Mitral annular calcification severity and invasive hemodynamic confirmation of HFpEF: A prospective observational...

Mitral annular calcification (MAC) is a common degenerative process in older adults that can impair mitral valve compliance, elevate transmitral gradients, and increase left ventricular filling pressure. However, the extent to which increasing MAC severity parallels invasive hemodynamic evidence of heart failure with preserved ejection fraction (HFpEF) and established diagnostic algorithms remains uncertain. This was a single-center cross-sectional study. We evaluated 160 patients referred for HFpEF assessment who underwent comprehensive echocardiography. MAC severity was graded from 1 to 4 (n = 40 per group). HFpEF was defined invasively as a pulmonary capillary wedge pressure of ≥15 mm Hg at rest or ≥18 mm Hg after a standardized fluid challenge. Multivariable regression models tested the independent association between MAC grade (per 1-category increase) and invasive HFpEF diagnosis, as well as continuous H2FPEF (Heavy, Hypertensive, Atrial fibrillation, Pulmonary hypertension, Elder, Filling pressure score) and HFA-PEFF (Heart Failure Association Pretest Assessment, Echocardiography and Natriuretic Peptide, Functional Testing, Final Etiology) scores, adjusting for natriuretic peptide levels and key echocardiographic diastolic parameters. Participants were older (mean age, 76 years) and two-thirds were female, with preserved left ventricular ejection fraction (~59%). Higher MAC severity was associated with progressive elevations in pulmonary capillary wedge pressure (13.0-18.0 mm Hg at rest; 16.0-24.5 mm Hg after fluid challenge; P < .001) and, among catheterized participants, with a higher proportion meeting invasive HFpEF criteria (28.1%, 30.0%, 60.0%, and 85.0% across grades 1-4, respectively; P < .001). MAC grade was independently associated with invasively defined HFpEF (odds ratio, 1.78; 95% confidence interval, 1.22-2.38; P = .03), H2FPEF (β, 0.31; P = .03), and HFA-PEFF (β, 0.42; P = .004) scores. N-terminal pro-B-type natriuretic peptide was correlated with all outcomes. MAC severity showed a graded relationship with diastolic burden, invasive HFpEF confirmation, and diagnostic scores, suggesting that advanced MAC is associated with a hemodynamic profile consistent with HFpEF.