Presence Of Mitral Annular Calcification Research Articles

Mitral complex geometric changes aggravate mitral stenosis after transcatheter aortic valve replacement.

Severe aortic valve stenosis (AS) often coexists with mitral valve stenosis (MS). MS aggravation after transcatheter aortic valve replacement (TAVR) is common, and its etiology is multifactorial. We hypothesized that geometric changes in the mitral complex (mitral valvular and annular deformities) are adjunctive factors aggravating MS after TAVR, particularly in older adults with a smaller left ventricle (LV). This study aimed to evaluate the mitral complex geometric changes before and after TAVR and to assess the important predictors of MS aggravation after TAVR. This retrospective study enrolled consecutive adult patients who underwent TAVR and surgical AVR (SAVR) for severe AS. The mitral valve area (MVA), the angle between the anterior mitral valve leaflet (AMVL) and left ventricular outflow tract (LVOT), AMVL length, mitral annular diameter, presence of mitral annular calcification, and LV size were evaluated using transthoracic echocardiography. This study included 258 patients who underwent TAVR and SAVR. MVA index decreased from 2.3 ± 0.6cm² to 1.9 ± 0.5cm² in the TAVR group. The angle between the AMVL and LVOT was 56.3 ± 9.7° preoperatively and increased to 67.3 ± 11.5° after TAVR. In multivariate analysis, the most important predictive factors of MS aggravation after TAVR were a smaller mitral annular diameter, restricted AMVL mobility, and implantation depth (odds ratio: 4.5, 5.3,3.0; 95% confidence interval: 1.6-14, 1.9-17, 1.0-8.9; and p = 0.005, p = 0.001, p = 0.042, respectively). The reduction in MVA after TAVR was related to the restriction of AMVL opening, depth of implantation and narrowing of the mitral annulus.

Prognostic Value of Mitral Annular Calcification in Liver Transplant Patients: Implication in Posttransplant Outcomes.

With the rise of metabolic diseases and aging in liver transplant (LT) candidates, mitral annular calcification (MAC) is more recognizable. Despite cardiovascular risk becoming a leading cause of mortality in LT recipients, the influence of MAC remains unexamined. This study investigates the prevalence, related factors, and impact of MAC on LT outcomes. We explored 4148 consecutive LT patients who underwent routine pretransplant echocardiography from 2008 to 2019. Multivariate logistic analysis and the tree-based Shapley additive explanation scores in machine learning were used to evaluate the significant and important related factors. The primary outcome was 30-d major adverse cardiac events (MACE), and the secondary outcome was a median of 5-y cumulative all-cause mortality. MAC was found in 123 (3.0%) patients. Significant and important related factors included age, alcoholic liver disease, chronic kidney disease, hyperuricemia, hypertension, and coronary artery disease. The MACE rate was higher in patients with MAC compared with those without MAC at 30 d (P < 0.001, adjusted hazard ratio 1.67; 95% confidence interval, 1.08-2.57). Patients with MAC had poorer cumulative overall survival probability compared with those without MAC (P = 0.0016; adjusted hazard ratio 1.47; 95% confidence interval, 1.01-2.15). Specifically, women with MAC had a poorer survival probability compared with men without MAC (65.0% versus 80.7%, P < 0.001) >10 y post-LT. The presence of MAC before LT was linked to increased 30-d MACE and lower long-term survival rates, especially in women. Identification and management of MAC and potential risk factors are crucial for improving post-LT survival.

Application of a novel echocardiographic scoring system to estimate left ventricular filling pressure in aortic stenosis

