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Anatomic classification of mitral annular calcification for surgical and transcatheter mitral valve replacement

Sophia L Alexis1, Talal S Alzahrani2, Deniz Akkoc3

  • 1Department of Cardiovascular Surgery, Mount Sinai Medical Center, New York, New York, USA.

Journal of Cardiac Surgery
|April 2, 2021
PubMed

Insights

A new multidetector computed tomography (MDCT) method quantifies mitral annular calcification (MAC) to guide treatment. This approach offers an objective algorithm for managing MAC patients, improving treatment selection and outcomes.

Area of Science:

  • Cardiology
  • Radiology
  • Medical Imaging

Background:

  • Quantifying mitral annular calcification (MAC) in all patients using multidetector computed tomography (MDCT) is crucial for guiding treatment decisions.
  • A systematic and objective approach to MAC quantification is currently lacking.

Purpose of the Study:

  • To develop and validate a systematic approach for quantifying MAC using MDCT in all-comers.
  • To establish an objective treatment algorithm for MAC based on anatomical classification and operability.

Main Methods:

  • 82 patients with MAC underwent MDCT for evaluation of surgical mitral valve replacement (SMVR), transcatheter mitral valve replacement (TMVR), or medical management.
  • MAC was classified as Type 1 (<270° annular calcium) or Type 2 (≥270°).
  • Type 2 MAC was further sub-classified into 2A/2B based on the presence or absence of predicted left ventricular outflow tract (LVOT) obstruction with virtual valve placement.

Main Results:

  • Type 1 MAC was observed in 51.2% of patients, Type 2A in 18.3%, and Type 2B in 30.5%.
  • Hybrid transatrial TMVR or SMVR was performed in 50.0% of operable Type 1 patients and 40.0% of Type 2B surgical candidates.
  • All percutaneous TMVR patients (primarily Type 2A) expired, while the hybrid TMVR group (Type 1/2B) showed comparable mortality to medical management and lower predicted operative risk.

Conclusions:

  • Percutaneous TMVR in Type 2A MAC patients, despite high-risk profiles, was associated with the highest mortality.
  • The developed MAC classification and treatment algorithm provide an objective framework for managing diverse MAC presentations.
  • Hybrid transatrial TMVR demonstrated a potentially safer approach for specific MAC subtypes (Type 1/2B) compared to percutaneous options in high-risk individuals.

Keywords:
hybrid transatrial transcatheter mitral valve replacementmitral annular calcificationmultidetector computed tomographypercutaneous transcatheter mitral valve replacementsurgical mitral valve replacement

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