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Does Mitral Valve Calcium in Patients Undergoing Mitral Valve Replacement Portend Worse Survival?
Nishant Saran1, Kevin L Greason1, Hartzell V Schaff1
1Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
Background:
Mitral annular calcification (MAC) is associated with worse outcomes after mitral valve replacement (MVR). With limited data available on long-term outcomes, we reviewed our experience of MVR in presence of MAC.
Methods:
A retrospective review of 1,710 consecutive patients who underwent MVR between January 2000 and December 2015 was performed. Patients with isolated primary MVR (n = 496) were included, whereas patients with concomitant cardiac surgery (n = 1,068), previous MVR (n = 110), and mitral valve (MV) endocarditis (n = 36) were excluded. MV calcification was classified as MAC present in anterior/posterior annulus and vertically at the level of leaflets/subvalvular apparatus. A conservative approach towards annular debridement was followed.
Results:
Our sample's mean age was 64.4 ± 14.1 years, and included 279 (56%) women. MV calcification was observed in 169 (34%) patients with MAC in 115 (23%). Older age, higher ejection fraction, peripheral vascular disease, diabetes, dialysis, and previous aortic valve surgery were associated with increased prevalence of MAC. Patients with MV calcification had higher stroke rate (p = 0.040), patients with anterior leaflet and commissural calcification had higher pacemaker implantation (p = 0.010, p = 0.001, respectively), and patients with circumferential MAC had higher postoperative dialysis (p = 0.006). Operative mortality was not significantly different (p = 0.466) between MAC (n = 1, 1%) and non-MAC (n = 9, 2%) patients. MAC was associated with late mortality (unadjusted hazard ratio, 1.62; 95% confidence interval, 1.20 to 2.18), though on multivariable analysis age, diabetes, dialysis, hypertension, previous aortic valve surgery, previous coronary artery bypass grafting, and MVR with a bioprosthetic valve were found to be independent risk factors for mortality whereas MAC was not.
Conclusions:
A conservative approach to treat MAC achieves satisfactory results. Patients with MAC have significant comorbidities contributing to a worse survival, though MAC in itself is not a risk factor for mortality.
Insights
Mitral annular calcification (MAC) is linked to worse outcomes after mitral valve replacement (MVR). However, a conservative surgical approach shows satisfactory results, with MAC not being an independent mortality risk factor.
Area of Science:
- Cardiology
- Cardiac Surgery
- Valvular Heart Disease
Background:
- Mitral annular calcification (MAC) is recognized as a negative prognostic indicator following mitral valve replacement (MVR).
- Limited data exists on the long-term outcomes of MVR in patients with MAC.
Purpose of the Study:
- To review the institutional experience with MVR in patients who have MAC.
- To evaluate the outcomes of MVR in the presence of MAC, particularly focusing on long-term results and the impact of a conservative surgical approach.
Main Methods:
- Retrospective review of 1,710 patients undergoing MVR between 2000 and 2015.
- Inclusion criteria: isolated primary MVR (n=496). Exclusion criteria: concomitant cardiac surgery, prior MVR, or MV endocarditis.
- MAC classification based on location (annulus, leaflets, subvalvular); a conservative debridement strategy was employed.
Main Results:
- MAC was present in 23% of the studied patient cohort (n=115).
- MAC was associated with increased stroke rates, higher pacemaker implantation for anterior/commissural calcification, and increased postoperative dialysis for circumferential MAC.
- Operative mortality did not differ significantly between MAC and non-MAC groups; however, unadjusted analysis showed MAC associated with late mortality, but this was not confirmed in multivariable analysis.
Conclusions:
- A conservative surgical approach to managing MAC during MVR yields satisfactory outcomes.
- While patients with MAC often have comorbidities that impact survival, MAC itself is not an independent predictor of mortality after MVR.
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