Abstract Background Despite the increased number of aortic stenosis (AS) patients, non-invasive estimation of the left ventricular (LV) filling pressure (FP) is often challenging partly because of unavailability of E/e' due to the presence of mitral annular calcification (MAC). Recently, an echocardiographic scoring system to estimate LVFP, visually assessed time difference between the mitral valve and tricuspid valve opening (VMT) score was proposed. Because VMT score can be applied for patients with significant MAC, we hypothesized that VMT score could be an alternative parameter of E/e' in AS. Purpose To test whether VMT score could be used as an alternative marker of LVFP to E/e' in AS patients. Methods We enrolled consecutive 116 patients with at least moderate AS in sinus rhythm who underwent right heart catheterization and echocardiography within 7 days. Mean pulmonary artery wedge pressure (PAWP) was measured as invasive parameter of LVFP. LV diastolic dysfunction (DD) was graded according to the ASE / EACVI guidelines. Using two-dimensional echocardiographic images, time sequence of opening of mitral and tricuspid valves was assessed and scored to 0 to 2 (0: tricuspid valve first, 1: simultaneous, 2: mitral valve first). This was based on the phenomenon in which early-diastolic opening of the mitral valve becomes earlier than tricuspid valve with an increase in LV FP and pulmonary artery pressure. When the inferior vena cava was dilated, 1 point was added and VMT score was finally calculated as 0 to 3. Results Overall, PAWP was 12±7 mmHg and elevated (≥15 mmHg) in 29 patients. MAC was observed in 82 patients. Although E/e' was higher in patients with elevated PAWP than in those without (23±11 vs 18±8, P=0.007), its predictive ability to elevated PAWP was non-significant (c-index: 0.59, P=0.13), resulting in low specificity of DD grading to predict elevated LVFP (sensitivity: 79%, specificity: 36%). In contrast, VMT score predicted elevated LVFP with c-index of 0.74 (P&amp;lt;0.001). When VMT score was used instead of E/e', diagnostic accuracy of DD grading was improved (c-index: 0.57 vs 0.82, P&amp;lt;0.001). Conclusion VMT score could be an alternative marker of LVFP to E/e' in AS patients.

Abstract 18273: Mitral Annular Calcification is Associated With Higher Operative Risks and Worse Survival in Hypertrophic Cardiomyopathy

Background: Mitral annular calcification (MAC) is common in hypertrophic cardiomyopathy (HCM), usually accompanied by mitral leaflet calcification, subvalvular apparatus calcification, and mitral valve dysfunction. However, the impact of MAC on surgical strategy and clinical outcomes in HCM is not fully understood. Methods: This cohort enrolled 1035 consecutively recruited patients diagnosed with HCM between January 2016 and December 2021. All patients received a computed tomographic scan prior to surgery. Results: Of the 1035 patients, 112 (10.8%) had MAC, including 39 patients with moderate or severe MAC (calcification area greater than one-third of the annulus). Patients with MAC were significantly older (59.6±8.2 years vs. 47.5±12.3 years, p&lt;0.001) and more likely to be female (61.8% vs. 35.4%, p&lt;0.001). Echocardiography showed a higher proportion of mitral leaflet thickening (17.9% vs. 6.0%, p&lt;0.001) in patients with MAC. Moreover, patients with MAC had a higher rate of annular reconstruction (1.79% vs 0.11%, p=0.002), plastic ring implantation (5.36% vs 1.84%, p=0.017), chordae release (12.50% vs 5.09%, p=0.002), artificial neochordoplasty (2.68% vs 0.54%, p=0.015), and fibrous membrane removal (8.93% vs 4.12%, p=0.022), as well as longer ventilation time [19 hours, interquartile range (IQR) 17.0-26.0 vs. 18 hours, IQR 14.0-20.5, p&lt;0.001], intensive care unit stay [61 hours, IQR 36.5-96.0 hours vs. 48 hours IQR 24.0-72.0 hours, p&lt;0.001] and postoperative hospital stay [8days, IQR 7-11 days vs. 7 days, IQR 6-8 days, p&lt;0.001]. During a median follow-up time of 26.2 months (IQR, 17.0 to 39.5 months), 5 death and 158 major adverse cardiovascular events (MACE) were observed. Kaplan-Meier survival curves showed that patients with MAC had a higher cumulative rate of all-cause mortality (p=0.026) and MACE (p=0.003) compared to their counterparts. On multivariable Cox regression analysis, moderate or severe MAC was an independent risk factor for MACE (Hazard ratio =2.38, 95% confidence interval: 1.31-4.32). Conclusions: The prevalence of MAC was 10.8% in this study. The presence of MAC was associated with a higher rate of concomitant operations, longer hospital stays, and worse survival.

