Key result
Surgical or transcatheter intervention for mitral annular calcification was associated with 46.3% mortality compared to 39.0% with medical management at 29.6 months (p=0.47).
Why the study?
A systematic approach to quantify mitral annular calcification by multidetector computed tomography in all-comers to guide treatment was lacking.
Does surgical or transcatheter mitral valve replacement improve mortality compared to medical management in patients with mitral annular calcification?
Cohort (n=82)
Yes
Does surgical or transcatheter mitral valve replacement improve mortality compared to medical management in patients with mitral annular calcification?
Absolute Event Rate: 46.3% vs 39%
p-value: p=0.47
An anatomic classification of mitral annular calcification using MDCT can guide treatment selection, though mortality remains high, particularly in high-risk patients undergoing percutaneous TMVR.
No mortality difference seen with valve replacement versus medical therapy; leaves open optimal strategy in mitral annular calcification and requires randomized trials.
BACKGROUND AND AIM OF THE STUDY: A systematic approach to quantify mitral annular calcification (MAC) in all-comers by multidetector computed tomography (MDCT) is essential to guide treatment, but lacking. METHODS: From September 2015 to July 2019, 82 patients with MAC underwent MDCT at two institutions to evaluate for surgical mitral valve replacement (SMVR), transcatheter mitral valve replacement (TMVR), or medical management. Type 1 MAC was defined as <270° annular calcium and Type 2 as ≥270°. Absence/presence of predicted left ventricular outflow tract (LVOT) obstruction with virtual valve placement was used to further define Type 2 MAC into 2A/B for our treatment algorithm. RESULTS: Type 1 MAC was present in 51.2%, Type 2A in 18.3%, and Type 2B in 30.5%. Operable Type 1 patients (50.0%) underwent hybrid transatrial TMVR or SMVR. Type 2A underwent a variety of treatments, and Type 2B surgical candidates (40.0%) underwent hybrid transatrial TMVR secondary to difficult suture anchoring with significant MAC and predicted LVOT obstruction. At a follow-up of 29.6 ± 12.0 months, mortality was 42.7% with 46.3% in the intervention group and 39.0% in the medical group (p = 0.47). All percutaneous TMVR patients expired. This translated to a disproportionate number of Type 2A deaths (80.0% with intervention), but all were high/extreme surgical risk. The hybrid TMVR group consisted of 95.0% Type 1/2B patients and had a lower Society of Thoracic Surgeons predicted risk of operative mortality (7.4% vs. 9.2%, p = 0.43)/mortality. CONCLUSIONS: The highest mortality was seen in percutaneous TMVR Type 2A MAC patients, but they were at the greatest risk. Here we provide an objective MAC treatment algorithm for all-comers based on operability/anatomy.
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Alexis et al. (2021) conducted a cohort in Mitral annular calcification (n=82). Surgical or transcatheter mitral valve replacement vs. Medical management was evaluated on Mortality (p=0.47). Surgical or transcatheter intervention for mitral annular calcification was associated with 46.3% mortality compared to 39.0% with medical management at 29.6 months (p=0.47).
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