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Infective Endocarditis in Patients with Mitral Annular Calcification: Clinical and Echocardiographic Presentation,
Gaspard Suc1, Lawrence Lau1, Serah Seo1
1Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
Background:
Mitral annular calcification (MAC) poses unique challenges in infective endocarditis (IE). This study aimed to characterize echocardiographic features of IE involving MAC and assess its management and outcomes.
Methods:
We reviewed cases discussed during our IE multidisciplinary meetings, 2021-2024. Clinical data, imaging findings, and outcomes were collected through chart review.
Results:
Among 741 patients evaluated, 51 patients (7%; aged 73 ± 11 years; 45% female) had possible or definite IE and moderate-severe MAC. IE involved the mitral valve in 24 patients (47%). Mitral IE was more frequent in women (63% vs 30%, P = 0.02) and was less commonly associated with prior aortic valve replacement (17% vs 59%, P < 0.01). Staphylococcus aureus was the most common pathogen, with no difference between groups (38% vs 30% in the mitral vs nonmitral IE groups, respectively, P = 0.55). Patients with mitral IE often presented with large vegetations (median 13 mm), frequent valvular or perivalvular complications (moderate or greater mitral regurgitation in 54%, perforation in 33%, and perivalvular abscess in 13%). A succulent aspect of the vegetation mass with abnormal MAC mobility, described as "rocking," was observed in 7 patients (29%). Surgical indications were found in 63% of patients, but only 40% underwent surgery due to high perceived risk. The in-hospital mortality incidence was not different between the mitral and nonmitral IE groups (29% vs 15%, P = 0.32).
Conclusions:
In patients with IE and MAC, the mitral valve was often primarily affected, showing large, mobile vegetations with a "rocking" motion. Despite frequent surgical indications, few underwent surgery, highlighting the need for improved management in this high-risk group.
Insights
Mitral annular calcification (MAC) complicates infective endocarditis (IE), often affecting the mitral valve with large vegetations. Management challenges persist, with surgery often indicated but underutilized in this high-risk patient group.
Area of Science:
- Cardiology
- Infectious Diseases
- Echocardiography
Background:
- Mitral annular calcification (MAC) presents unique challenges in managing infective endocarditis (IE).
- Understanding the specific echocardiographic features, management strategies, and outcomes of IE in patients with MAC is crucial.
Purpose of the Study:
- To characterize the echocardiographic features of infective endocarditis (IE) in patients with mitral annular calcification (MAC).
- To assess the management and clinical outcomes of IE in this specific patient population.
Main Methods:
- Retrospective review of cases discussed in IE multidisciplinary meetings from 2021-2024.
- Collection of clinical data, imaging findings, and outcomes through chart review for patients with possible or definite IE and moderate-to-severe MAC.
Main Results:
- Of 741 patients, 51 (7%) had IE with moderate-severe MAC. The mitral valve was involved in 24 patients (47%), more frequently in women.
- Patients with mitral IE presented with large vegetations (median 13 mm), significant mitral regurgitation (54%), and a characteristic "rocking" motion of MAC in some cases.
- Surgical indications were high (63%), but only 40% underwent surgery due to perceived risk. In-hospital mortality was similar between mitral and non-mitral IE groups (29% vs. 15%).
Conclusions:
- Infective endocarditis with mitral annular calcification frequently involves the mitral valve, characterized by large, mobile vegetations and a "rocking" MAC appearance.
- Despite high surgical indications, underutilization of surgery due to perceived risk highlights a critical management gap in this high-risk IE population.
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