Evaluation of the relationship between mitral annular calcification and triglyceride-glucose index

Aims: Mitral annular calcification (MAC) is an echocardiographic condition with a multicomponent etiopathogenesis, one of which is insulin resistance. Triglyceride-glucose (TyG) index is an excellent biochemical parameter that has proven itself in determining insulin resistance in recent years. This study aims to reveal the relationship between the TyG index and the presence of MAC.&#x0D; Methods: The study included 159 patients with MAC and 167 control group. The control group has similar demographic characteristics such as age, gender, presence of hypertension (HT), and diabetes mellitus with the MAC group. TyG index was calculated as a formula: ln[fasting triglyceride (mg/dl) × fasting plasma glucose (mg/dl)/2].&#x0D; Results: The mean age of the patients was 74.2 and 48.2% of the patients were male. Coronary artery disease (CAD) (p: 0.031), glucose (p:0.001), total cholesterol (p:0.009), low-density lipoprotein (LDL) (p:0.004), triglyceride (TG) (p

Transcatheter transseptal treatment of patients with severe mitral regurgitation using an atrial fixation mitral valve replacement technology

BackgroundMitral regurgitation (MR) is the most common valvular heart disease worldwide with a 5-year mortality rate of 50 % with medical therapy alone. Several transcatheter mitral valve replacement (TMVR) devices are being investigated in clinical trials. Early evidence has demonstrated clinical benefits with a reduction in heart failure symptoms, low rates of residual MR, and reverse remodeling of the left ventricle (LV) over time. However, high anatomical screen failure rates limit its applicability. The primary reasons for the anatomical screen failure are risk of LV outflow tract obstruction, large mitral valve annulus size, and the presence of mitral annular calcification. Our clinical experiences using an atrial only fixation TMVR technology delivered via a transfemoral-transseptal approach is described. MethodsThree consecutive patients with severe functional MR underwent TMVR implantation using an atrial only fixation technology and a low-profile transseptal delivery system. ResultsTechnical success was achieved in 100 % of the patients with a clinically significant reduction in MR. Longer-term follow-up (up to 6-months) has demonstrated a sustained reduction in MR and significant improvement in quality of life for all patients. ConclusionsLonger-term outcomes in our patients showed persistent reduction in MR, sustained implant performance, and notable improvements in NYHA Class and quality of life. There were no major adverse events. Follow-up CT data showed no evidence of device-related thrombosis, with stable valve position and integrity. The atrial fixation TMVR technology may have benefits in preserving the dynamics of the native mitral valve annulus thereby reducing the overall risk of LVOT obstruction. Short AbstractWe present a single-center experience of three consecutive patients with severe functional MR treated with the AltaValve using a low-profile transseptal delivery system. A clinically significant reduction in mitral regurgitation was achieved in all patients, and longer-term follow-up has demonstrated sustained clinical benefits.

Non-alcoholic faty liver disease and liver fibrosis score have an independent relationship with the presence of mitral annular calcification.

Non-alcoholic faty liver disease (NAFLD) and liver fibrosis score (FIB 4) are associated with increased mortality from cardiovascular causes. NAFLD and cardiac diseases are different manifestations of systemic metabolic syndrome. In this study, we aimed to reveal the relationship between NAFLD and FIB 4 liver fibrosis scores and mitral annular calcification (MAC). One hundred patients were included in the study. Blood samples and echocardiography measurements were obtained from each subject. The two groups were compared in terms of demographic and echocardiographic characteristics. Thirty-one men and 69 women with a mean age of 48.6 ± 13.1years were included in the analysis. The patients were divided into two groups as those with MAC (n = 26) and those without (n = 74). The baseline demographic and laboratory data for the two groups were compared. In the group with MAC (+) age, serum creatinine levels, FIB4 and NAFLD Scores; HL, DM rates, angiotensin converting enzyme (ACE) inhibitor and statin usage rates were higher, with statistical significance. NAFLD and FIB 4 liver fibrosis scores have an independent relationship with MAC.

