Mitral Valve Dysfunction in Patients With Annular Calcification: JACC Review Topic of the Week

Diagnosis and Management of Mitral Valve Disease in the Elderly

Calcific mitral stenosis, commonly seen in the elderly in developed countries, occurs primarily due to mitral annular calcification, and its prevalence is increasing secondary to an aging population. Mitral regurgitation, commonly seen across all age groups, occurs primarily due to anatomical or functional impairment of one or more components of the mitral apparatus or the left ventricle that are necessary for normal valve function, and its prevalence is increasing secondary to an increasing number of patients with heart failure. The current review discusses the diagnosis of and treatment options (medical, surgical, and transcatheter) for mitral valve disease, including the associated challenges, specifically in the elderly.

Mixed valvular heart disease: diagnosis and management

Mixed valvular diseases (MVDs) are common but have received little attention in the literature, especially regarding the mitral valve (MV) and the right-sided cardiac valves. Whereas echocardiography plays a pivotal diagnostic role, the diagnosis is made difficult due to haemodynamic interactions that may invalidate common indices of severity used in isolated stenosis or regurgitation. The diagnostic strategy should aim at initially separately assessing stenosis and regurgitation, taking into account the diagnostic pitfalls, with complementary use of multimodality imaging in cases of persisting diagnostic uncertainties. Unlike aortic stenosis, the calcium score cannot be used as a surrogate for haemodynamic severity of mixed MV disease. Severe stenosis and/or severe regurgitation are indicative of severe MVD, and management should follow recommendations on the predominant lesion. However, some patients with the combination of moderate stenosis and moderate regurgitation have a poor prognosis when left untreated. Concordant data suggest that, in patients with mixed aortic or MV disease, transvalvular velocities and pressure gradients are more powerful prognostic indicators than valve area or the severity of regurgitation. It is essential to consider the global repercussions that indicate poor outcomes in patients with MVD. However, whereas symptoms and/or ventricular dysfunction are considered as clear indication for intervention, imaging cut-offs have not been validated for balanced moderate regurgitation and stenosis. Although emerging evidence tends to support earlier management, further prospective studies are required, and pending the results of these studies, asymptomatic patients with MVD should be closely monitored.

Global, Regional, and National Burden of Valvular Heart Disease, 1990 to 2021

BACKGROUND

Valvular heart disease poses an escalating global health challenge with an increasing impact on mortality and disability. This study aims to comprehensively analyze the global burden of valvular heart disease.

METHODS AND RESULTS

Using the Global Burden of Disease 2021 data, we analyzed the prevalence and disability-adjusted life years, examining implications across demographics and geographic regions. In 2021, an estimated 54.8 million (95% uncertainty interval [UI], 43.3-67.6) cases of rheumatic heart disease, 13.3 million (95% UI, 11.4-15.2) cases of nonrheumatic calcific aortic valve disease (CAVD), and 15.5 million (95% UI, 14.5-16.7) cases of nonrheumatic degenerative mitral valve disease (DMVD) were reported globally. Despite the rising prevalence, disability-adjusted life years declined between 1991 and 2021. Among individuals aged 70 years or older, the age-standardized prevalences were 1803.6 per 100 000 (95% UI, 1535.5-2055.7) for CAVD and 2148.9 per 100 000 (95% UI, 2001.4-2310.1) for DMVD. Sub-Saharan Africa had the highest age-standardized prevalence for rheumatic heart disease; Conversely, high-income regions led in CAVD and DMVD prevalence. Rheumatic heart disease had the highest age-standardized prevalence of 1184.2 per 100 000 (95% UI, 932.4-1478.2) in low Socio-Demographic Index (SDI) regions, whereas CAVD peaked at 349.8 per 100 000 (95% UI, 303.6-395.8) in high SDI regions. The most substantial increases in age-standardized prevalences of CAVD from 1990 to 2021 occurred in the middle SDI and low-middle SDI regions. A parallel trend was noted for DMVD.

