June 1, 2020Journal of the American College of Cardiology
The Natural History of Severe Calcific Mitral Stenosis
Key result
High transmitral gradient, elevated RVSP, and inactivity strongly predict mortality in severe calcific mitral stenosis.
- HR 1.68
- HR 2.27
- HR 6.59
Why the study?
The prevalence of calcific MS increases with age, but its natural history and relation to cardiac symptoms or comorbidities are not well defined.
What are the clinical and echocardiographic determinants of all-cause mortality in adults with isolated severe calcific mitral stenosis?
Key Points
- To assess the prevalence of symptoms and comorbidities and identify determinants of all-cause mortality in patients with isolated severe calcific mitral stenosis.
- Retrospectively evaluated adults with isolated severe calcific mitral stenosis and mitral valve area ≤1.5 cm² between July 2003 and December 2017 (N=200; mean age 78 ± 11 years; mean follow-up 2.8 ± 3.0 years).
- Assessed baseline clinical symptoms, functional inactivity (requirement for assistance with activities of daily living), Charlson Comorbidity Index, and echocardiographic hemodynamics.
- One-year Kaplan-Meier survival without intervention was 72%, with baseline symptoms present in 60% of patients (n=120) and developing in an additional 10% (n=20) during follow-up.
- Independent determinants of all-cause mortality were functional inactivity (HR: 6.59; 95% CI: 3.54 to 12.3; p < 0.01), Charlson Comorbidity Index >5 (HR: 1.53; 95% CI: 1.04 to 2.26; p < 0.01), transmitral gradient ≥8 mm Hg (HR: 1.68; 95% CI: 1.12 to 2.51; p = 0.012), and right ventricular systolic pressure ≥50 mm Hg (HR: 2.27; 95% CI: 1.50 to 3.43; p < 0.01).
- Presence of clinical symptoms at baseline or during follow-up was not significantly associated with mortality.
Structured PICO
What are the clinical and echocardiographic determinants of all-cause mortality in adults with isolated severe calcific mitral stenosis?
P
Population
200 adults with isolated severe calcific mitral stenosis (mitral valve area ≤1.5 cm2), mean age 78 ± 11 years, 18% male.
O
Outcome
All-cause mortalityhard clinical
In patients with severe calcific mitral stenosis, mortality is driven by comorbidities, inactivity, and echocardiographic severity (TMG ≥8 mm Hg, RVSP ≥50 mm Hg) rather than the presence of symptoms.
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Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“We have looked at that natural history of patients with calcific mitral valve disease and it is a bad disease to get. In the past, mitral stenosis was a consequence of rheumatic fever, but now increasingly we're seeing it as a manifestation of calcific disease. The process of calcification is becoming a more common etiology of mitral stenosis, and it is harder to treat. It's also harder to evaluate, but I think there will be a lot more research about therapies and progression in the years to come.”
“The association between mitral annulus calcification and mitral valve dysfunction is important to understand because it affects treatment considerations for valve dysfunction. Mitral valve surgery is associated with high risk for patients with mitral annulus calcification, in part because advanced age can be a factor. Severe calcification makes mitral valve procedures more challenging to perform.”
Implication
Inactivity and echo severity markers identify higher-risk patients; hypothesis-generating for risk stratification beyond symptoms in calcific mitral stenosis.
Abstract
BACKGROUND Prevalence of calcific mitral stenosis (MS) increases with age; however, its natural history and relation to cardiac symptoms or comorbidities are not well defined. OBJECTIVES This study assessed the prevalence of symptoms, comorbidities, and determinants of all-cause mortality in patients with severe calcific MS. METHODS The authors retrospectively investigated adults with isolated severe calcific MS and mitral valve area ≤1.5 cm2 from July 2003 to December 2017. Inactivity was defined as requirement for assistance with activities of daily living. RESULTS Of 491 patients with isolated severe MS, calcific MS was present in 200 (41%; age 78 ± 11 years, 18% men, 32% with atrial fibrillation). Charlson Comorbidity Index was 5.1 ± 1.7 and 14 (7%) were inactive. Mitral valve area and transmitral gradient (TMG) were 1.26 ± 0.19 cm2 and 8.1 ± 3.8 mm Hg, respectively. Symptoms were present at baseline in 120 (60%); 20 (10%) developed symptoms during follow-up of 2.8 ± 3.0 years. Kaplan-Meier survival at 1 year was 72% without intervention. Inactivity (hazard ratio [HR]: 6.59; 95% confidence interval [CI]: 3.54 to 12.3; p < 0.01), Charlson Comorbidity Index >5 (HR: 1.53; 95% CI: 1.04 to 2.26; p < 0.01), TMG ≥8 mm Hg (HR: 1.68; 95% CI: 1.12 to 2.51; p = 0.012), and right ventricular systolic pressure ≥50 mm Hg (HR: 2.27; 95% CI: 1.50 to 3.43; p < 0.01) were independently associated with mortality. Symptoms were not associated with mortality. CONCLUSION Patients with isolated severe calcific MS had a high burden of comorbidities, resulting in high mortality without intervention. Symptoms were reported in 60%, but not associated with mortality. TMG ≥8 mm Hg and right ventricular systolic pressure ≥50 mm Hg were independently associated with mortality.
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Cite This Study
Kato et al. (2020) studied this question. Transmitral gradient ≥8 mmHg (HR 1.68), right ventricular systolic pressure ≥50 mmHg (HR 2.27), and inactivity (HR 6.59) independently predicted mortality in severe calcific mitral stenosis.