Mitral annular calcification severity and invasive hemodynamic confirmation of HFpEF

Q: What are the key findings of this study?

Each 1-category increase in mitral annular calcification severity was independently associated with a 78% higher odds of invasively confirmed heart failure with preserved ejection fraction (OR 1.78).

Q: What is the clinical evidence from this study?

Study design: Cross-Sectional. Population: Heart failure with preserved ejection fraction (HFpEF) (n=160). Intervention: Mitral annular calcification (MAC) severity vs. Lower MAC grades. Primary outcome: Invasively confirmed HFpEF defined by PCWP criteria (OR 1.78, 95% CI 1.22-2.38, p=0.03).

Q: What does this research mean for the field?

Higher mitral annular calcification severity is independently associated with an increased likelihood of invasively confirmed HFpEF and higher diagnostic HFpEF scores. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Gizem Çabuk; BURCU ULUDAĞ ARTUN

doi:10.1097/md.0000000000050835

September 25, 2026MedicineOpen Access

Mitral annular calcification severity and invasive hemodynamic confirmation of HFpEF

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Key result

Greater mitral annular calcification severity is linked to ~78% higher odds of HFpEF per grade.

OR 1.78
95% CI 1.22-2.38
P=0.03
n=160

Figures

Why the study?

The extent to which increasing mitral annular calcification severity parallels invasive hemodynamic evidence of HFpEF and established diagnostic algorithms was uncertain.

Is increasing mitral annular calcification severity associated with invasive hemodynamic confirmation of HFpEF and higher diagnostic scores in older adults?

Key Points

To determine whether mitral annular calcification severity parallels invasive hemodynamic criteria for heart failure with preserved ejection fraction and established clinical diagnostic scores.
Single-center cross-sectional study of 160 patients (mean age 76 years; 67% female; preserved LVEF ~59%) referred for HFpEF assessment, stratified equally across mitral annular calcification grades 1 to 4 (n = 40 per group).
Invasive hemodynamic catheterization was performed in 152 patients, defining HFpEF as a pulmonary capillary wedge pressure ≥15 mm Hg at rest or ≥18 mm Hg following a standardized fluid challenge.
Multivariable logistic and linear regression evaluated independent associations between calcification grade, invasive HFpEF, and continuous H2FPEF and HFA-PEFF diagnostic scores, adjusting for natriuretic peptides and echocardiographic diastolic markers.
Resting pulmonary capillary wedge pressure rose from 13.0 mm Hg in grade 1 to 18.0 mm Hg in grade 4, and post-fluid pressure increased from 16.0 to 24.5 mm Hg (both P < .001).
Invasively defined HFpEF criteria were met in 28.1% of catheterized patients in grade 1, 30.0% in grade 2, 60.0% in grade 3, and 85.0% in grade 4 (P < .001).
Each 1-category increase in calcification grade independently associated with invasive HFpEF diagnosis (OR, 1.78; 95% CI, 1.22–2.38; P = .03), higher H2FPEF scores (β, 0.31; P = .03), and higher HFA-PEFF scores (β, 0.42; P = .004).

Study Design

Type

Cross-Sectional (n=160)

Multicenter

No

Structured PICO

Is increasing mitral annular calcification severity associated with invasive hemodynamic confirmation of HFpEF and higher diagnostic scores in older adults?

P

Population

160 older adults (mean age 76 years, 67% female) with mitral annular calcification referred for HFpEF assessment, evaluated cross-sectionally across four predefined MAC severity grades.

E

Exposure

Mitral annular calcification (MAC) severity graded 1 to 4 based on circumferential extent at the mitral annulus.

C

Comparator

Internal comparison across the 4 predefined MAC severity grades (n=40 per group).

O

Outcome

Invasively confirmed HFpEF defined by pulmonary capillary wedge pressure (PCWP) ≥15 mm Hg at rest or ≥18 mm Hg after a standardized fluid challenge.surrogate

Main Result

Odds Ratio: 1.78 (95% CI 1.22–2.38)

p-value: p=0.03

Increasing severity of mitral annular calcification is independently associated with a higher likelihood of invasively confirmed HFpEF and elevated diagnostic scores, suggesting it is a structural correlate of HFpEF.