CONCLUSIONS

Rheumatic heart disease remains a significant burden in low SDI regions, whereas CAVD and DMVD pose challenges in high SDI regions with aging populations.

Understanding Vascular Calcification in Chronic Kidney Disease: Pathogenesis and Therapeutic Implications

Vascular calcification (VC) is a biological phenomenon characterized by an accumulation of calcium and phosphate deposits within the walls of blood vessels causing the loss of elasticity of the arterial walls. VC plays a crucial role in the incidence and progression of chronic kidney disease (CKD), leading to a significant increase in cardiovascular mortality in these patients. Different conditions such as age, sex, dyslipidemia, diabetes, and hypertension are the main risk factors in patients affected by chronic kidney disease. However, VC may occur earlier and faster in these patients if it is associated with new or non-traditional risk factors such as oxidative stress, anemia, and inflammation. In chronic kidney disease, several pathophysiological processes contribute to vascular calcifications, including osteochondrogenic differentiation of vascular cells, hyperphosphatemia and hypercalcemia, and the loss of specific vascular calcification inhibitors including pyrophosphate, fetuin-A, osteoprotegerin, and matrix GLA protein. In this review we discuss the main traditional and non-traditional risk factors that can promote VC in patients with kidney disease. In addition, we provide an overview of the main pathogenetic mechanisms responsible for VC that may be crucial to identify new prevention strategies and possible new therapeutic approaches to reduce cardiovascular risk in patients with kidney disease.

Thrombus on Mitral Annular Calcification: A Systematic Review of Management and Outcomes

Background

Mitral annular calcification (MAC) is a common chronic degenerative process of the mitral valve. Thrombus formation on MAC is a rare complication that likely contributes to the increased risk of thromboembolic events. Outcomes and management strategies for this condition are unknown. The aim of this study was to perform a systematic review to describe the management and outcomes of patients who have thrombus on MAC.

Methods

The MEDLINE, Embase, and Cochrane databases were searched. Patients with a prior mitral valve intervention or prosthesis were excluded. The primary outcomes were treatment, mortality, and thromboembolic events.

Results

Fifteen studies, with a total of 22 cases (patients aged 69.1 ± 14.8 years; n = 18 [82%] female) were included. Most patients presented with stroke or a transient ischemic event (n = 15; 68%) or myocardial infarction (n = 4; 18%). All patients were diagnosed with either transthoracic (n = 18; 82%) or transesophageal (n = 4; 18%) echocardiography. Seventeen patients (77%) were treated with anticoagulation therapy alone, and 5 (23%) required surgery. The most common surgical indication was prevention of recurrent embolization (n = 3; 14%). No mortality was reported. Six patients (27%) had thromboembolic events after diagnosis. For those treated with anticoagulation therapy alone, 5 (23%) had persistent thrombus with or without embolization.

Conclusions

In this systematic review, patients with MAC who present with a thromboembolic event require careful echocardiographic assessment of the MAC, to exclude the presence of thrombus. Although most patients can be managed with anticoagulation therapy alone, a significant number will require surgery. Persistent thrombus, despite anticoagulation therapy, and recurrent embolization are common. Larger studies are needed to elucidate what constitutes the optimal long-term care for these patients.

Outcomes of mitral transcatheter edge-to-edge repair in patients with mitral annular calcification: A meta-analysis

BACKGROUND

The impact of mitral annular calcification (MAC) on the clinical outcomes of patients undergoing mitral transcatheter edge-to-edge repair (MTEER) remains unclear. This meta-analysis aims to evaluate the clinical outcomes of MTEER among patients with moderate to severe MAC compared to those with mild or no MAC.

