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Ahmad S, Yousaf A, Ghumman GM, Dvalishvili M, Ahsan MJ, Dilibe A, Reis HL, Qavi AH, Szerlip M, Goldsweig AM. Outcomes of transcatheter aortic valve replacement in patients with mitral annular calcification and concomitant mitral valve dysfunction: A systematic review and meta-analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 61:99-109. [PMID: 37867120 DOI: 10.1016/j.carrev.2023.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/07/2023] [Accepted: 10/12/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Calcific aortic stenosis is the principal indication for transcatheter aortic valve replacement (TAVR). Comorbid mitral annular calcification (MAC) is often present in patients undergoing TAVR. Limited data exist on the impact of MAC on TAVR outcomes. We conducted a systematic review and meta-analysis to explore the effects of MAC and concomitant mitral valve dysfunction (MVD) on TAVR outcomes. METHODS A comprehensive literature review was conducted using PubMed, Embase, Google Scholar, ClinicalTrials.gov, Scopus, and OVID for studies until March 20, 2023. Using the random-effects Mantel-Haenszel method, we calculated pooled risk ratios (RRs) and their corresponding 95 % confidence intervals (CIs) for all dichotomous variables. RESULTS Six studies comprising 5822 patients (2541 with MAC [severe MAC (>4 mm thickness) 583; non-severe MAC 1958; 400 with MVD; and 1071 without MVD], 3281 without MAC) met inclusion criteria. At 30 days and 1 year, no significant differences were observed between the overall MAC and no MAC groups in terms of mortality, stroke, and permanent pacemaker implantation. However, MAC with MVD was associated with a higher risk of all-cause mortality compared to MAC without MVD at 30 days (RR = 3.43, 95 % CI 2.04-5.76, P < 0.00001) and at 1 year (RR = 2.44, 95 % CI 1.85-3.20, P < 0.00001). Moreover, the risk of cardiovascular mortality was higher in patients with MAC and MVD compared to those with MAC alone (RR = 2.77, 95 % CI 1.89-4.06, P < 0.00001). Additionally, patients with severe MAC had a higher risk of major bleeding at 30 days compared to the non-severe MAC group (RR = 1.33, 95 % CI 1.04-1.69, P = 0.02). CONCLUSION TAVR appears to be safe in patients with non-severe MAC, but severe MAC is associated with a higher risk of major bleeding and concomitant MVD increases the mortality risk in patients undergoing TAVR.
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Affiliation(s)
- Soban Ahmad
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, NE, USA; Department of Medicine, East Carolina University, Greenville, NC, USA.
| | - Amman Yousaf
- Department of Medicine, McLaren Flint-Michigan State University, Flint, MI, USA
| | | | | | | | - Arthur Dilibe
- Department of Medicine, East Carolina University, Greenville, NC, USA
| | - Heidi Lynn Reis
- William E Laupus Health Sciences Library, East Carolina University, Greenville, NC, USA
| | - Ahmed Hassaan Qavi
- Division of Cardiovascular Medicine, East Carolina Heart Institute, Greenville, NC, USA
| | - Molly Szerlip
- Department of Cardiology, Baylor Scott and White, The Heart Hospital Plano, Plano, TX, USA
| | - Andrew Michael Goldsweig
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, NE, USA; Department of Cardiology, Baystate Medical Center/UMass Chan Medical School, Springfield, MA, USA
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Moin A, Lak HM, Zafar M, Tariq R, Shaikh FH, Mussa M, Bansal A, Shekhar S, Harb S, Unai S, Kapadia SR. A Systematic Review and Meta-Analysis of Prevalence, Characteristics, and Impact of Mitral Annular Calcification on Outcomes After Transcatheter Aortic Valve Implantation. Am J Cardiol 2023; 201:123-130. [PMID: 37385163 DOI: 10.1016/j.amjcard.2023.05.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 04/28/2023] [Accepted: 05/27/2023] [Indexed: 07/01/2023]
Abstract
There is a paucity of data on the prognostic impact of mitral annular calcification (MAC) in patients who underwent transcatheter aortic valve implantation (TAVI) with conflicting results being reported by the studies that are published. Therefore, we performed a meta-analysis to assess the short-term and long-term outcomes of MAC in patients after TAVI. Of 25,407 studies identified after the initial database search, 4 observational studies comprising 2,620 patients (2,030 patients in the nonsevere MAC arm and 590 patients in the severe MAC arm) were included in the final analysis. Compared with patients with nonsevere MAC, the severe MAC group was associated with significantly higher incidences of overall bleeding (0.75 [0.57 to 0.98], p = 0.03, I2 = 0%) at 30 days. However, no significant difference was observed between the 2 groups for the rest of the 30-day outcomes: all-cause mortality (0.79 [0.42 to 1.48], p = 0.46, I2 = 9%), myocardial infarction (1.62 [0.37 to 7.04], p = 0.52, I2 = 0%), cerebrovascular accident or stroke (1.22 [0.53 to 2.83], p = 0.64, I2 = 0%), acute kidney injury (1.48 [0.64 to 3.42], p = 0.35, I2 = 0%), and pacemaker implantation (0.70 [0.39 to 1.25], p = 0.23, I2 = 68%). Similarly, follow-up outcomes also showed no significant difference between the 2 groups: all-cause mortality (0.69 [0.46 to 1.03], p = 0.07, I2 = 44%), cardiovascular mortality (0.52 [0.24 to 1.13], p = 0.10, I2 = 70%) and stroke (0.83 [0.41 to 1.69], p = 0.61, I2 = 22%). The sensitivity analysis, however, demonstrated significant results for all-cause mortality (0.57 [0.39 to 0.84], p = 0.005, I2 = 7%) by removing the study by Okuno et al5 and cardiovascular mortality (0.41 [0.21 to 0.82], p = 0.01, I2 = 66%) by removing the study by Lak et al.7 In conclusion, our meta-analysis corroborates the notion that isolated MAC is not an independent predictor of long-term mortality after TAVI and determines severe MAC to be a predictor of mortality at follow-up because of the higher incidence of mitral valve dysfunction associated with it.