Limitations

Cross-sectional observational design cannot determine causality, temporal sequence, or prognostic significance.
Stratified enrollment strategy does not reproduce the natural distribution of MAC severity in an unselected population, limiting external generalizability.
Absence of a non-MAC comparator prevents assessment of the specificity of the findings for MAC.
Invasive hemodynamic assessment was not performed in 8 patients with low-probability noninvasive scores, potentially introducing verification bias.
Exercise right heart catheterization was not available, and rapid fluid challenge was used as an alternative.
Left atrial and right ventricular strain were not assessed.
Observational cross-sectional design cannot establish causality
Stratified enrollment strategy does not reflect the real-world distribution of MAC severity, limiting external generalizability
Absence of a non-MAC comparator prevents assessment of whether the hemodynamic profile is specific to MAC
Invasive hemodynamic assessment was not performed in 8 patients with low-probability noninvasive scores

Implication

MAC severity was associated with invasive HFpEF odds; leaves open whether grading aids diagnosis or risk stratification in referred patients.

Abstract

Mitral annular calcification (MAC) is a common degenerative process in older adults that can impair mitral valve compliance, elevate transmitral gradients, and increase left ventricular filling pressure. However, the extent to which increasing MAC severity parallels invasive hemodynamic evidence of heart failure with preserved ejection fraction (HFpEF) and established diagnostic algorithms remains uncertain. This was a single-center cross-sectional study. We evaluated 160 patients referred for HFpEF assessment who underwent comprehensive echocardiography. MAC severity was graded from 1 to 4 (n = 40 per group). HFpEF was defined invasively as a pulmonary capillary wedge pressure of ≥15 mm Hg at rest or ≥18 mm Hg after a standardized fluid challenge. Multivariable regression models tested the independent association between MAC grade (per 1-category increase) and invasive HFpEF diagnosis, as well as continuous H 2 FPEF (Heavy, Hypertensive, Atrial fibrillation, Pulmonary hypertension, Elder, Filling pressure score) and HFA-PEFF (Heart Failure Association Pretest Assessment, Echocardiography and Natriuretic Peptide, Functional Testing, Final Etiology) scores, adjusting for natriuretic peptide levels and key echocardiographic diastolic parameters. Participants were older (mean age, 76 years) and two-thirds were female, with preserved left ventricular ejection fraction (~59%). Higher MAC severity was associated with progressive elevations in pulmonary capillary wedge pressure (13.0–18.0 mm Hg at rest; 16.0–24.5 mm Hg after fluid challenge; P < .001) and, among catheterized participants, with a higher proportion meeting invasive HFpEF criteria (28.1%, 30.0%, 60.0%, and 85.0% across grades 1–4, respectively; P < .001). MAC grade was independently associated with invasively defined HFpEF (odds ratio, 1.78; 95% confidence interval, 1.22–2.38; P = .03), H 2 FPEF (β, 0.31; P = .03), and HFA-PEFF (β, 0.42; P = .004) scores. N-terminal pro–B-type natriuretic peptide was correlated with all outcomes. MAC severity showed a graded relationship with diastolic burden, invasive HFpEF confirmation, and diagnostic scores, suggesting that advanced MAC is associated with a hemodynamic profile consistent with HFpEF.

Discussion

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Cite This Study

Çabuk et al. (2026) conducted a cross-sectional in Heart failure with preserved ejection fraction (HFpEF) (n=160). Mitral annular calcification (MAC) severity vs. Lower MAC grades was evaluated on Invasively confirmed HFpEF defined by PCWP criteria (OR 1.78, 95% CI 1.22-2.38, p=0.03). Each 1-category increase in mitral annular calcification severity was independently associated with a 78% higher odds of invasively confirmed heart failure with preserved ejection fraction (OR 1.78).

synapsesocial.com/papers/6ab8a897f6e2e6b1238b4d6f https://doi.org/10.1097/md.0000000000050835

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Mitral annular calcification severity and invasive hemodynamic confirmation of HFpEF

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Mitral annular calcification severity and invasive hemodynamic confirmation of HFpEF

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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