostic method. TTE involves the injection of agitated saline intravenously, and the passage of microbubbles from the right atrium to the left atrium is monitored. The reliability of this method has been questioned in various case series, with a low incidence (0.062%) of generally transient, mild clinical cerebrovascular events reported. Silent cerebral ischemia (SSI) is asymptomatic, radiographically identified acute neuronal damage. SSI is associated with an increased risk of stroke, dementia, and cognitive impairment. Neuron-specific enolase (NSE) with high specificity for neural cells can be used to detect SSI. While symptomatic patients have been evaluated in reported case series, there is no study determining the relationship and reliability of intravenous agitated saline echocardiography (SCE) with SSI. This study aims to determine whether TTE, performed on patients with PFO without neurological history and a healthy control group, can cause SSI by evaluating NSE with SCE. Materials and methods 52 patients undergoing SCE for color flow through interatrial septum or prominent interatrial septal aneurysm and are diagnosed with PFO were included. Additionally, 51 control patients without detected PFO or ASA were also included. Serum samples were taken from the patients before and 12 hours after the SCE test, and NSE levels were measured by the ELISA method. Results The mean baseline NSE level was 12.7 ng/mL with a median of 5.3 ng/mL in the PFO group, and in the control group, the mean was 9.1 ng/mL with a median of 6.4 ng/mL. At 12 hours, the mean NSE levels in the PFO group were 9.8 ng/mL with a median of 6.6 ng/mL, and in the control group, the mean was 12.7 ng/mL with a median of 5.8 ng/mL. The increase in NSE levels after SCE, was not statistically significant when comparing the PFO and control groups (p=0.77). No relationship was found between age, presence of interatrial septal aneurysm, presence of mitral annulus calcification, the number of bubbles passed in the SCE test, and the basal and 12-hour change in NSE levels (p=0.926). NSE level changes were found to be correlated between groups (p<0.001). Conclusion This study is the first to evaluate whether SCE causes subclinical neuronal damage. Our study suggests that when evaluated with NSE, the SCE method is safe and does not cause subclinical neuronal damage in patients without underlying neuronal susceptibility.results

Particularities of a Cardiac Amorphous Left Ventricular Tumor in a Patient with Coronary Artery Disease—Diagnostic and Therapeutic Challenges: A Case Report and Literature Review

Background: Cardiac calcified amorphous tumors (CATs) are rare non-neoplastic formations containing amorphous fibrinous material and calcifications. In our research, we present the case of a 42-year-old male patient who developed, during his 6-months monitoring for coronary artery disease, a left ventricular (LV) CAT raising diagnostic challenges. Methods: To gather additional information on CATs, we researched the international medical literature for scientific articles published with the full text in English, on PubMed, ResearchGate, Clarivate, and Google Scholar between 2020 and 2024. Results: Compared to most described cases, our patient was a young male, without mitral annular calcification or chronic renal disease, but he was suffering from chronic peripheral and coronary artery disease, and genetic testing revealed a higher risk for thromboembolic events. During 6 months, he developed a LV CAT of 4.5/3.5/3 cm. Although we found in the medical literature 16 case reports of patients with CAT, only six authors could specify a precise postoperative evolution of the CAT, most of them sustaining that if completely removed, it would not relapse, an aspect observed also in our patient during 3 years of follow-up. Conclusions: CATs are rare heart tumors with slow growth, but with a high embolization risk that raises diagnostic and therapeutic challenges.

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

BackgroundThe impact of mitral annular calcification (MAC) on the clinical outcomes of patients undergoing mitral transcatheter edge-to-edge repair (MTEER) remains unclear. This meta-analysis aims to evaluate the clinical outcomes of MTEER among patients with moderate to severe MAC compared to those with mild or no MAC. MethodsWe systematically searched PubMed, EMBASE, and Cochrane CENTRAL databases through March 31st, 2024, comparing clinical outcomes of MTEER among patients with moderate/severe (MAC+) versus no/mild MAC (MAC-). We assessed pooled estimates for procedural success, all-cause mortality, residual mitral regurgitation (MR) ≤ moderate, and New York Heart Association (NYHA) class III/IV status at one year. ResultsAmong five studies (2533 patients; mean age 76.4 ± 10.9 years, 39.8 % women), MAC+ patients were predominantly women (55.7 % vs 37.5 %, p < 0.001), older (87.9 ± 11.1 vs. 75.9 ± 9.1 years; mean difference (MD) = 3.99, p = 0.011) and had higher STS scores (7.7 ± 6.7 % vs. 4.9 ± 4.6 %; MD = 1.34, p < 0.001). MAC+ patients had comparable procedural success rates, residual MR < moderate, and NYHA III/IV at 1 year. However, all-cause mortality at 1 year was higher for MAC+ patients (Relative Risk = 1.56, 95 % CI = 1.06–2.29). ConclusionsMTEER is a safe and feasible option for carefully selected patients with MAC and significant MR, offering durable MR reduction and functional status improvement. Significantly higher one-year mortality associated with MAC despite significant MR reduction suggests an increased risk unrelated to valvular dysfunction and highlights the need for further investigation into identifying patients who benefit the most from MTEER.