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Affiliation(s)
- Ariba Moin
- Department of Internal Medicine, Dow Medical College, Civil Hospital, Karachi, Pakistan
| | - Hassan Mehmood Lak
- Section of Clinical Cardiology, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marium Zafar
- Department of Internal Medicine, Dow Medical College, Civil Hospital, Karachi, Pakistan
| | - Rabbia Tariq
- Department of Internal Medicine, Dow Medical College, Civil Hospital, Karachi, Pakistan
| | - Fahad Hassan Shaikh
- Department of Cardiology, Dow Medical College, Civil Hospital, Karachi, Pakistan
| | - Muhammad Mussa
- Department of Internal Medicine, Dow Medical College, Civil Hospital, Karachi, Pakistan
| | - Agam Bansal
- Aortic Valve Center, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shashank Shekhar
- Aortic Valve Center, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Serge Harb
- Aortic Valve Center, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shinya Unai
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Samir R Kapadia
- Aortic Valve Center, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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Haensig M, Kuntze T, Gonzalez DL, Lapp H, Lauten P, Owais T. Extensive calcification of the mitral valve annulus in transcatheter aortic valve implants. Interact Cardiovasc Thorac Surg 2021; 34:167-175. [PMID: 34601608 PMCID: PMC8766209 DOI: 10.1093/icvts/ivab235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 01/13/2021] [Accepted: 07/02/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES This study sought to report the calcification pattern of the mitral valve annulus and its implications for procedural and safety outcomes in transcatheter aortic valve implantation. METHODS Between November 2018 and September 2019, a total of 305 patients had transcatheter aortic valve implants at our institution. The extent of calcification of the mitral valve annulus was analysed, and the impact on safety outcomes was evaluated. RESULTS The prevalence of mitral annular calcification (MAC) was 43%. Calcification of the mitral valve annulus was either less than or at least one-third of the posterior annulus (34% and 32%), the whole posterior annulus (28%) or the extension to the attachment of the anterior leaflets (7%). Severe circumferential MAC revealed moderate paravalvular leaks in 5/8 (63%) patients and was associated with right branch bundle block [odds ratio (OR) 2.01 (0.39–3.06); P = 0.098] and low cardiac output [OR 3.12 (1.39–7.04); P = 0.033]. Subannular calcification at the anterolateral trigonum represented a risk factor for left ventricular outflow tract injury [OR 3.54 (1.38–8.27); P = 0.001] in balloon-expandable valves, associated with relevant rhythm disorders [OR 2.26 (1.17–5.65); P = 0.014] and female gender (7/8, 88%). The 30-day all-cause mortality in circumferential MAC reaching into the anterior annulus (grade IV) compared to patients with less MAC (grade I–III) was 13% vs 2% with a mean valve size of 24.6 vs 25.7 mm. CONCLUSIONS Extensive MAC was associated with moderate paravalvular leaks, with implications for the prosthesis size and survival in transcatheter aortic valve implants. In severe MAC, we recommend implanting oversized self-expandable prostheses, the goal being to reduce the risk of right branch bundle block and paravalvular leaks. Subj collection 122, 125
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Affiliation(s)
- Martin Haensig
- Corresponding author. Department of Cardiothoracic Surgery, Central Clinic Hospital of Bad Berka, Rhön AG, Robert-Koch Allee 9, 99438 Bad Berka, Germany. Tel: +49-364585-41137; fax: +49-364585-3510; e-mail: (M. Haensig)
| | - Thomas Kuntze
- Department of Cardiothoracic Surgery, Central Clinic Hospital of Bad Berka, Bad Berka, Germany
| | - David Lopez Gonzalez
- Department of Cardiothoracic Surgery, Central Clinic Hospital of Bad Berka, Bad Berka, Germany
| | - Harald Lapp
- Department of Cardiology and Internal Medicine, Central Clinic Hospital of Bad Berka, Bad Berka, Germany
| | - Philipp Lauten
- Department of Cardiology and Internal Medicine, Central Clinic Hospital of Bad Berka, Bad Berka, Germany
| | - Tamer Owais
- Department of Cardiothoracic Surgery, Central Clinic Hospital of Bad Berka, Bad Berka, Germany
- Department of Cardiothoracic Surgery, Cairo University, Cairo, Egypt
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David TE, Lafreniere-Roula M, David CM, Issa H. Outcomes of combined aortic and mitral valve replacement with reconstruction of the fibrous skeleton of the heart. J Thorac Cardiovasc Surg 2021; 164:1474-1484. [PMID: 34627607 DOI: 10.1016/j.jtcvs.2021.09.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 07/25/2021] [Accepted: 09/02/2021] [Indexed: 10/31/2022]
Abstract
OBJECTIVES The objectives of this study were to examine operative and long-term results of combined aortic and mitral valve replacement when reconstruction of the fibrous skeleton of the heart is needed because of calcification, abscess, previous operations, or patient-prosthesis mismatch. METHODS From 1985 to 2020, 182 consecutive patients underwent combined aortic and mitral valve replacement with reconstruction of the intervalvular fibrous skeleton in all cases and also the posterior mitral annulus in 63 patients. Bovine pericardium or Dacron grafts were used for the reconstructions. Median follow-up was 7.5 (interquartile range, 2.1-12.6) years and 98% complete. RESULTS Patient mean age was 62 years; 69% had 1 or more previous valve operations, and 92% were functional class III or IV. The indications for reconstruction were extensive calcification of the fibrous skeleton in 34%, abscess in 13%, tissue damage secondary to previous operations in 39%, and patient-prosthesis mismatch of the mitral valve in 13%. Bovine pericardium was used in two-thirds of cases and Dacron grafts in one-third. Operative mortality was 13.2% and postoperative complications were common. Survival at 1, 10, and 20 years was 81.8%, 51.1%, and 23.7%, respectively. Fourteen patients required reoperation and 3 transcatheter interventions. The cumulative probability of reinterventions at 1, 10, and 20 years were 3.3%, 5.8%, and 9.1%, respectively. Most patients experienced symptomatic improvement postoperatively. CONCLUSIONS Reconstructions of the fibrous skeleton of the heart are associated with high operative mortality but the long-term results are satisfactory because most patients would not have survived without surgical intervention.
