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Published on: October 16, 2021
Degenerative mitral stenosis by echocardiography: presentation and outcome
Roberta Batista1, Giovanni Benfari1,2, Benjamin Essayagh1
1Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN, USA.
Insights
Degenerative mitral stenosis (DMS) is common in the elderly and associated with high mortality, primarily due to comorbidities rather than stenosis severity. Careful evaluation and judicious treatment consideration are crucial for patients with limited comorbidity burden, especially those without anemia.
Area of Science:
- Cardiology
- Echocardiography
- Geriatric Medicine
Background:
- Degenerative mitral stenosis (DMS) arises from mitral annular and valvular calcification.
- The impact of DMS on patient outcomes and treatment needs remains poorly understood.
- DMS affects elderly individuals, often presenting with comorbidities.
Purpose of the Study:
- To evaluate the survival rates of patients diagnosed with degenerative mitral stenosis using Doppler echocardiography in routine clinical practice.
- To identify factors influencing short- and long-term mortality in patients with DMS.
Main Methods:
- A cohort of 2937 patients diagnosed with DMS between 2003 and 2014 was analyzed.
- Echocardiography was used to assess DMS severity, left atrial size, and pulmonary pressures.
- Survival analysis was performed, considering comorbidities, anemia, and DMS severity.
Main Results:
- One-year mortality was 22%, strongly linked to age, comorbidity, and abnormal hemoglobin/creatinine levels.
- Long-term mortality reached 56% at 5 years, primarily associated with aging and comorbidities.
- DMS severity was a weak, though independent, determinant of mortality, particularly in patients without anemia.
Conclusions:
- DMS is a condition in the elderly associated with significant mortality, largely driven by comorbidities.
- While DMS can cause severe mitral obstruction, its severity is a less critical predictor of mortality than comorbidities and anemia.
- Careful patient evaluation and selective consideration of interventional or surgical treatment are recommended for patients with DMS, especially those without anemia.
Aims:
Degenerative mitral stenosis (DMS) is due to degenerative mitral annular calcification (MAC) and valvular calcification. However, DMS impacts on the outcome, and therefore, potential treatment needs are poorly known. We aimed at evaluating survival after DMS diagnosis by Doppler echocardiography in routine practice.
Methods And Results:
A cohort of 2937 (75 ± 12 years, 67% women) consecutive patients were diagnosed between 2003 and 2014 with DMS (diastolic mean gradient ≥ 5 mmHg), with analysis of short- and long-term survival. All patients had overt mitral annular/valvular degenerative calcification without rheumatic involvement. Mean gradient was 6.5 ± 2.4 mmHg, and DMS was considered mild in 50%, moderate in 44%, and severe in 6%. DMS was associated with left atrial enlargement (52 ± 23 mL/m2) and elevated pulmonary pressure (49 ± 16 mmHg) despite generally normal ejection fraction (61 ± 13%). DMS was associated with frequent comorbid conditions (74% hypertension, 58% coronary disease, and 52% heart failure) and humoural alterations (haemoglobin 11.3 ± 1.8 g/dL and creatinine 1.5 ± 1.4 mg/dL). One-year mortality was 22%, most strongly related to older age, higher comorbidity, and abnormal haemoglobin/creatinine but only weakly to DMS severity (with anaemia 42% irrespective of DMS severity, P = 0.99; without anaemia 18, 23, and 28% with mild, moderate, and severe DMS, respectively, P < 0.0004). Long-term mortality was high (56% at 5 years) also mostly linked to aging and weakly to DMS severity [with anaemia P = 0.90; without anaemia: adjusted-hazard ratio: 1.30 (1.19-1.42), P < 0.0001, for moderate vs. mild DMS and 1.63 (1.34-1.98), P < 0.0001, for severe vs. mild DMS].
Conclusion:
DMS is a condition of the elderly potentially resulting in severe mitral obstruction and haemodynamic alterations. However, DMS is frequently associated with severe comorbidities imparting considerable mortality following diagnosis, whereas DMS severity is a weak (albeit independent) determinant of mortality. Hence, patients with DMS should be carefully evaluated and interventional/surgical treatment prudently considered in those with limited comorbidity burden, particularly without anaemia. Keywords: Degenerative Mitral Stenosis; Outcome; Natural history; Ecocardiography; Mitral Stenosis.
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