Mitral annulus calcification independently tied to all-cause death
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Mitral annulus calcification may be an independent risk factor for all-cause mortality and was more common among older patients and those with concomitant mitral valve dysfunction, according to data published in Mayo Clinic Proceedings.
“When you have mitral valve dysfunction of a severe degree, then the treatments are valve replacement or percutaneous therapy, but those therapies can be hard to do because of calcification. It’s harder than conventional valve surgery and the percutaneous therapies are much less advanced for the mitral valve compared with the aortic valve, where [transcatheter aortic valve replacement] has now become very routine,” Patricia A. Pellikka, MD, professor of medicine and chair of the division of cardiovascular ultrasound at Mayo Clinic, told Healio. “Ultimately we’d like to find out how to prevent it, or if it’s there, how to halt its progression and the subsequent development of mitral valve dysfunction.”
To better understand mitral annulus calcification, researchers conducted a retrospective review of 24,414 patients who underwent echocardiography in 2015 and identified all adults with mitral valve dysfunction, defined as mitral regurgitation or mitral stenosis of moderate or greater severity.
Pellikka and colleagues compared patient characteristics and trends in all-cause mortality between patients with mitral annulus calcification and those with mitral valve dysfunction during an average follow-up of 3 years.
“Mitral annulus calcification is a degenerative process that involves the base of the mitral valve with some calcification in that area,” Pellikka told Healio. “We noticed it on our echocardiograms and wanted to see how prevalent it was in the population and its relationship to disease and risk factors for it. And the results were quite interesting.”
Patient characteristics in mitral annulus calcification
Within the cohort, approximately 23% had mitral annulus calcification. These individuals were more often older (75 vs. 60 years; P < .001), more often had mitral stenosis (6.6% vs. 0.5%; P < .001) and mitral regurgitation without mitral stenosis (9.5% vs. 6.1%; P < .001) compared with those without mitral annulus calcification.
After adjustment, both aortic stenosis (OR = 4.03; 95% CI, 3.05-5.33; P < .01) and aortic valve replacement (OR = 3.67; 95% CI, 2.78-4.83; P < .01) were associated with mitral stenosis in patients with mitral annulus calcification.
Moreover, reduced left ventricular ejection fraction, LV outflow tract obstruction, estimated glomerular filtration rate, female sex, LV mass and age were all associated with the presence of mitral regurgitation in the setting of mitral annulus calcification.
Mitral annulus calcification and all-cause death
Researchers reported that mitral annulus calcification was independently associated with risk for all-cause mortality during follow-up compared with no annulus calcification (adjusted HR = 1.4; 95% CI, 1.31-1.49; P < .001), and the presence of mitral valve dysfunction conferred even greater risk in patients with mitral annulus calcification (aHR = 1.79; 95% CI, 1.58-2.01; P < .001).
Pellikka and colleagues observed no significant relationship between mortality in the setting of mitral annulus calcification and mitral valve dysfunction (P = .1); mitral stenosis (P = .18) and mitral regurgitation (P = .32).
“It can be hard for surgeons who are working on mitral annulus calcification with severe mitral valve disease,” Pellikka told Healio. “It’s hard to sew the prosthetic valve into something if the tissue is all calcified and rocklike.
“We have looked at that natural history of patients with calcific mitral valve disease and it is a bad disease to get,” Pellikka told Healio. “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.”
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