Cardiac Calcified Amorphous Tumor: An Unusual Etiology for Recurrent Cardioembolic Strokes (P3-5.026)

<h3>Objective:</h3> To report a patient with recurrent cardioembolic strokes, in whom an underlying calcified amorphous tumor (CAT) of the heart was detected as the etiology, 2 years after initial presentation. <h3>Background:</h3> CAT of the heart is a rare intracavitary cardiac mass characterized histologically by amorphous fibrinous material and calcification. It has a tendency for embolism. We use this illustrative case to bring awareness for this rare entity and utility of advanced cardiac imaging. <h3>Design/Methods:</h3> An 87-year-old woman with recurrent recent strokes was evaluated for her 5^th stroke. Her neuroimaging had suggested an embolic etiology, but routine cardiac workup had not identified a source. After her 5^th stroke happened despite being on anticoagulation, a trans-esophageal ECHO (TEE) was done followed by cardiac MRI. <h3>Results:</h3> TEE and MRI showed a left atrial non-enhancing calcified mass attached by a stalk to the interatrial septum suspicious for CAT. The tumor was surgically resected. Histological examination showed nodular amorphous calcification against the background of degenerating fibrinous material consistent with CAT. The immediate post-operative period was uneventful, and the patient was discharged to a rehabilitation facility on aspirin monotherapy. <h3>Conclusions:</h3> CAT is a rare cardiac tumor, and its presence is suggested by the presence of calcification of an intracardiac mass on cardiac imaging. The presence of mitral annular calcification (MAC) and renal disease can be additional clues to CAT being the cause for an intracardiac mass, which can then be identified by advanced cardiac imaging. A definitive diagnosis can be made only on pathology, and the definitive treatment is surgical. MAC-related CAT can grow rapidly, has a high embolic risk, and should be removed expeditiously to prevent embolic strokes, even in asymptomatic individuals. <b>Disclosure:</b> Mr. Sharma has nothing to disclose. Dr. Annam has nothing to disclose. Bilal Ali has nothing to disclose. Dr. Guler has nothing to disclose. Dr. Hussein has nothing to disclose.

Commentary: It is all about the skirt: Length and material

Mitral valve replacement in the setting of severe mitral annular calcification (MAC) remains a surgical challenge. The fundamental concern with mitral valve replacement in the presence of MAC is decalcification required to pass the sutures through the mitral annulus, which can lead to annular disruption or perivalvular leak (PVL). Complex en bloc decalcification and reconstruction of the mitral annulus have been described.1,2 However, these procedures are technically challenging and only done by a few skillful surgeons, and as such they are not ready for widespread use.

The Associations of Aortic Valve Sclerosis, Aortic Annular Increased Reflectivity, and Mitral Annular Calcification with Subsequent Aortic Stenosis in Older Individuals: Findings from the Cardiovascular Health Study

Although aortic valve sclerosis (AVS) is well described as preceding aortic stenosis (AS), the associations of AS with antecedent mitral annular calcification (MAC) and aortic annular increased reflectivity (AAIR) have not been characterized. In a population-based prospective study, the authors evaluated whether MAC, AAIR, and AVS are associated with the risk for incident AS. Among participants of the Cardiovascular Health Study free of AS at the 1994-1995 visit, the presence of MAC, AAIR, AVS, and the combination of all three was evaluated in 3,041 participants. Cox proportional-hazards regression was used to assess the association between the presence of calcification and the incidence of moderate or severe AS in three nested models adjusting for factors associated with atherosclerosis and inflammation both relevant to the pathogenesis of AS. Over a median follow-up period of 11.5years (interquartile range, 6.7-17.0years), 110 cases of incident moderate or severe AS were ascertained. Strong positive associations with incident moderate or severe AS were found for all calcification sites after adjustment for the main model covariates: AAIR (hazard ratio [HR], 2.90; 95% CI, 1.95-4.32; P<.0005), AVS (HR, 2.20; 95% CI, 1.44-3.37; P<.0005), MAC (HR, 1.67; 95% CI, 1.14-2.45; P=.008), and the combination of all three (HR, 2.50; 95% CI, 1.65-3.78; P<.0005). In a secondary analysis, the risk for AS increased with the number of sites at which calcification was present. In a large cohort of community-dwelling elderly individuals, there were strong associations between each of AAIR, AVS, MAC, and the combination of the three and incident moderate or severe AS. The novel finding that AAIR had a particularly strong association with incident AS, even after adjusting for other calcification sites, suggests its value in identifying individuals at risk for AS and potential inclusion in routine assessment by transthoracic echocardiography.