METHODS

We systematically searched PubMed, EMBASE, and Cochrane CENTRAL databases through March 31st, 2024, comparing clinical outcomes of MTEER among patients with moderate/severe (MAC+) versus no/mild MAC (MAC-). We assessed pooled estimates for procedural success, all-cause mortality, residual mitral regurgitation (MR) ≤ moderate, and New York Heart Association (NYHA) class III/IV status at one year.

RESULTS

Among five studies (2533 patients; mean age 76.4 ± 10.9 years, 39.8 % women), MAC+ patients were predominantly women (55.7 % vs 37.5 %, p < 0.001), older (87.9 ± 11.1 vs. 75.9 ± 9.1 years; mean difference (MD) = 3.99, p = 0.011) and had higher STS scores (7.7 ± 6.7 % vs. 4.9 ± 4.6 %; MD = 1.34, p < 0.001). MAC+ patients had comparable procedural success rates, residual MR < moderate, and NYHA III/IV at 1 year. However, all-cause mortality at 1 year was higher for MAC+ patients (Relative Risk = 1.56, 95 % CI = 1.06-2.29).

CONCLUSIONS

MTEER is a safe and feasible option for carefully selected patients with MAC and significant MR, offering durable MR reduction and functional status improvement. Significantly higher one-year mortality associated with MAC despite significant MR reduction suggests an increased risk unrelated to valvular dysfunction and highlights the need for further investigation into identifying patients who benefit the most from MTEER.

The Key Role of 3D TEE in Assessing the Morphology of Degenerative Mitral Valve Regurgitation

Two-dimensional transthoracic echocardiography (2D TTE) and two-dimensional transesophageal echocardiography (2D TEE) are regarded as the main imaging techniques for the assessment of degenerative mitral valve regurgitation (DMVR). However, describing the complex morphology of DMVR with 2D TTE and 2D TEE remains at the very least challenging. Three-dimensional (3D) TEE is an ideal technique for illustrating the extremely variable morphology of DMVR, providing images of unparalleled quality in terms of anatomical detail. In this review, we describe the key role of 3D TEE in various morphological scenarios that reflect everyday experiences in an echocardiographic laboratory. We also discuss the growing role of 3D TEE in mitral valve (MV) transcatheter edge-to-edge repair (TEER) and new modalities such as photorealistic and transparent displays, surface rendering parametric color maps, new algorithms for MVR quantification, and the potential role of new mini-TEE probes in adult patients with DMVR.

Outcomes Following Transcatheter Mitral Valve Replacement Using Dedicated Devices in Patients With Mitral Annular Calcification

BACKGROUND

Patients with mitral regurgitation (MR) and morphologic presence of relevant mitral annular calcification (MAC) represent a challenging phenotypic subset with limited treatment options.

OBJECTIVES

The aim of this study was to assess the feasibility of transcatheter mitral valve replacement (TMVR) using dedicated devices for the treatment of MAC patients.

METHODS

Consecutive patients with symptomatic MR receiving TMVR and with available computed tomography data from the CHOICE-MI (Choice of Optimal Transcatheter Treatment for Mitral Insufficiency) multicenter registry were stratified by the presence of none or mild mitral annular calcification (MACnone/mild) vs moderate or severe mitral annular calcification (MACmod/sev).

RESULTS

Among 279 eligible patients (median age = 76.0 years [Q1-Q3: 71.0-81.0 years], EuroSCORE II = 6.2% [Q1-Q3: 3.9%-12.1%]), 222 (79.6%) presented with MACnone/mild and 57 (20.4%) with MACmod/sev. Patients with MACmod/sev had a higher prevalence of extracardiac arteriopathy (P = 0.011) and primary MR (P < 0.001). Although the technical success rate and the extent of MR elimination did not differ, TMVR treatment in MACmod/sev patients was associated with higher rates of postprocedural bleeding complications (P = 0.02) and renal failure (P < 0.001). Functional improvement at the 1- and 2-year follow-up did not differ between groups. At the 2-year follow-up, there were no differences between patients with MACmod/sev and MACnone/mild regarding all-cause mortality (38.5% vs 37.7%; P = 0.76), cardiovascular mortality (21.3% vs 24.9%; P = 0.97), and all-cause mortality or heart failure hospitalization (52.4% vs 46.7%; P = 0.28) CONCLUSIONS: TMVR in patients with MACmod/sev is associated with higher rates of postprocedural complications but similar rates of survival, MR resolution, and functional improvement compared to MACnone/mild. Further studies are necessary to define the role of dedicated TMVR devices in this population. (Choice of Optimal Transcatheter Treatment for Mitral Insufficiency Registry [CHOICE-MI]; NCT04688190).