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Affiliation(s)
- Tirone E David
- Division of Cardiac Surgery of the Peter Munk Cardiac Centre at Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada.
| | - Myriam Lafreniere-Roula
- Division of Cardiac Surgery of the Peter Munk Cardiac Centre at Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Carolyn M David
- Division of Cardiac Surgery of the Peter Munk Cardiac Centre at Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Hugo Issa
- Division of Cardiac Surgery of the Peter Munk Cardiac Centre at Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada
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5
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Mesnier J, Urena M, Chong-Nguyen C, Fischer Q, Kikoïne J, Carrasco JL, Terzian Z, Brochet E, Iung B, Himbert D. Impact of Mitral Annular Calcium and Mitral Stenosis on Outcomes After Transcatheter Aortic Valve Implantation. Am J Cardiol 2021; 155:103-112. [PMID: 34284866 DOI: 10.1016/j.amjcard.2021.06.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 06/06/2021] [Accepted: 06/14/2021] [Indexed: 11/24/2022]
Abstract
Mitral annular calcium (MAC) is a common finding in patients undergoing transcatheter aortic valve implantation (TAVI) and may be associated with mitral stenosis (MAC-MS). Their impact on post-TAVI outcomes remains controversial. We sought to assess the impact of MAC and MAC-MS on clinical outcomes following TAVI. We included 1,177 patients who consecutively underwent TAVI in our institution between January 2008 and May 2018. MAC diagnosis reposed on echocardiogram and computed tomography. The combination of MAC and a mean transmitral gradient ≥ 5 mmHg defined MAC-MS. The study included 1,177 patients, of whom 504 (42.8%) had MAC and 85 (7.2%) had MAC-MS. Patients with and without MAC had similar outcomes except for a higher rate of pacemaker implantation in MAC patients (adjusted HR: 1.32, 95% CI: 1.03-1.69, p = 0.03). The subgroup of patients with severe MAC had similar outcomes. However, 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). In conclusion, MAC is present in nearly half of the patients treated with TAVI but MAC-MS is far less frequent. In itself, even severe, MAC does not influence outcomes while MAC-MS is an independent predictor of all-cause 1-year mortality. Measurement of mean transmitral gradient identifies patients with MAC at high risk after TAVI.
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Ancona MB, Toscano E, Moroni F, Ferri LA, Russo F, Bellini B, Sorropago A, Mula C, Festorazzi C, Gamardella M, Vella C, Beneduce A, Romano V, Belluschi I, Buzzatti N, Agricola E, Montorfano M. Patients younger than 70 undergoing transcatheter aortic valve implantation: Procedural outcomes and mid-term survival. IJC HEART & VASCULATURE 2021; 34:100817. [PMID: 34169142 PMCID: PMC8207181 DOI: 10.1016/j.ijcha.2021.100817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 05/31/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Based on recent data, the indication for transcatheter aortic valve implantation (TAVI) is expanding to individuals at lower surgical risk, who are generally younger than subjects historically treated for severe aortic stenosis. Indeed, younger patients have traditionally been under-represented in current TAVI literature. The aim of the present study is to report about clinical features, procedural outcomes and mid-term outcomes of patients younger than 70 who underwent TAVI in a single high-volume center. MATERIALS AND METHODS Consecutive patients younger than 70 years of age who underwent TAVI for severe, symptomatic aortic stenosis between 2007 and 2019 at a single, tertiary referral center have been included in this retrospective study. Procedural and mid-term outcomes were analyzed, comparing 1st generation with 2nd generation devices. RESULTS Between 2007 and 2019, 1740 TAVI procedures were performed in our center. Among these, one hundred twenty-nine (7.4%) patients were younger than 70 years at the time of the intervention and were included in the present analysis. Fifty-eight patients (45%) were implanted with a 1st generation prosthesis while seventy-one patients (55%) were implanted with a 2nd generation device. Reasons which lead to a transcatheter approach in this population were: previous CABG (27.9%); porcelain aorta (24%); severe left ventricular systolic dysfunction (21.7%); prior chest radiation (19.4%); severe lung disease (8.5%); hemodynamic instability (7.0%); advanced liver disease (4.6%) and active cancer (3.9%). Overall device success rate was 89%, with no differences among 1st and 2nd generation devices. Threeyears all-cause mortality was 34%, with no difference among the two groups. Low incidence of aortic-valve re-intervention was observed at mid-term follow-up (late valve re-intervention = 2.3%). CONCLUSIONS TAVI in young patient with appropriate indication for intervention is a safe procedure, associated with low rate of in hospital mortality and low rate of severe complications both with 1st and with 2nd generation devices. When considering long term durability, more data are needed; in our case series long-term follow up shows a good survival and also an extremely low rate of valve re-intervention.
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Affiliation(s)
- Marco B. Ancona
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Evelina Toscano
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Interventional Cardiology Department, Policlinico di Monza, Monza, Italy
| | - Francesco Moroni
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca A. Ferri
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Filippo Russo
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Barbara Bellini
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Sorropago
- Interventional Cardiology Department, Policlinico di Monza, Monza, Italy
| | - Caterina Mula
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Costanza Festorazzi
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Gamardella
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ciro Vella
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Beneduce
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Vittorio Romano
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Igor Belluschi
- Heart Surgery Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nicola Buzzatti
- Heart Surgery Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Eustachio Agricola
- Cardiovascular Imaging Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Matteo Montorfano
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Silbiger JJ. Mitral Annular Calcification and Calcific Mitral Stenosis: Role of Echocardiography in Hemodynamic Assessment and Management. J Am Soc Echocardiogr 2021; 34:923-931. [PMID: 33857624 DOI: 10.1016/j.echo.2021.04.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 02/23/2021] [Accepted: 04/06/2021] [Indexed: 12/01/2022]
Abstract
As the life expectancy of the population continues to increase, mitral annular calcification has emerged as an important cause of mitral stenosis (MS), commonly referred to as calcific or degenerative MS. Mitral annular calcification results in valvular stenosis when calcification extends into the base of the mitral leaflet(s) and displaces the mitral valve hinge point(s) into the left ventricular inlet. Echocardiographic determination of mitral vale area is fraught with difficulties and often precludes using planimetry or the Hatle formula. Given the numerous confounders that affect transmitral flow in calcific MS, evaluation of lesion severity should incorporate flow-independent methods such as the continuity equation and the mitral valve dimensionless index. In light of the significant risks entailed, there is little enthusiasm for mitral valve replacement in patients with calcific MS. Transcatheter mitral valve replacement is generally offered on a compassionate use basis to patients deemed to be at high surgical risk.