Mitral annular calcification in hypertrophic cardiomyopathy

BackgroundChanges in mitral valve anatomy contribute to left ventricular outflow tract obstruction (LVOTO) in hypertrophic cardiomyopathy (HCM). Mitral annular calcification (MAC) is common among patients with HCM but its implications are currently unknown. MethodsWe tested the hypothesis that echocardiographic MAC would be associated with anterior displacement of the mitral valve and LVOTO in a cohort of 304 patients with HCM aged ≥ 60 years (mean [SD] age 71.6 [7.7] years, 52% women). ResultsMAC was present in 141 (46%) patients. The mean (SD) MAC offset distance was 9.8 (4.8) mm. A higher proportion of those with MAC compared to those without MAC had SAM (84.2 vs. 63.8%, p < 0.001) and LVOTO (80.9 vs. 57.9%, p < 0.001). In patients with MAC, the septal-mitral valve distance was shorter compared to those without (19.4 [4.0] vs 21.5 [4.9] mm, p < 0.001). The mitral valve position ratio was greater in those with MAC compared to those without (1.00 [0.79, 1.22] vs. 0.86 [0.67, 1.05], p < 0.001) denoting greater anterior displacement, especially in those with MAC and LVOTO. After multivariable adjustment, MAC offset distance was associated with LVOTO (OR 1.16 [95% CI 1.07, 1.28] per mm, p = 0.001). Over a median follow-up of 2.7 years, 42 (29.8%) patients with MAC underwent surgery to relieve LVOTO, with no deaths. ConclusionThis study adds MAC to the known geometrical alterations of the mitral valve that predispose to LVOTO and suggests that surgical relief of LVOTO in the presence of MAC is safe when performed by an experienced surgeon.

Effects of mitral annular calcification on the outcomes of transcatheter aortic valve implantation

Abstract Background Transcatheter aortic valve implantation (TAVI) has become the standard of care treatment in patients with severe aortic stenosis who carry intermediate or high risk for surgical aortic valve replacement. Mitral annular calcification (MAC) is frequently seen in patients with aortic stenosis and it is associated with increased cardiovascular morbidity and mortality. It is reported that MAC is an independent predictor of all cause mortality after TAVI. Aim The aim of this study is to both evaluate the relationship between mitral annular calcification and TAVI related complications and mortality; and to define the predictors of both all cause mortality and permanent pacemaker implantation after TAVI. Methods All of the patients who underwent TAVI procedure due to severe aortic stenosis between 01.01.2020 and 01.06.2020 in our University Hospital were screened and patients fullfilling including criterias were enrolled. Patients' baseline demographic datas, laboratory, echocardiography and TAVI procedure related parameters were recorded. Outcomes are identified as follows; association between mitral annular calcification and TAVI related complications, establishment of the predictors of all cause mortality and permanent pacemaker implantation, definition of the in-hospital and all cause mortality rates. Results A total of 245 patients including 98 males (40%) and 147 females (60%) were enrolled in the study. The mean age of the population was 76,3±8,3 years. The mean left ventricular ejection fraction was % 54,8±11,4; aortic valve area was 0,74±0,14 cm2 and mean aortic transvalvular gradient was 47,0±14,3 mmHg. MAC was detected in 148 (% 60,4) patients (Table 1). In-hospital mortality was occurred in 14 (5,7%) cases. Permanent pacemaker implantation was performed in %17,8 (n=42) patients and all cause mortality was developed in 89 (36,3%) cases during the median 23,1 (11,6–44,3) months follow-up. Pericardial effusion (26,4% vs 12,4%; p=0,013) and contrast induced nephropathy (21,6% vs 7,2%; p=0,005) were developed more frequently in patients with MAC than without MAC (Table-2). Only the presence of MAC extending to left ventricular outflow tract was detected to be independent predictor of permanent pacemaker implantation requirement (HR: 3,32; p=0,002). All cause mortality predictors were established as; use of renin-angiotensin-aldosterone system blockers (HR: p=0,012), level of hemoglobin (HR: 0,79; p=0,006), severe mitral annular calcification (HR: 1,94; p=0,024) and atrial fibrillation development after TAVI (HR: 2,39; p=0,002). There was not any correlation between aortic valve area and MAC vloume (r=0,03; p=0,689), MAC Hounsfield Unit (r=−0,007; p=0,934) and MAC Agatston score (r=−0,08; p=0,290). Discussion MAC is associated with all cause mortality after TAVI and MAC extending to left ventricular outflow tract is an independent predictor of permanent pacemaker implantation requirement. Funding Acknowledgement Type of funding sources: None.