Structural Cardiac Interventions in Patients With Heart Failure: JACC Scientific Statement

Pathologic left ventricular remodeling and valvular heart disease may contribute to the clinical presentation and outcomes of patients presenting with heart failure, and limit the effectiveness of guideline-directed medical therapy. Although surgical interventions including surgical ventricular restoration techniques and valve repair or replacement are effective therapies, there is growing evidence that transcatheter interventions may be options for patients with persistent symptoms of heart failure despite optimal medical therapy, where surgical options may be limited. This scientific statement will review the current available and investigational percutaneous strategies for the management of structural contributors to heart failure: dilated left ventricular cardiomyopathies and valvular heart disease.

Rethinking Mitral Annular Calcification and Its Clinical Significance: From Passive Process to Active Pathology

BACKGROUND

Mitral annulus calcification is a chronic degenerative condition affecting the fibrous base of the mitral valve. Historically viewed as an age-related phenomenon, recent studies suggest it is driven by active mechanisms involving systemic inflammation, hemodynamic stress, abnormal calcium-phosphorus metabolism, and lipid accumulation. Despite often being asymptomatic and incidentally detected, its clinical relevance stems from its strong association with increased cardiovascular disease risk, higher cardiovascular mortality, and elevated overall mortality.

METHODS

This article investigates the complexities and controversies surrounding mitral annular calcification as a potential embolic source, focusing on its diagnosis, its relationship with systemic inflammation, and its links to metabolic and chronic disorders.

RESULTS

The findings highlight that mitral annular calcification is not merely a passive marker of aging but an active indicator of atherosclerotic burden with significant implications for cardiovascular health.

CONCLUSION

Mitral annulus calcification should be recognized as an important factor in cardiovascular risk assessment, offering insight into systemic inflammatory processes and metabolic dysregulation.

Progression of Mild Mitral Annulus Calcification to Mitral Valve Dysfunction and Impact on Mortality

BACKGROUND

Mitral annulus calcification (MAC) represents a degenerative process resulting in calcium deposition in the mitral valve apparatus. Mitral annulus calcification is associated with adverse clinical outcomes. We sought to examine the long-term significance of mild MAC and its relationship to subsequent mitral valve dysfunction (MVD) and mortality in patients without MVD on the initial echocardiogram.

METHODS

A total of 1,420 patients with mild MAC and no MVD at baseline and 1 or more follow-up echocardiograms at least 1 year after the baseline echocardiogram were included in the analysis. For patients with >1 echocardiogram during follow-up, the last echocardiogram was used. The same criteria were used to identify 6,496 patients without MAC. Mitral valve dysfunction was defined as mitral regurgitation (MR) and/or mitral stenosis (MS) of moderate or greater severity. Mixed disease was defined as the concurrent presence of both moderate or greater MS and MR. The primary end point was development of MVD, and the secondary end point was all-cause mortality.

RESULTS

For patients with mild MAC, age was 74 ± 10 years and 528 (37%) were female. Over a median follow-up of 4.7 (interquartile range, 2.7-6.9) years, 215 patients with mild MAC developed MVD, including MR in 170 (79%), MS in 37 (17%), and mixed disease in 8 (4%). In a multivariable regression model compared to patients without MAC, the presence of mild MAC was independently associated with increased mortality (hazard ratio = 1.43; 95% CI 1.24, 1.66; P < .001). Kaplan-Meier 4-year survival rates were 80% and 90% for patients with mild MAC and no MAC, respectively.