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Alexis SL, Alzahrani TS, Akkoc D, Salna M, Khalique OK, El-Eshmawi A, Sengupta A, Hahn RT, Lerakis S, Kini A, Sharma SK, Dangas GD, Kodali SK, Leon MB, Adams DH, Bapat VB, George I, Tang GHL. Anatomic classification of mitral annular calcification for surgical and transcatheter mitral valve replacement. J Card Surg 2021; 36:2410-2418. [PMID: 33797788 DOI: 10.1111/jocs.15535] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/08/2021] [Accepted: 02/15/2021] [Indexed: 11/27/2022]
Abstract
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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Affiliation(s)
- Sophia L Alexis
- Department of Cardiovascular Surgery, Mount Sinai Medical Center, New York, New York, USA
| | - Talal S Alzahrani
- Division of Cardiology, Columbia University Medical Center, New York, New York, USA
| | - Deniz Akkoc
- Division of Cardiac Thoracic and Vascular Surgery, Columbia University Medical Center, New York, New York, USA
| | - Michael Salna
- Division of Cardiac Thoracic and Vascular Surgery, Columbia University Medical Center, New York, New York, USA
| | - Omar K Khalique
- Division of Cardiology, Columbia University Medical Center, New York, New York, USA
| | - Ahmed El-Eshmawi
- Department of Cardiovascular Surgery, Mount Sinai Medical Center, New York, New York, USA
| | - Aditya Sengupta
- Department of Cardiovascular Surgery, Mount Sinai Medical Center, New York, New York, USA
| | - Rebecca T Hahn
- Division of Cardiology, Columbia University Medical Center, New York, New York, USA
| | - Stamatios Lerakis
- Division of Cardiology, Mount Sinai Medical Center, New York, New York, USA
| | - Annapoorna Kini
- Division of Cardiology, Mount Sinai Medical Center, New York, New York, USA
| | - Samin K Sharma
- Division of Cardiology, Mount Sinai Medical Center, New York, New York, USA
| | - George D Dangas
- Division of Cardiology, Mount Sinai Medical Center, New York, New York, USA
| | - Susheel K Kodali
- Division of Cardiology, Columbia University Medical Center, New York, New York, USA
| | - Martin B Leon
- Division of Cardiology, Columbia University Medical Center, New York, New York, USA
| | - David H Adams
- Department of Cardiovascular Surgery, Mount Sinai Medical Center, New York, New York, USA
| | - Vinayak B Bapat
- Division of Cardiac Thoracic and Vascular Surgery, Columbia University Medical Center, New York, New York, USA
| | - Isaac George
- Division of Cardiac Thoracic and Vascular Surgery, Columbia University Medical Center, New York, New York, USA
| | - Gilbert H L Tang
- Department of Cardiovascular Surgery, Mount Sinai Medical Center, New York, New York, USA
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Relevance of Functional Mitral Regurgitation in Aortic Valve Stenosis. Am J Cardiol 2020; 136:115-121. [PMID: 32941813 DOI: 10.1016/j.amjcard.2020.09.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 09/11/2020] [Accepted: 09/11/2020] [Indexed: 01/03/2023]
Abstract
The clinical relevance of functional-mitral-regurgitation (FMR) in patients with aortic valve stenosis (AS) has been poorly studied using a quantitative approach. In addition, FMR prognostic value has mostly been analyzed after aortic valve replacement. Between 2010 and 2014 the echocardiograms of consecutive AS patients were retrospectively reviewed. Inclusion criteria were calcified aortic valve with transaortic-velocity >2.5 m/s and calculated mitral effective regurgitant orifice area (ERO) in the presence of mitral regurgitation. Organic mitral valve disease was an exclusion-criteria. Primary endpoint was heart failure or death under medical management. Secondary endpoint was heart failure or death. Eligible patients were 189, age 79 ± 8 years, 61% NYHA I/II, indexed aortic valve area (AVA) 0.55 ± 0.17 cm2/m2. Mitral ERO was 7.6 ± 4.2 mm2 (>10 mm2 in 30% of patients). Longitudinal function (by S'-TDI) was associated with mitral ERO independently of ejection fraction and ventricular volumes (p = 0.01). Mitral ERO greater than 10 mm2 (threshold identified by spline survival-modeling) was associated with severe symptoms (Odds ratio [OR] 3.1 [1.6 to 6.0]; p = 0.0006) and higher pulmonary-arterial-pressure (OR 3.0 [1.4 to 5.9]; p = 0.002). Follow-up was completed for 175 patients. After 4.7 [1.4 to 7.2] years, 87 (50%) patients underwent AVR, 66 (38%) had heart-failure, 64 (37%) died. No procedure on FMR was required. Mitral ERO was independently associated with primary and secondary endpoints both as continuous variable (Hazard ratio [HR] 1.15 [1.00 to 1.30]; p = 0.04 and HR 1.23 [1.05 to 1.43]; p = 0.01 per 5 mm2 ERO increase) or as ERO> versus ≤10 mm2. Adjustment for S'-TDI or subgroup-analysis did not affect results. The analysis by AVA revealed the incremental prognostic role of mitral ERO over AS severity. In conclusion, AS patients with concomitant FMR >10 mm2 holds a higher risk during medical follow-up. FMR quantitation, even for volumetrically modest regurgitation, provides incremental prognostic information over AS severity.