Surgical implantation of balloon-expandable heart valves for the treatment of mitral annular calcification

ObjectivesThe treatment of mitral valve disease in the presence of mitral annular calcification (MAC) is associated with an increased risk of cardiovascular and all-cause mortality. Various surgical and transcatheter techniques for the treatment of mitral disease with severe MAC have been described. However, these procedures are associated with high risk of operative morbidity and mortality. We describe our experience with open surgical implantation of a balloon-expandable valve (BEV) in patients with severe MAC as an alternative approach. MethodsBEV implantation was performed with direct vision through the left atrium via a median sternotomy or minimally invasive approach. The midportion of the anterior leaflet is excised, and a ventricular septal myectomy performed if there is high risk for left ventricular outflow tract obstruction. The primary outcome was technical success according to the Mitral Valve Academic Research Consortium criteria; secondary outcomes were 30-day and 1-year mortality. ResultsFrom October 2015 through October 2020, 51 patients at 2 institutions underwent BEV-in-MAC (mean age, 73.9 ± 8.8 years; 60.8% [31/51] were female; mean Society of Thoracic Surgeons predicted risk of mortality: 6.8% ± 4.8%). Technical success was 94.1% (48/51). Thirty-day and 1-year mortality were 13.7% (7/51) and 33.3% (15/45), and for stroke 3.9% (2/51) and 4.4% (2/45), respectively. ConclusionsSurgical implantation of a BEV in the mitral position offers a treatment option for patients with mitral valve disease complicated by severe MAC who are at increased risk for conventional surgical approaches and at risk for left ventricular outflow tract obstruction with transcatheter approaches.

Association between calcifications of mitro-aortic continuity and mitral regurgitation in patients undergoing transcatheter aortic valve replacement.

The presence of mitral annular calcification (MAC) affects prognosis in patients undergoing transcatheter aortic valve implantation (TAVI). MAC frequently coexists with calcifications of mitro-aortic continuity (CMAC). We aimed at qualitative and semi-quantitative analysis of calcifications of the mitral complex - MAC and CMAC in multi-slice computed tomography, in order to assess their impact on the occurrence and dynamics of mitral regurgitation (MR) following TAVI. The study group consisted of 94 patients (mean [SD] age was 79.9 [8.02] years; 67.1% female). Agatston scale - Calcium Score was used for quantitative analysis. MAC and CMAC were also assessed semi-quantitatively as either non-severe or severe. MR following TAVI was defined as unchanged, improved or worsened by at least one degree. Patients with MAC (59.6%) had higher mean aortic gradients (P = 0.02) and smaller left ventricular diastolic diameter (P = 0.002). Patients with CMAC (48.9%) had higher Calcium Score aortic valve (P = 0.006). After TAVI MR improved in 17 (18.1%) patients and worsened in 7 (7.5%) patients. In multivariable logistic regression analysis MR worsening was associated with higher CMAC (OR, 1.092; 95% CI, 1.006-1.185; P = 0.03), as well as bicuspid aortic valve (OR, 6.348; 95% CI, 1.048-38.436; P = 0.04). CMAC was associated with MR worsening following TAVI. This is of relevance in procedural planning in patients with severe aortic stenosis (AS) and coexisting MR in whom arguments for and against surgical repair of concomitant mitral insufficiency are considered.