CONCLUSIONS

Mild MAC observed on transthoracic echocardiography is an important clinical finding with prognostic implications for both valvular function and mortality.

Staging Extramitral Cardiac Damage in Mitral Annular Calcification With Mitral Valve Dysfunction

BACKGROUND

Mitral annular calcification (MAC) is a progressive degenerative process associated with comorbidities and increased mortality. A staging system that considers extramitral cardiac damage in MAC may help improve patient selection for mitral valve interventions.

OBJECTIVES

This study sought to develop a transthoracic echocardiogram (TTE)-based cardiac staging system in patients with MAC and significant mitral valve dysfunction and assess its prognostic utility.

METHODS

We retrospectively evaluated all adults who underwent TTE over 1 year at Mayo Clinic with MAC and significant mitral valve dysfunction defined as mitral stenosis and/or at least moderate mitral regurgitation. Patients were categorized into 5 stages according to extramitral cardiac damage by TTE. All-cause mortality and heart failure hospitalization were assessed.

RESULTS

For the 953 included patients, the mean age was 76.2 ± 10.7 years, and 54.0% were women. Twenty-eight (2.9%) patients were classified in stages 0 to 1, 499 (52.4%) in stage 2, 115 (12.1%) in stage 3, and 311 (32.6%) in stage 4. At the 3.8-year follow-up, mortality was significantly higher in patients in stages 2 to 4 compared to stages 0 to 1 and increased with each stage. Survival differences were maintained after adjustment for age, diabetes mellitus, and glomerular filtration rate. The rate of heart failure hospitalization was significantly higher in stages 3 and 4 compared to stages 0 to 1. Similar results were observed in subgroup analysis in patients with moderate or severe MAC, predominant mitral stenosis, or predominant mitral regurgitation.

CONCLUSIONS

Using the proposed extramitral cardiac damage staging system in patients with MAC and significant mitral valve dysfunction, more advanced stages are associated with higher mortality.

2023 Korean Society of Echocardiography position paper for the diagnosis and management of valvular heart disease, part II: mitral and tricuspid valve disease

This manuscript represents the official position of the Korean Society of Echocardiography on valvular heart diseases. This position paper focuses on the diagnosis and management of valvular heart diseases with referring to the guidelines recently published by the American College of Cardiology/American Heart Association and the European Society of Cardiology. The committee sought to reflect national data on the topic of valvular heart diseases published to date through a systematic literature search based on validity and relevance. In the part II of this article, we intend to present recommendations for diagnosis and treatment of mitral valve disease and tricuspid valve disease.

Acute Heart Valve Emergencies

Within the cardiac intensive care unit, prompt recognition of severe acute valvular lesions is essential because hemodynamic collapse can occur rapidly, especially when cardiac chambers have not had time for compensatory remodeling. Within this context, optimal medical management, considerations for temporary mechanical circulatory support and decisive treatments strategies are addressed. Fundamental concepts include an appreciation for how sudden changes in flow and pressure gradients between cardiac chambers can impact hemodynamic and echocardiographic findings differently compared to similarly severe chronic lesions, as well as understanding the main causes for decompensated heart failure and cardiogenic shock for each valvular abnormality.

Contemporary experience with the Commando procedure for anterior mitral anular calcification

Objective

Anterior mitral anular calcification, particularly in radiation heart disease, and previous valve replacement with destroyed intervalvular fibrosa are challenging for prosthesis sizing and placement. The Commando procedure with intervalvular fibrosa reconstruction permits double-valve replacement in these challenging conditions. We referenced outcomes after Commando procedures to standard double-valve replacements.