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10
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Okuno T, Brugger N, Asami M, Heg D, Siontis GCM, Winkel MG, Lanz J, Gräni C, Huber A, Stortecky S, George I, Kodali S, Pilgrim T, Windecker S, Khalique OK, Praz F. Clinical impact of mitral calcium volume in patients undergoing transcatheter aortic valve implantation. J Cardiovasc Comput Tomogr 2020; 15:356-365. [PMID: 33121904 DOI: 10.1016/j.jcct.2020.10.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 10/02/2020] [Accepted: 10/12/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Mitral annular calcification (MAC) has been associated with mitral valve (MV) disease and cardiovascular events in patients undergoing transcatheter aortic valve implantation (TAVI). We aimed to investigate the incidence and impact of mitral calcium volume (MCV) quantified by multidetector computed tomography (MDCT) on MV function and clinical outcomes after TAVI. METHODS Consecutive patients with exploitable echocardiography and MDCT performed during TAVI screening were enrolled in this retrospective analysis. Mitral calcium was assessed visually and measured using a semi-automatic tool developed for the aortic valve in an off-label fashion. RESULTS MCV >0 mm3 was found in 65% of the 875 included patients. Patients with calcification were older (82 ± 6 versus 81 ± 7; P = 0.002) and had high prevalence of renal dysfunction (69% versus 61%; P = 0.017) and mitral stenosis (25% versus 4%, P < 0.001). MCV correlated well with visual MAC severity (r = 0.94; P < 0.001), but showed a greater predictive value for mitral stenosis (AUC = 0.804 vs. 0.780, P = 0.012) , while it was not a predictor of mitral regurgitation (AUC = 0.514). Correlations were found between MCV and echocardiographic parameters including MV area, mean transmitral gradient, and pressure half-time (P < 0.001 for all). MCV did not impact on cardiovascular mortality or new permanent pacemaker implantation after TAVI. CONCLUSIONS Calcification of the mitral apparatus is common in TAVI candidates and results in mitral stenosis in 25% of the patients. Increasing MCV predicts mitral stenosis, but had no impact on clinical outcomes following TAVI. CLINICAL TRIAL REGISTRATION NCT01368250.
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Affiliation(s)
- Taishi Okuno
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Nicolas Brugger
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Masahiko Asami
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Dik Heg
- CTU, University of Bern, Bern, Switzerland
| | - George C M Siontis
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Mirjam G Winkel
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Jonas Lanz
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Christoph Gräni
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Adrian Huber
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, University of Bern, Bern, Switzerland
| | - Stefan Stortecky
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Isaac George
- Structural Heart and Valve Center, Division of Cardiology, New York-Presbyterian Hospital-Columbia University Medical Center, New York, USA
| | - Susheel Kodali
- Structural Heart and Valve Center, Division of Cardiology, New York-Presbyterian Hospital-Columbia University Medical Center, New York, USA
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - Omar K Khalique
- Structural Heart and Valve Center, Division of Cardiology, New York-Presbyterian Hospital-Columbia University Medical Center, New York, USA
| | - Fabien Praz
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland.
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11
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Kamoen V, El Haddad M, De Backer T, De Buyzere M, Timmermans F. Outcome of degenerative nonprolapse mitral regurgitation using the average pixel intensity method. Echocardiography 2020; 37:1329-1335. [PMID: 32777144 DOI: 10.1111/echo.14695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 04/27/2020] [Accepted: 04/27/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Primary mitral valve regurgitation (MR) is a comprehensive term that mostly comprises mitral valve prolapse (MVP), while other causes of degenerative MR are often not considered. We describe the echocardiographic characteristics of degenerative nonprolapse mitral regurgitation (DMR) and assess the outcome at medium-term follow-up using the novel average pixel intensity (API) method. METHODS Of 126 patients with any nonprolapse DMR were consecutively included. MR was graded according to all guideline-recommended parameters and with the API method. MR flow dynamics in DMR were compared to MVP-MR and functional MR (FMR). RESULTS DMR is associated with moderate-to-severe calcifications of the mitral valve apparatus, and a low event rate was observed at a mean follow-up of 27 months. The API grading method had a higher feasibility (94%) compared to proximal isovelocity surface area (PISA) (60%) method and vena contracta width (VCW) (71%) for assessing MR. The API method was predictive for events. The API method also provides insights into DMR flow dynamics: A triphasic pattern was observed with a midsystolic nadir for both API and PISA-EROA, which is similar to the dynamic flow pattern described in FMR, but distinct from holosystolic MVP-MR. Compared to FMR and MVP-MR patients, DMR is less severe and patients with DMR are generally older than MVP-MR patients. CONCLUSIONS DMR is a distinct MR pathology and conveys a relatively low event rate. MR grading was feasible with the API method, and flow dynamics demonstrated a similar triphasic pattern compared to FMR but distinct from holosystolic MVP-MR.
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Affiliation(s)
- Victor Kamoen
- Department of Cardiology, Heart Center, Ghent University Hospital, Ghent, Belgium
| | - Milad El Haddad
- Department of Cardiology, Heart Center, Ghent University Hospital, Ghent, Belgium
| | - Tine De Backer
- Department of Cardiology, Heart Center, Ghent University Hospital, Ghent, Belgium
| | - Marc De Buyzere
- Department of Cardiology, Heart Center, Ghent University Hospital, Ghent, Belgium
| | - Frank Timmermans
- Department of Cardiology, Heart Center, Ghent University Hospital, Ghent, Belgium
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12
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Eberhard M, Schönenberger ALN, Hinzpeter R, Euler A, Sokolska J, Weber L, Kuzo N, Manka R, Kasel AM, Tanner FC, Alkadhi H. Mitral annular calcification in the elderly - Quantitative assessment. J Cardiovasc Comput Tomogr 2020; 15:161-166. [PMID: 32798185 DOI: 10.1016/j.jcct.2020.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/04/2020] [Accepted: 06/01/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE To determine the reliability of subjective and objective quantification of mitral annular calcification (MAC) in elderly patients with severe aortic stenosis, to define quantitative sex- and age-related reference values of MAC, and to correlate quantitative MAC with mitral valve disease. METHODS In this retrospective, IRB-approved study, we included 559 patients (268 females, median age 81 years, inter-quartile range 77-85 years) with severe aortic stenosis undergoing CT. Four independent readers performed subjective MAC categorization as follows: no, mild, moderate, and severe MAC. Two independent readers performed quantitative evaluation of MAC using the Agatston score method (AgatstonMAC). Mitral valve disease was determined by echocardiography. RESULTS Subjective MAC categorization showed high inter-reader agreement for no (k = 0.88) and severe MAC (k = 0.75), whereas agreement for moderate (k = 0.59) and mild (k = 0.45) MAC was moderate. Intra-reader agreement for subjective MAC categorization was substantial (k = 0.69 and 0.62). Inter- and intra-reader agreement for AgatstonMAC were excellent (ICC = 0.998 and 0.999, respectively), with minor inconsistencies in MAC involving the left ventricular outflow tract/aortic valve. There were significantly more women than men with MAC (n = 227, 85% versus n = 209, 72%; p < 0.001), with a significantly higher AgatstonMAC (median 597, range 81-2055 versus median 244; range 0-1565; p < 0.001), particularly in patients ≥85 years of age. AgatstonMAC showed an area-under-the-curve of 0.84 to diagnose mitral stenosis, whereas there was no association of AgatstonMAC with mitral regurgitation (p > 0.05). CONCLUSIONS Our study in elderly patients with severe aortic stenosis shows that quantitative MAC scoring is more reliable than subjective MAC assessment. Women show higher AgatstonMAC scores than men, particularly in the elderly population. AgatstonMAC shows high accuracy to diagnose mitral stenosis.