Systematic Approach to the Calcified Mitral Valve Apparatus at Time of Mitral Valve Replacement

Mitral annular calcification (MAC) represents a surgical challenge to mitral valve replacement. The presence of MAC at the time of mitral valve replacement is associated with perivalvular leak and atrial-ventricular groove injury. Although percutaneous and hybrid approaches may offer alternatives to surgical mitral valve replacement, the early and late results from these techniques remain unknown. As such, the surgical management of MAC remains relevant in the contemporary treatment of patients with MAC. Herein, we present a systematic approach to the management of MAC at the time of mitral valve replacement.

Clinical Significance of Circumferential Mitral Annular Calcification in Mitral Valve Replacement

Objective: Mitral valve surgery in the presence of mitral annular calcification (MAC) is a technical challenge. We aimed to evaluate the clinical significance of circumferential MAC in patients who underwent mitral valve replacement (MVR). Methods: 387 patients (61.3±12.5 years) who underwent MVR between 2003 and 2020 were enrolled; mitral regurgitation (n=168), stenosis (n=127), and steno-insufficiency (n=92). The preoperative computed tomography was reviewed to evaluate the presence and distribution of MAC. Patients were divided into two groups by distribution of MAC; circumferential MAC (CMAC) group (n=36) vs none-or-trivial MAC (NMAC) group (n=351). Cox regression was used to evaluate the influence of CMAC on overall death and MACCE. Results: Cardiopulmonary bypass time was significantly longer in CMAC group (176±69 min) than in NMAC group (149±54 min), P=0.005. The operative mortality was significantly higher in CMAC group; CMAC group (7/36, 19%) vs NMAC group (15/351, 4%), P=0.002. The overall survival and freedom from MACCE were significantly worse in CMAC group (log-rank P=0.011 and 0.009, respectively). In multivariable analysis, age, smoking, chronic kidney disease, left ventricular dysfunction and rheumatic valve disease were independent predictors of overall deaths and MACCE. Adjusting for these independent predictors, CMAC was associated with increased risk of MACCE (P=0.045, hazard ratio [HR] 1.96, 95% confidence interval [CI] 1.02-3.78), but CMAC was not an independent predictor of overall death (P=0.166, HR 1.68, 95% CI 0.81-3.51). Conclusions: Circumferential MAC was associated with higher early mortality and increased risk of MACCE after MVR. Further study to address circumferential MAC during MVR should be performed.

Impact of mitral annulus calcification and associated mitral stenosis on clinical outcomes of transcatheter aortic valve replacement

We sought to assess the impact of mitral annular calcification (MAC) and associated mitral stenosis (MAC-MS) on clinical outcomes of transcatheter aortic valve replacement (TAVR). MAC is a common finding in patients undergoing TAVR. Studies evaluating the impact of MAC on the outcomes of TAVR have yielded conflicting results. Furthermore, the impact of MAC-MS remains unknown. We evaluated all the patients who consecutively underwent TAVR in our institution between January 2008 and May 2018. The presence of MAC was confirmed on computed tomography (CT). The combination of MAC and a mean transmitral gradient ≥ 5 mmHg defined MAC-MS. The study included 1177 patients, of whom 504 (42.8%) had. Patients with MAC had similar outcomes after TAVR than those without except for a higher rate of permanent pacemaker implantation which more frequently occurred in MAC patients (adjusted HR: 1.32, 95%CI: 1.03–1.69, P = 0.03). Similar findings were observed when only patients with severe MAC were selected. Among MAC patients, 85 (7.2%) had MAC-MS. Compared to no–MAC patients, MAC-MS was an independent predictor of all-cause mortality at 30 days (adjusted HR: 2.30,95%CI: 1.08–4.86, P = 0.03) and 1–year (adjusted HR: 1.73, 95%CI: 1.04–2.89, P = 0.04). MAC is a common finding in patients treated with TAVR and even severe does not impact on most clinical outcomes. However, when associated with MS, it is an independent predictor of all-cause mortality and cardiovascular mortality at 1 year. In patients with MAC, the measurement of the transmitral gradient is simple, reproducible and effective to identify those at high early and late risk after TAVR.