Methods

From January 2011 to January 2022, 129 Commando procedures and 1191 aortic and mitral double-valve replacements were performed at the Cleveland Clinic, excluding endocarditis. Reasons for the Commando were severe calcification after radiation (n = 67), without radiation (n = 43), and others (n = 19). Commando procedures were referenced to a subset of double-valve replacements using balancing-score methods (109 pairs).

Results

Between balanced groups, Commando versus double-valve replacement had higher total calcium scores (median 6140 vs 2680 HU, P = .03). Hospital outcomes were similar, including operative mortality (12/11% vs 8/7.3%, P = .35) and reoperation for bleeding (9/8.3% vs 5/4.6%, P = .28). Survival and freedom from reoperation at 5 years were 54% versus 67% (P = .33) and 87% versus 100% (P = .04), respectively. Higher calcium score was associated with lower survival after double-valve replacement but not after the Commando. The Commando procedure had lower aortic valve mean gradients at 4 years (9.4 vs 11 mm Hg, P = .04). After Commando procedures for calcification, 5-year survival was 60% and 59% with and without radiation, respectively (P = .47).

Conclusions

The Commando procedure with reconstruction of the intervalvular fibrosa destroyed by mitral anular calcification, radiation, or previous surgery demonstrates acceptable outcomes similar to standard double-valve replacement. More experience and long-term outcomes are required to refine patient selection for and application of the Commando approach.

Implementation of Endoscopic Minimally Invasive Mitral Valve Replacement Surgery With Automated Suturing Technology

In the evolving landscape of cardiac surgery, this article explores the potential of minimally invasive mitral valve replacement procedures as a viable alternative to conventional surgical techniques. Leveraging advancements in automated suturing devices and video endoscopy, our work aims to demonstrate that minimally invasive approaches can be applied across a broad spectrum of surgical scenarios. Herein we highlight preoperative diagnostics and operative techniques, with a focus on infra-axillary anterolateral minithoracotomy as the access point. Our technique utilizes technology from LSI SOLUTIONS® (Victor, NY, USA), including the RAM® Device for automated suturing, which has an ergonomic design and safety features. The device's capabilities are further enhanced by the SEW-EASY® Device, the RAM® RING, and the COR-KNOT MINI® Device, which streamline suture management and securement. This work outlines how these technological advancements can mitigate concerns about technical complexity and learning curves, thereby encouraging wider adoption of minimally invasive techniques. Clinical benefits may include reduced surgical trauma, quicker recovery, and cost-effectiveness, making it a compelling option in an era of aggressively promoted transcatheter interventions.

Mitral Annular Calcification-Related Valvular Disease: A Challenging Entity

Mitral valve annular calcification-related valvular disease is increasingly common due to the rising prevalence of age-related mitral annular calcifications. Mitral annular calcification alters the structure and function of the mitral valve annulus, which in turn causes mitral valve regurgitation, stenosis, or both. As it frequently coexists with comorbid conditions and overlapping symptoms, mitral annular calcification-related valvular disease poses significant diagnostic and therapeutic challenges. For instance, left ventricular diastolic dysfunction hinders the assessment of mitral valvular disease. Detection of mitral annular calcifications and assessment of related mitral valve disease hinge on two-dimensional echocardiography. Comprehensive assessment of mitral annular calcifications and related mitral valve disease may require multidetector computed tomography and three-dimensional echocardiography. Invasive hemodynamic testing with exercise helps identify the cause of symptoms in patients with comorbid conditions, and transcatheter interventions have emerged as a viable therapeutic option for older patients. After an outline of the normal mitral annulus, we examine how mitral annular calcifications lead to mitral valve disease and how to accurately assess mitral regurgitation and stenosis. Lastly, we review surgical and transcatheter approaches to the management of mitral annular calcification-related mitral valve regurgitation, stenosis, or both.