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Affiliation(s)
- M Eberhard
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Switzerland.
| | - A L N Schönenberger
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Switzerland
| | - R Hinzpeter
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Switzerland
| | - A Euler
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Switzerland
| | - J Sokolska
- Department of Cardiology, University Heart Center Zurich, Zurich, Switzerland; Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - L Weber
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Switzerland
| | - N Kuzo
- Department of Cardiology, University Heart Center Zurich, Zurich, Switzerland
| | - R Manka
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Switzerland; Department of Cardiology, University Heart Center Zurich, Zurich, Switzerland
| | - A M Kasel
- Department of Cardiology, University Heart Center Zurich, Zurich, Switzerland
| | - F C Tanner
- Department of Cardiology, University Heart Center Zurich, Zurich, Switzerland
| | - H Alkadhi
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Switzerland
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13
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Schaefer A, Sarwari H, Schofer N, Schneeberger Y, Westermann D, Schoen G, Blankenberg S, Reichenspurner H, Schäfer U, Conradi L. TAVI in Patients with Mitral Annular Calcification and/or Mitral Stenosis. Thorac Cardiovasc Surg 2020; 69:428-436. [PMID: 32114689 DOI: 10.1055/s-0039-1700966] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND We herein aimed for analysis of influence of mitral annular calcification (MAC) and mitral stenosis (MS) on outcomes in transcatheter aortic valve implantation (TAVI). METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Andreas Schaefer
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
| | - Harun Sarwari
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
| | - Niklas Schofer
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | - Yvonne Schneeberger
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
| | - Dirk Westermann
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | - Gerhard Schoen
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Blankenberg
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | | | - Ulrich Schäfer
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | - Lenard Conradi
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
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14
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Kato N, Shibayama K, Omori N, Hoshina M, Makihara Y, Okumura H, Tabata M, Obunai K, Hirao K, Pellikka PA, Watanabe H. Impact of transcatheter aortic valve replacement on hemodynamic status in patients with aortic stenosis and mitral stenosis: Doppler echocardiographic study. J Cardiol 2019; 74:532-538. [DOI: 10.1016/j.jjcc.2019.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 05/02/2019] [Accepted: 05/23/2019] [Indexed: 01/23/2023]
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15
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Li Y, Lu Z, Li X, Huang J, Wu Q. Mitral annular calcification is associated with atrial fibrillation and major cardiac adverse events in atrial fibrillation patients: A systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e17548. [PMID: 31689756 PMCID: PMC6946188 DOI: 10.1097/md.0000000000017548] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 07/23/2019] [Accepted: 09/18/2019] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The incidence of atrial fibrillation (AF) varies from 5.4% to 47.1% in patients with mitral annulus calcification (MAC). We conducted a systematic review and meta-analysis on the association between MAC and AF, as well as the relation between MAC and major cardiac adverse events (MACEs) in AF patients. METHODS We conducted comprehensive search for literature on associations between MAC and AF using the following databases: MEDLINE, PubMed, Embase, and the Web of Science. The pooled odds ratio (OR) or relative risk and the corresponding 95% confidence intervals (CIs) were calculated to assess the relationship between MAC and AF, as well as the rates of MACEs in AF patients with or without MAC. RESULTS Thirteen studies met our eligibility criteria on associations between MAC and AF, including 6232 patients with MAC and 15,199 patients without MAC. Moreover, 5 studies met our eligibility criteria on the rates of MACEs in AF patients with or without MAC. The pooled analysis demonstrated a statistically significant increased risk of development of incident AF in patients with MAC than those without MAC (random effects OR: 2.34; 95% CI: 1.91, 2.85; P = .000). And the pooled analysis demonstrated a statistically significant increased risk of development of MACEs in AF patients with MAC (random effects OR: 2.34; 95% CI: 1.24, 4.41; P = .009). CONCLUSION MAC was independently associated with AF and AF patients with MAC were at greater risk for cardiovascular and cerebrovascular events.
