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Prognostic importance of the transmitral pressure gradient in mitral annular calcification with associated mitral
Philippe B Bertrand1, Timothy W Churchill1, Evin Yucel1
1Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St Boston, MA 02114, USA.
Aims:
The aim of this study was to define the natural history of patients with mitral annular calcification (MAC)-related mitral valve dysfunction and to assess the prognostic importance of mean transmitral pressure gradient (MG) and impact of concomitant mitral regurgitation (MR).
Methods And Results:
The institutional echocardiography database was examined from 2001 to 2019 for all patients with MAC and MG ≥3 mmHg. A total of 5754 patients were stratified by MG in low (3-5 mmHg, n = 3927), mid (5-10 mmHg, n = 1476), and high (≥10 mmHg, n = 351) gradient. The mean age was 78 ± 11 years, and 67% were female. MR was none/trace in 32%, mild in 42%, moderate in 23%, and severe in 3%. Primary outcome was all-cause mortality, and outcome models were adjusted for age, sex, and MAC-related risk factors (hypertension, diabetes, coronary artery disease, chronic kidney disease). Survival at 1, 5, and 10 years was 77%, 42%, and 18% in the low-gradient group; 73%, 38%, and 17% in the mid-gradient group; and 67%, 25%, and 11% in the high-gradient group, respectively (log-rank P < 0.001 between groups). MG was independently associated with mortality (adjusted HR 1.064 per 1 mmHg increase, 95% CI 1.049-1.080). MR severity was associated with mortality at low gradients (P < 0.001) but not at higher gradients (P = 0.166 and 0.372 in the mid- and high-gradient groups, respectively).
Conclusion:
In MAC-related mitral valve dysfunction, mean transmitral gradient is associated with increased mortality after adjustment for age, sex, and MAC-related risk factors. Concomitant MR is associated with excess mortality in low-gradient ranges (3-5 mmHg) but gradually loses prognostic importance at higher gradients, indicating prognostic utility of transmitral gradient in MAC regardless of MR severity.
Insights
Mitral annular calcification (MAC)-related mitral valve dysfunction shows increased mortality with higher mean transmitral gradients (MG). While mitral regurgitation (MR) impacts outcomes in low-gradient ranges, MG remains a key predictor of mortality in MAC patients.
Area of Science:
- Cardiology
- Echocardiography
- Valvular Heart Disease
Background:
- Mitral annular calcification (MAC) can lead to mitral valve dysfunction.
- The prognostic significance of mean transmitral gradient (MG) and mitral regurgitation (MR) in MAC is not fully defined.
Purpose of the Study:
- To determine the natural history of MAC-related mitral valve dysfunction.
- To assess the prognostic importance of MG and the impact of MR on mortality.
Main Methods:
- Retrospective analysis of 5754 patients with MAC and MG ≥3 mmHg from 2001-2019.
- Patients stratified into low (3-5 mmHg), mid (5-10 mmHg), and high (≥10 mmHg) gradient groups.
- All-cause mortality as primary outcome, adjusted for age, sex, and MAC risk factors.
Main Results:
- Higher MG was independently associated with increased mortality (adjusted HR 1.064 per 1 mmHg increase).
- Survival rates at 10 years were 18% (low), 17% (mid), and 11% (high) gradient groups (P < 0.001).
- MR severity impacted mortality in low-gradient MAC but lost prognostic importance at higher gradients.
Conclusions:
- Mean transmitral gradient is a significant independent predictor of mortality in MAC-related mitral valve dysfunction.
- Transmitral gradient retains prognostic utility regardless of mitral regurgitation severity in MAC.
- Understanding these factors aids in risk stratification and management of MAC patients.
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