Valvular Heart Disease in the Cardiac Intensive Care Unit

Valvular heart disease pathologies are commonly encountered in the cardiac intensive care unit (CICU). Clinical presentations may range from an acute pathology of the aortic or mitral valve necessitating emergency intervention to a more subtle decompensation of longstanding valvular disease. With growing numbers of transcatheter valvular interventions, CICU providers must recognize and manage common complications after transcatheter aortic, mitral, and tricuspid interventions. In addition, prosthetic valve dysfunction should always be excluded in a CICU patient presenting with an acute cardiopulmonary decompensation. Multidisciplinary valve teams can assist with challenging valvular pathologies to determine candidacy for potential interventions.

Diagnosis, Classification, and Management Strategies for Mitral Annular Calcification: A Heart Valve Collaboratory Position Statement

Mitral annular calcium (MAC) with severe mitral valvular dysfunction presents a complex problem, as valve replacement, either surgical or transcatheter, is challenging because of anatomy, technical considerations, concomitant comorbidities, and advanced age. The authors review the clinical and anatomical features of MAC that are favorable (green light), challenging (yellow light), or prohibitive (red light) for surgical or transcatheter mitral valve interventions. Under the auspices of the Heart Valve Collaboratory, an expert working group of cardiac surgeons, interventional cardiologists, and interventional imaging cardiologists was formed to develop recommendations regarding treatment options for patients with MAC as well as a proposed grading and staging system using both anatomical and clinical features.

Clinical outcomes of transcatheter mitral valve replacement: two-year results of the CHOICE-MI Registry

BACKGROUND

Transcatheter mitral valve replacement (TMVR) using dedicated devices is an alternative therapy for high-risk patients with symptomatic mitral regurgitation (MR).

AIMS

This study aimed to assess the 2-year outcomes and predictors of mortality in patients undergoing TMVR from the multicentre CHOICE-MI Registry.

METHODS

The CHOICE-MI Registry included consecutive patients with symptomatic MR treated with 11 different dedicated TMVR devices at 31 international centres. The investigated endpoints included mortality and heart failure hospitalisation rates, procedural complications, residual MR, and functional status. Multivariable Cox regression analysis was applied to identify independent predictors of 2-year mortality.

RESULTS

A total of 400 patients, median age 76 years (interquartile range [IQR] 71, 81), 59.5% male, EuroSCORE II 6.2% (IQR 3.8, 12.0), underwent TMVR. Technical success was achieved in 95.2% of patients. MR reduction to ≤1+ was observed in 95.2% at discharge with durable results at 1 and 2 years. New York Heart Association Functional Class had improved significantly at 1 and 2 years. All-cause mortality was 9.2% at 30 days, 27.9% at 1 year and 38.1% at 2 years after TMVR. Chronic obstructive pulmonary disease, reduced glomerular filtration rate, and low serum albumin were independent predictors of 2-year mortality. Among the 30-day complications, left ventricular outflow tract obstruction, access site and bleeding complications showed the strongest impact on 2-year mortality.

CONCLUSIONS

In this real-world registry of patients with symptomatic MR undergoing TMVR, treatment with TMVR was associated with a durable resolution of MR and significant functional improvement at 2 years. Two-year mortality was 38.1%. Optimised patient selection and improved access site management are mandatory to improve outcomes.

High lipoprotein(a) levels and mitral valve disease: A systematic review

AIMS

The role of lipoprotein(a) [Lp(a)] as a possibly causal risk factor for atherosclerotic artery disease and aortic valve stenosis has been well established. However, the information available on the association between Lp(a) levels and mitral valve disease is limited and controversial. The main objective of the present study was to assess the association between Lp(a) levels and mitral valve disease.

