Mitral Annular Calcification Score Determined by 3-D Transesophageal Echocardiography vs Cardiac Computed Tomography

A cardiac computed tomography (CT)-based mitral annular calcification (MAC) scoring system systematically grades MAC severity, but its correlation with three-dimensional transesophageal echocardiography (3D-TEE) remains unclear.

The authors aimed to compare MAC severity assessment by 3D-TEE vs CT and evaluate their associations with hemodynamic parameters indicative of mitral valve disease.

We analyzed patients with MAC enrolled in the MITRAL (Mitral Implantation of TRAnscathether vaLves) II trial (NCT04408430) across 13 centers undergoing transcatheter mitral valve replacement screening. Core laboratories assessed MAC severity using 3D-TEE and CT. Correlation and agreement were assessed via Spearman and intraclass correlation coefficients. Hemodynamic parameters of mitral stenosis (MS) and regurgitation were obtained from two-dimensional transthoracic echocardiography (2D-TTE) and 3D-TEE. Linear regression evaluated associations with MAC scores.

The analysis included 164 patients (75% females, mean age 75.5 ± 9.1 years). The mean MAC scores were 8.0 ± 0.44 by CT and 8.2 ± 0.45 by 3D-TEE. A modest positive correlation (Spearman correlation coefficient = 0.34; P < 0.001) was observed between 3D-TEE and CT scores, with better agreement in severe MAC. Each unit increase in the 3D-TEE MAC score was associated with a 0.15 cm² decrease in 3D-TEE mitral valve area, a 0.05 cm² decrease in 2D-TTE mitral valve area, and an increase in mean diastolic pressure gradient (1 mm Hg by 3D-TEE; 0.96 mm Hg by 2D-TTE). 3D-TEE MAC scores showed no significant correlation with regurgitation parameters. CT-MAC scores showed weak, nonsignificant correlations with both MS and mitral regurgitation.

3D-TEE provides complementary and functionally relevant MAC assessment, correlating with MS severity. It may serve as a useful adjunct to CT in transcatheter mitral valve replacement evaluation, especially when contrast imaging is limited.