Systematic transoesophageal echocardiography after mitral valve replacement: Rates and determinants of paravalvular regurgitation

Natural History of Mitral Annulus Calcification and Calcific Mitral Valve Disease

BACKGROUND

The natural history of mitral annular calcification (MAC) and risk for developing calcific mitral valve disease (CMVD) has been poorly defined. We sought to evaluate the progression rate of MAC and of the development of CMVD.

METHODS

Patients with MAC and paired echocardiograms at least one year apart between 2005 and 2019 were included. Progression rates from mild/moderate to severe MAC and to CMVD (defined as severe MAC and significant mitral stenosis and/or regurgitation) were assessed, along with potential association with sex.

RESULTS

A total of 11,605 patients (73±10years, 51%male) with MAC (78% mild, 17% moderate, 5% severe) were included and had a follow up echocardiogram at 4.2±2.7years. In patients with mild/moderate MAC, 33% presented with severe MAC at 10 years. The rate of severe MAC was higher in females than in males (41% vs. 24%, P<0.001, HR=1.3, P<0.001) and in patients with moderate vs. mild MAC (71% vs. 22%, P<0.001, HR=6.1, P<0.001). At 10 years 10% presented with CMVD (4%, 23% and 60% in patients with mild, moderate, and severe MAC respectively) and was predicted by female sex (15% vs. 5%, P<0.0001), even after adjustment for MAC severity (HR=1.9, P<0.001).

CONCLUSION

In this large cohort of patients with MAC, progression to severe MAC was common and frequently results in CMVD. Female sex was associated with higher progression rates. MAC and CMVD are expected to dramatically increase as the population ages highlighting the importance of a better understanding of the pathophysiology of MAC in order to develop effective preventive medical therapies.

Early paravalvular leak after conventional mitral valve replacement: A single-center analysis

Introduction

Paravalvular leak (PVL) is a well‐recognized complication after mitral valve replacement (MVR). However, there are only a few studies analyzing leak occurrence and postoperative results after surgical MVR. The aim of this study was to assess the rate and determinants of early mitral PVL and to evaluate the impact on survival.

Methods

We performed a retrospective analysis involving patients who underwent MVR from January 2012 to December 2019 at our Institution. Postoperative transthoracic echocardiography evaluation was done for all subjects before hospital discharge. Multivariable analysis was carried out by constructing a logistic regression model to identify predictors for PVL occurrence.

Results

Four hundred ninety‐four patients were enrolled. Operative mortality was 4.9%. Early mitral PVL was found in 16 patients (3.2%); the majority were mild (75%). Leaks occurred more frequently along the posterior segment of the mitral valve annulus (62.5%). Only one individual with moderate‐to‐severe PVL underwent reoperation during the same hospital admission. Multivariable analysis revealed that preoperative diagnosis of infective endocarditis was the only factor associated with early leak after MVR (odds ratio: 4.96; 95% confidence interval: 1.45–16.99; p = .011). Overall mortality at follow‐up (mean follow‐up time: 4.7 [SD: 2.5] years) was 19.6% and favored patients without early mitral PVL.

Conclusion

The incidence of early PVL after MVR is low. PVL is usually mild and develop more frequently along the posterior segment of the mitral valve annulus. Preoperative diagnosis of infective endocarditis increases the risk of PVL formation.

Review: application of current imaging modalities in the management of left-sided valvular heart disease

In terms of valvular heart disease (VHD) imaging, transthoracic echocardiography (TTE) is the preferred first choice because of its widespread availability. Other modalities, such as transesophageal echocardiography, computed tomography and magnetic resonance imaging, have played a supplementary role in diagnosis for severity, deciding the timing/type of treatment, detection of post procedural complications, and prognostic predictions. However, there are few consensuses on how to employ these modalities, as the evidence is not extensive as that for TTE. On the other hand, these imaging modalities also have their own unique strengths. If employed properly, these modalities have the potential to play a more prominent role in clinical decision making. In this review, we focus on the potential, limitations and application of current imaging modalities in the management of left-sided VHD.

Clinical outcomes of mitral valve intervention in patients with mitral annular calcification: A systematic review and meta-analysis

BACKGROUND

Mitral valve (MV) disease with mitral annular calcification (MAC) poses a surgical challenge and the clinical outcomes of MV surgery as well as transcatheter mitral valve replacement (TMVR) remain relatively unexplored. We performed a systematic review and meta-analysis to assess the effects of MAC on clinical outcomes following MV surgery and TMVR.

METHODS

We searched MEDLINE and EMBASE databases until February 2019 for studies comparing clinical outcomes of MV surgery or TMVR in patients with and without MAC. Data were extracted by two independent investigators. Outcomes were perioperative and midterm complications and mortality.

RESULTS

Seven observational studies enrolling 2902 patients were included. MAC patients were older, more likely to be female with greater chronic lung disease and kidney failure. Perioperative mortality was similar between patients with and without MAC undergoing MV surgery (risk ratio [RR], 1.15; 95% confidence interval [CI], 0.50-2.65; P = .74). MAC was associated with a higher risk of bleeding, permanent pacemaker implantation, and periprosthetic leak. Midterm mortality was greater in MAC patients undergoing MV surgery (incident rate ratio [IRR], 1.32; 95% CI, 1.05-1.67; P = .02). MAC patients undergoing TMVR had higher perioperative (RR, 4.65; 95% CI, 2.93-7.38; P < .01) and 1-year (RR, 5.44; 95% CI, 3.49-8.49; P < .01) mortality, decreased procedural success, greater left ventricular outflow tract obstruction and need for conversion to surgery when compared with patients undergoing TMVR for dysfunction of a bioprosthetic valve or annuloplasty ring.

CONCLUSION

MV procedures in patients with MAC are associated with higher mortality and morbidity. This is largely driven by the high-risk patient profile associated with MAC. TMVR holds promise but has important limitations and should be reserved for select patients.