DATA SYNTHESIS

This systematic review was performed according to PRISMA guidelines (PROSPERO CRD42022379044). A literature search was performed to detect studies that evaluated the association between Lp(a) levels or single-nucleotide polymorphisms (SNPs) related to high levels of Lp(a) and mitral valve disease, including mitral valve calcification and valve dysfunction. Eight studies including 1,011,520 individuals were considered eligible for this research. The studies that evaluated the association between Lp(a) levels and prevalent mitral valve calcification found predominantly positive results. Similar findings were reported in two studies that evaluated the SNPs related to high levels of Lp(a). Only two studies evaluated the association of Lp(a) and mitral valve dysfunction, showing contradictory results.

CONCLUSIONS

This research showed disparate results regarding the association between Lp(a) levels and mitral valve disease. The association between Lp(a) levels and mitral valve calcification seems more robust and is in line with the findings already demonstrated in aortic valve disease. New studies should be developed to clarify this topic.

Sex Differences in Extensive Mitral Annular Calcification With Associated Mitral Valve Dysfunction

Mitral annular calcification (MAC)-related mitral valve (MV) dysfunction is an increasingly recognized entity, which confers a high burden of morbidity and mortality. Although more common among women, there is a paucity of data regarding how the phenotype of MAC and the associated adverse clinical implications may differ between women and men. A total of 3,524 patients with extensive MAC and significant MAC-related MV dysfunction (i.e., transmitral gradient ≥3 mm Hg) were retrospectively analyzed from a large institutional database, with the goal of defining gender differences in clinical and echocardiographic characteristics and the prognostic importance of MAC-related MV dysfunction. We stratified patients into low- (3 to 5 mm Hg), moderate- (5 to 10 mm Hg), and high- (≥10 mm Hg) gradient groups and analyzed the gender differences in phenotype and outcome. The primary outcome was all-cause mortality, assessed using adjusted Cox regression models. Women represented the majority (67%) of subjects, were older (79.3 ± 10.4 vs 75.5 ± 10.9 years, p <0.001) and had a lower burden of cardiovascular co-morbidities than men. Women had higher transmitral gradients (5.7 ± 2.7 vs 5.3 ± 2.6 mm Hg, p <0.001), more concentric hypertrophy (49% vs 33%), and more mitral regurgitation. The median survival was 3.4 years (95% confidence interval 3.0 to 3.6) among women and 3.0 years (95% confidence interval 2.6 to 4.5) among men. The adjusted survival was worse among men, and the prognostic impact of the transmitral gradient did not differ overall by gender. In conclusion, we describe important gender differences among patients with MAC-related MV dysfunction and show worse adjusted survival among men; although, the adverse prognostic impact of the transmitral gradient was similar between men and women.

Cardiovascular Calcification Heterogeneity in Chronic Kidney Disease

Patients with chronic kidney disease (CKD) exhibit tremendously elevated risk for cardiovascular disease, particularly ischemic heart disease, due to premature vascular and cardiac aging and accelerated ectopic calcification. The presence of cardiovascular calcification associates with increased risk in patients with CKD. Disturbed mineral homeostasis and diverse comorbidities in these patients drive increased systemic cardiovascular calcification in different manifestations with diverse clinical consequences, like plaque instability, vessel stiffening, and aortic stenosis. This review outlines the heterogeneity in calcification patterning, including mineral type and location and potential implications on clinical outcomes. The advent of therapeutics currently in clinical trials may reduce CKD-associated morbidity. Development of therapeutics for cardiovascular calcification begins with the premise that less mineral is better. While restoring diseased tissues to a noncalcified homeostasis remains the ultimate goal, in some cases, calcific mineral may play a protective role, such as in atherosclerotic plaques. Therefore, developing treatments for ectopic calcification may require a nuanced approach that considers individual patient risk factors. Here, we discuss the most common cardiac and vascular calcification pathologies observed in CKD, how mineral in these tissues affects function, and the potential outcomes and considerations for therapeutic strategies that seek to disrupt the nucleation and growth of mineral. Finally, we discuss future patient-specific considerations for treating cardiac and vascular calcification in patients with CKD-a population in need of anticalcification therapies.