The Effects of Transcatheter Aortic Valve Replacement on Mitral Valve Function.

The transcatheter aortic valve replacement (TAVR) procedure provides a way to treat severe aortic stenosis in the large population of patients who are not candidates for surgical aortic valve replacement. Mitral regurgitation is often concomitant to aortic stenosis in these patients due to the high pressure of the left ventricle and long-term damage to the mitral valve. Due to the proximity of the aortic valve to the mitral valve, TAVR can impact the functional status of the mitral valve by affecting left ventricular outlet obstruction and the mitral valve annular shape. As TAVR becomes increasingly prevalent to treat aortic stenosis, consideration into the impact of TAVR on mitral valve function is important in order determine whether patients will be able to undergo mitral valve repair or replacement, whether surgically or percutaneously. In this review, we seek to explore the effect of TAVR on the mitral annular geometry, mitral valve flow, and the impact of TAVR on the mitral valve in the presence of mitral annular calcification.

Predicting the presence of coronary artery disease by transesophageal echocardiography.

SummaryBackgroundThe accuracy of ultrasound signs as predictors for the presence of coronary artery disease (CAD) has been evaluated extensively in the 1990s and 2000s. Imaging quality has improved tremendously over the last decades.HypothesisHigh-end ultrasound systems allow for accurate prediction of the presence or absence of CAD.MethodsAll patients who underwent a transesophageal echocardiography examination (TEE) between 2007 and 2016 and who had coronary angiography within 24 months before or after the TEE were retrospectively evaluated.ResultsA total of 242 patients fulfilled the inclusion criteria, 60% were male. Mean age was 70 years (SD ± 13 years). In multivariate regression analysis, plaque in the ascending aorta (odds ratio [OR] 2.51, 95% confidence interval [CI] 1.18–5.32, p = 0.017), plaque in at least one of the thoracic aortic segments (OR 2.07, 95% CI 1.02–4.22, p = 0.045), and the presence of mitral annular calcification (MAC, OR 1.84, 95% CI 1.01–3.36, p = 0.046) were predictors of significant CAD. The isolated finding of aortic stenosis (AS) (OR 2.53, 95%CI 1.23–5.21, p = 0.012) was a significant predictor for the absence of normal coronary arteries.ConclusionWith an negative predictive value (NPV) of 80%, the absence of MAC, AS, and aortic plaque makes the presence of significant CAD unlikely. If at least mild AS is present, normal coronary arteries are improbable.

TAVI in Patients with Mitral Annular Calcification and/or Mitral Stenosis.

We herein aimed for analysis of influence of mitral annular calcification (MAC) and mitral stenosis (MS) on outcomes in transcatheter aortic valve implantation (TAVI). Between 11/2009 and 06/2017, 1,058 patients underwent TAVI in the presence of concomitant MAC or MS at our center. Subgroups were built and multivariate logistic regression, COX regression, Kaplan-Meier survival analyses, and receiver operating characteristics method were performed. Thirty-day mortality was 7.5% (79/1,058) with highest mortality in patients severe MS (MAC: 3.4% vs. mild MS: 5.9% vs. moderate MS: 15.0% vs. severe MS: 72.7%; p < 0.001). Moderate-to-severe MS (odds ratio [OR]: 7.75, confidence interval [CI]: 3.94-16.26, p < 0.001), impaired left ventricular ejection fraction (OR: 1.38, CI: 1.10-1.72, p < 0.01), and coronary artery disease (OR: 1.36, CI: 1.11-1.67, p < 0.01) were predictive of 30-day survival. Left ventricular systolic/end-diastolic pressure drop of <59.5 mm Hg / <19.5 mm Hg was associated with increased mortality. TAVI in the presence of MAC and mild MS is associated with acceptable acute outcomes but should be considered high-risk procedures in patients with moderate and especially those with severe MS. Our results suggest adverse hemodynamics after TAVI with concomitant MS, which may be caused by underfilling of the left ventricle leading to low-cardiac output.