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Affiliation(s)
- Yimin Li
- Department of Cardiology, Second Affiliated Hospital of Nanchang University, Nanchang
- Department of Cardiology, Affiliated Brain Hospital of Nanjing Medical University (Chest Branch), Nanjing, China
| | - Zhiping Lu
- Department of Cardiology, Affiliated Brain Hospital of Nanjing Medical University (Chest Branch), Nanjing, China
| | - Xiangyu Li
- Department of Cardiology, Affiliated Brain Hospital of Nanjing Medical University (Chest Branch), Nanjing, China
| | - Jin Huang
- Department of Cardiology, Affiliated Brain Hospital of Nanjing Medical University (Chest Branch), Nanjing, China
| | - Qinghua Wu
- Department of Cardiology, Second Affiliated Hospital of Nanchang University, Nanchang
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16
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Kato N, Padang R, Pislaru C, Miranda WR, Hoshina M, Shibayama K, Watanabe H, Scott CG, Greason KL, Pislaru SV, Nkomo VT, Pellikka PA. Hemodynamics and Prognostic Impact of Concomitant Mitral Stenosis in Patients Undergoing Surgical or Transcatheter Aortic Valve Replacement for Aortic Stenosis. Circulation 2019; 140:1251-1260. [PMID: 31589485 DOI: 10.1161/circulationaha.119.040679] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Mitral stenosis frequently coexists in patients with severe aortic stenosis. Mitral stenosis severity evaluation is challenging in the setting of combined aortic stenosis and mitral stenosis because of hemodynamic interactions between the 2 valve lesions. The impact of aortic valve replacement (AVR) for severe aortic stenosis on mitral stenosis is unknown. This study aimed to assess the effect of AVR on mitral stenosis hemodynamics and the clinical outcomes of patients with severe aortic stenosis with and without mitral stenosis. METHODS We retrospectively investigated patients who underwent surgical AVR or transcatheter AVR for severe aortic stenosis from 2008 to 2015. Mean transmitral gradient by Doppler echocardiography ≥4 mm Hg was identified as mitral stenosis; patients were then stratified according to mitral valve area (MVA, by continuity equation) as >2.0 cm2 or ≤2.0 cm2. MVA before and after AVR in patients with mitral stenosis were evaluated. Clinical outcomes of patients with and without mitral stenosis were compared using 1:2 matching for age, sex, left ventricular ejection fraction, method of AVR (surgical AVR versus transcatheter AVR) and year of AVR. RESULTS Of 190 patients with severe aortic stenosis and mitral stenosis (age 76±9 years, 42% men), 184 were matched with 362 with severe aortic stenosis without mitral stenosis. Among all mitral stenosis patients, the mean MVA increased after AVR by 0.26±0.59 cm2 (from 2.00±0.50 to 2.26±0.62 cm2, P<0.01). MVA increased in 105 (55%) and remained unchanged in 34 (18%). Indexed stroke volume ≤45 mL/m2 (odds ratio [OR] 2.40; 95% CI, 1.15-5.01; P=0.020) and transcatheter AVR (OR, 2.36; 95% CI, 1.17-4.77; P=0.017) were independently associated with increase in MVA. Of 107 with significant mitral stenosis (MVA ≤2.0 cm2), MVA increased to >2.0 cm2 after AVR in 52 (49%, pseudo mitral stenosis) and remained ≤2.0 cm2 in 55 (51%, true mitral stenosis). During follow-up of median 2.9 (0.7-4.9) years, true mitral stenosis was an independent predictor of all-cause mortality (adjusted hazard ratio, 1.88; 95% CI, 1.20-2.94; P<0.01). CONCLUSIONS MVA improved after AVR in nearly half of patients with severe aortic stenosis and mitral stenosis. MVA remained ≤2.0 cm2 (true mitral stenosis) in nearly half of patients with severe aortic stenosis and significant mitral stenosis; this was associated with worse survival among patients undergoing AVR for severe aortic stenosis.
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Affiliation(s)
- Nahoko Kato
- Department of Cardiovascular Medicine (N.K., R.P., C.P., W.R.M., S.V.P., V.T.N., P.A.P.), Mayo Clinic, Rochester, MN
| | - Ratnasari Padang
- Department of Cardiovascular Medicine (N.K., R.P., C.P., W.R.M., S.V.P., V.T.N., P.A.P.), Mayo Clinic, Rochester, MN
| | - Cristina Pislaru
- Department of Cardiovascular Medicine (N.K., R.P., C.P., W.R.M., S.V.P., V.T.N., P.A.P.), Mayo Clinic, Rochester, MN
| | - William R Miranda
- Department of Cardiovascular Medicine (N.K., R.P., C.P., W.R.M., S.V.P., V.T.N., P.A.P.), Mayo Clinic, Rochester, MN
| | - Mizuho Hoshina
- Tokyo Bay Urayasu/Ichikawa Medical Center, Urayasu, Japan (M.H., K.S., H.W.)
| | - Kentaro Shibayama
- Tokyo Bay Urayasu/Ichikawa Medical Center, Urayasu, Japan (M.H., K.S., H.W.)
| | - Hiroyuki Watanabe
- Tokyo Bay Urayasu/Ichikawa Medical Center, Urayasu, Japan (M.H., K.S., H.W.)
| | | | - Kevin L Greason
- Department of Cardiovascular Surgery (K.L.G.), Mayo Clinic, Rochester, MN
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine (N.K., R.P., C.P., W.R.M., S.V.P., V.T.N., P.A.P.), Mayo Clinic, Rochester, MN
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine (N.K., R.P., C.P., W.R.M., S.V.P., V.T.N., P.A.P.), Mayo Clinic, Rochester, MN
| | - Patricia A Pellikka
- Department of Cardiovascular Medicine (N.K., R.P., C.P., W.R.M., S.V.P., V.T.N., P.A.P.), Mayo Clinic, Rochester, MN
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17
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Okuno T, Asami M, Khan F, Praz F, Heg D, Lanz J, Kassar M, Khalique OK, Gräni C, Brugger N, Räber L, Stortecky S, Valgimigli M, Windecker S, Pilgrim T. Does isolated mitral annular calcification in the absence of mitral valve disease affect clinical outcomes after transcatheter aortic valve replacement? Eur Heart J Cardiovasc Imaging 2019; 21:522-532. [DOI: 10.1093/ehjci/jez208] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/15/2019] [Accepted: 08/07/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
Aims
Mitral annular calcification (MAC) has been associated with adverse outcomes in patients undergoing transcatheter aortic valve replacement (TAVR) but has been investigated in isolation of co-existent mitral regurgitation or mitral stenosis, which may represent important confounders. This study sought to investigate the effect of MAC with and without concomitant mitral valve disease (MVD) on clinical outcomes in patients treated with TAVR.
Methods and results
Computed tomography (CT) and echocardiographic data in consecutive TAVR patients enrolled into a prospective registry were categorized according to presence or absence of severe MAC and significant MVD, respectively. A total of 967 patients with adequate CT and echocardiography data were included between 2007 and 2017. Severe MAC was found in 172 patients (17.8%) and associated with MVD in 87 patients (50.6%). Compared to TAVR patients without severe MAC or MVD, all-cause mortality at 1 year was significantly increased among patients with severe MAC in combination with MVD [adjusted hazard ratio (HRadj): 1.97, 95% confidence interval (CI): 1.12–3.44, P = 0.018] and patients with isolated MVD (HRadj: 2.33, 95% CI: 1.56–3.47, P < 0.001), but not in patients with isolated severe MAC in the absence of MVD (HRadj: 0.52, 95% CI: 0.21–1.33, P = 0.173).
Conclusion
We found no effect of isolated MAC on clinical outcomes following TAVR in patients with preserved mitral valve function. Patients with MVD had an increased risk of death at 1 year irrespective of MAC.