TCT-945 AltaValve System TMVR for the Treatment of Patients With Severe Mitral Regurgitation and Mitral Annular Calcification

TCT-945 AltaValve System TMVR for the Treatment of Patients With Severe Mitral Regurgitation and Mitral Annular Calcification

Direct Implantation of Transcatheter Valve in Mitral Annular Calcification: A Multicenter Study

BackgroundMitral valve replacement in the setting of severe annular calcification (MAC) is associated with high morbidity and mortality. Direct surgical implantation of a transcatheter heart valve (THV) through a transatrial approach is a strategy to mitigate surgical risk. This study reports the perioperative and 1-year outcomes of mitral valve replacement using a THV in patients with severe circumferential MAC at 3 Canadian centers. MethodsCharts were reviewed between January 1, 2018 and September 30, 2023 to identify patients with severe circumferential MAC who had undergone direct implantation of a THV. Primary outcomes were 30-day mortality, debilitating stroke, and 1-year mortality. Secondary outcomes included left ventricular outflow tract obstruction, degree of paravalvular leak (PVL), transvalvular mean pressure gradient, and length of stay. ResultsTwenty-two patients at the 3 centers underwent direct implantation of a THV. Nineteen patients were female, with mean age of 70.41 ± 9.33 years. A THV was successfully implanted in all patients. There were 2 deaths at 30 days. Four patients of noncardiac causes at 1 year, and 1 patient had a postoperative stroke. Seventeen (77%) patients had no PVL or trace PVL, 4 had mild PVL, and 1 patient had mild-moderate PVL. The mean transvalvular gradient was 4.42 ± 4.40 mm Hg. There were no cases of left ventricular outflow tract obstruction. ConclusionsDirect deployment of a THV in patients with severe MAC may be a reasonable option. Thirty-day and 1-year mortality rates of 9% and 18%, respectively, suggest that this approach should be reserved for high-risk patients who are not able to undergo conventional strategies.

TCT-614 Clinical Characteristics and Prognosis of Patients With Mitral Annular Calcification

TCT-614 Clinical Characteristics and Prognosis of Patients With Mitral Annular Calcification

TCT-613 Mitral Valve Dysfunction in Patients With Mitral Annular Calcification

TCT-613 Mitral Valve Dysfunction in Patients With Mitral Annular Calcification

Cardiovascular Risk Factors Associated with Mitral Annular Calcification in a Non-Rheumatic Population

Mitral Annular Calcification (MAC), cardiovascular disease marker was common in non-rheumatic populations but was frequently disregarded in clinical evaluations. Objective: To MAC and to assess effect of these factors on cardiac function in non-rheumatic adult population. Methods: From September 2022 to August 2023, we conducted this cross-sectional study at Cardiac Center, Pakistan institute of medical sciences Islamabad that included 182 adults aged 50 years and older. We evaluated the patient's clinical history, demographic data and echocardiographic and laboratory results. The association between the presence of MAC and cardiovascular risk factors (age, hypertension, diabetes, dyslipidemia, smoking, obesity and chronic renal disease) was analyzed using logistic regression. Echocardiographic data were used to provide insight into cardiac function. Results: The prevalence of MAC was substantially correlated with hypertension (OR = 2.30), diabetes (OR = 2.00), dyslipidemia (OR = 1.75) and obesity (OR = 1.07). Also, smoking demonstrated a significant correlation with MAC. In comparison to those without MAC, individuals with MAC exhibited substantially lower ejection fractions, increased left atrial diameters and impaired diastolic function, as indicated by cardiac function assessments. Conclusion: In non-rheumatic population, MAC was significantly associated with conventional cardiovascular risk factors, particularly hypertension and diabetes.

Stroke after heart valve surgery: a single center institution report

IntroductionStroke is a potentially debilitating complication of heart valve replacement surgery, with rates ranging from 1 to 10%. Despite advancements in surgical techniques, the incidence of postoperative stroke remains a significant concern, impacting patient outcomes and healthcare resources. This study aims to investigate the incidence, risk factors, and outcomes of in-hospital adverse neurologic events, particularly stroke, following valve replacement. The analysis focuses on identifying patient characteristics and procedural factors associated with increased stroke risk.MethodsThis retrospective study involves a review of 417 consecutive patients who underwent SVR between January 2004 and December 2022. The study cohort was extracted from a prospectively recorded cardiac intensive care unit database. Preoperative and perioperative data were collected, and subjects with specific exclusion criteria were omitted from the analysis. The analysis includes demographic information, preoperative risk factors, and perioperative variables.ResultsThe study identified a 4.3% incidence of postoperative stroke among SVR patients. Risk factors associated with increased stroke susceptibility included prolonged cardiopulmonary bypass time, aortic cross-clamp duration exceeding 90 min, prior stroke history, diabetes mellitus, and mitral valve annulus calcification. Patients undergoing combined procedures, such as aortic valve replacement with mitral valve replacement or coronary artery bypass grafting with AVR and MVR, (OR = 10.74, CI:2.65–43.44, p-value = < 0.001) and (OR = 11.66, CI:1.02–132.70, p-value = 0.048) respectively, exhibited elevated risks. Internal carotid artery stenosis (< 75%) and requiring prolonged inotropic support were also associated with increased stroke risk(OR = 3.04, CI:1.13–8.12, P-value = 0.026). The occurrence of stroke correlated with extended intensive care unit stay (OR = 1.12, CI: 1.04–1.20, P-value = 0.002) and heightened in-hospital mortality.ConclusionIn conclusion, our study identifies key risk factors and underscores the importance of proactive measures to reduce postoperative stroke incidence in surgical valve replacement patients.