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Affiliation(s)
- Taishi Okuno
- Department of Cardiology, Inselspital, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland
| | - Masahiko Asami
- Department of Cardiology, Inselspital, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland
| | - Faisal Khan
- Department of Cardiology, Inselspital, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland
| | - Fabien Praz
- Department of Cardiology, Inselspital, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland
| | - Dik Heg
- Clinical Trials Unit, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland
| | - Jonas Lanz
- Department of Cardiology, Inselspital, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland
| | - Mohammad Kassar
- Department of Cardiology, Inselspital, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland
| | - Omar K Khalique
- Division of Cardiology, Structural Heart and Valve Center, Columbia University Medical Center, 177 Fort Washington Avenue, New York, NY 10032, USA
| | - Christoph Gräni
- Department of Cardiology, Inselspital, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland
| | - Nicolas Brugger
- Department of Cardiology, Inselspital, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland
| | - Lorenz Räber
- Department of Cardiology, Inselspital, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland
| | - Stefan Stortecky
- Department of Cardiology, Inselspital, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland
| | - Marco Valgimigli
- Department of Cardiology, Inselspital, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland
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18
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Bertrand PB, Mihos CG, Yucel E. Mitral Annular Calcification and Calcific Mitral Stenosis: Therapeutic Challenges and Considerations. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:19. [PMID: 30929092 DOI: 10.1007/s11936-019-0723-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE OF REVIEW Mitral annular calcification (MAC) and associated calcific mitral stenosis (MS) are frequent in the aging population, although optimal management remains debated and outcomes are poor. This article summarizes challenges in the diagnosis and therapy of calcific MS, the indications for valve intervention, procedural concerns, and emerging treatment options. RECENT FINDINGS Surgical mitral valve replacement is the procedure of choice in symptomatic patients at acceptable surgical risk, with transcatheter mitral valve replacement (TMVR) being evaluated in clinical trials as an alternative for patients at prohibitive surgical risk. Significant challenges exist with the currently available technology and outcomes have been suboptimal. Optimizing the patient-selection process by using multimodality imaging tools has proven to be essential. MAC and calcific MS is an increasingly prevalent, challenging issue with poor outcomes. While surgical valve replacement can be performed in patients with acceptable surgical risk, TMVR can be considered for patients at higher risk. Clinical trials are underway to optimize outcomes. Dedicated device designs and techniques to minimize risk of left ventricular outflow tract obstruction, paravalvular leakage, and device embolization are to be awaited.
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Affiliation(s)
- Philippe B Bertrand
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Yawkey 5E, Boston, MA, 02114, USA
| | - Christos G Mihos
- Echocardiography Laboratory, Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
| | - Evin Yucel
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Yawkey 5E, Boston, MA, 02114, USA.
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19
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Brodov Y, Konen E, Di Segni M, Samoocha D, Chernomordik F, Barbash I, Regev E, Raanani E, Guetta V, Segev A, Fefer P, Glikson M, Goitein O. Mitral Annulus Calcium Score. Circ Cardiovasc Imaging 2019; 12:e007508. [DOI: 10.1161/circimaging.117.007508] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Yafim Brodov
- Leviev Heart Center (Y.B., F.C., I.B., E.R., V.G., A.S., P.F., M.G.), Sheba Medical Center, Tel Hashomer, Tel-Aviv University, Israel
- Department of Diagnostic Imaging (Y.B., E.K., M.D.S., D.S.), Sheba Medical Center, Tel Hashomer, Tel-Aviv University, Israel
| | - Eli Konen
- Department of Diagnostic Imaging (Y.B., E.K., M.D.S., D.S.), Sheba Medical Center, Tel Hashomer, Tel-Aviv University, Israel
| | - Mattia Di Segni
- Department of Diagnostic Imaging (Y.B., E.K., M.D.S., D.S.), Sheba Medical Center, Tel Hashomer, Tel-Aviv University, Israel
| | - David Samoocha
- Department of Diagnostic Imaging (Y.B., E.K., M.D.S., D.S.), Sheba Medical Center, Tel Hashomer, Tel-Aviv University, Israel
| | - Fernando Chernomordik
- Leviev Heart Center (Y.B., F.C., I.B., E.R., V.G., A.S., P.F., M.G.), Sheba Medical Center, Tel Hashomer, Tel-Aviv University, Israel
| | - Israel Barbash
- Leviev Heart Center (Y.B., F.C., I.B., E.R., V.G., A.S., P.F., M.G.), Sheba Medical Center, Tel Hashomer, Tel-Aviv University, Israel
| | - Ehud Regev
- Leviev Heart Center (Y.B., F.C., I.B., E.R., V.G., A.S., P.F., M.G.), Sheba Medical Center, Tel Hashomer, Tel-Aviv University, Israel
| | - Ehud Raanani
- Department of Cardiac Surgery (E. Raanani), Sheba Medical Center, Tel Hashomer, Tel-Aviv University, Israel
| | - Victor Guetta
- Leviev Heart Center (Y.B., F.C., I.B., E.R., V.G., A.S., P.F., M.G.), Sheba Medical Center, Tel Hashomer, Tel-Aviv University, Israel
| | - Amit Segev
- Leviev Heart Center (Y.B., F.C., I.B., E.R., V.G., A.S., P.F., M.G.), Sheba Medical Center, Tel Hashomer, Tel-Aviv University, Israel
| | - Paul Fefer
- Leviev Heart Center (Y.B., F.C., I.B., E.R., V.G., A.S., P.F., M.G.), Sheba Medical Center, Tel Hashomer, Tel-Aviv University, Israel
| | - Michael Glikson
- Leviev Heart Center (Y.B., F.C., I.B., E.R., V.G., A.S., P.F., M.G.), Sheba Medical Center, Tel Hashomer, Tel-Aviv University, Israel
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Mitral Effective Regurgitant Orifice Area Predicts Pulmonary Artery Pressure Level in Patients with Aortic Valve Stenosis. J Am Soc Echocardiogr 2018; 31:570-577.e1. [DOI: 10.1016/j.echo.2017.12.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Indexed: 11/22/2022]
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Peripheral artery disease and transcatheter aortic valve implantation: The tip of the atherosclerotic iceberg. Int J Cardiol 2018; 255:213-214. [DOI: 10.1016/j.ijcard.2017.12.083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 12/21/2017] [Indexed: 11/20/2022]
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