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Mitral annular calcification (MAC) is a chronic degenerative process involving the fibrous support structure of the mitral valve. The prevalence of this condition significantly increases with age, and is higher in patients with cardiovascular risk factors or end-stage renal disease. However, patients with systemic lupus erythematosus (SLE) may develop atherosclerosis and MAC at a relatively young age. Caseous calcification of the mitral annulus (CCMA) is a rare subtype of MAC that occurs because of caseous transformation of the inner material. Rarely, CCMA merges with infective endocarditis (IE). This case presented an unusual example of a recurrent mass caused by CCMA after surgery for IE. A 62-year-old Japanese woman was admitted to our hospital with fever of unknown origin. She had a documented history of SLE. Blood cultures were positive, and a transesophageal echocardiography, performed to investigate IE, revealed a mass attached to the CCMA. The patient was diagnosed with IE and underwent lumpectomy. Postoperatively, the patient remained free of fever and embolism; however, the mass recurred. She was considered to have a mass due to CCMA recurrence; although revision surgery was scheduled, the mass resolved spontaneously. Therefore, owing to the risk of recurrence, CCMA requires careful preoperative and postoperative observation. Caseous calcification of the mitral annulus may rarely occur, even in middle-aged patients. This condition carries the risk of infective endocarditis complications and postoperative recurrence, and careful follow-up is required. [ABSTRACT FROM AUTHOR]

Background: Mitral annulus calcification is a chronic degenerative condition affecting the fibrous base of the mitral valve. Historically viewed as an age-related phenomenon, recent studies suggest it is driven by active mechanisms involving systemic inflammation, hemodynamic stress, abnormal calcium-phosphorus metabolism, and lipid accumulation. Despite often being asymptomatic and incidentally detected, its clinical relevance stems from its strong association with increased cardiovascular disease risk, higher cardiovascular mortality, and elevated overall mortality. Methods: This article investigates the complexities and controversies surrounding mitral annular calcification as a potential embolic source, focusing on its diagnosis, its relationship with systemic inflammation, and its links to metabolic and chronic disorders. Results: The findings highlight that mitral annular calcification is not merely a passive marker of aging but an active indicator of atherosclerotic burden with significant implications for cardiovascular health. Conclusion: Mitral annulus calcification should be recognized as an important factor in cardiovascular risk assessment, offering insight into systemic inflammatory processes and metabolic dysregulation. [ABSTRACT FROM AUTHOR]

Calcification of the mitral valve annulus is common in patients on dialysis. The growing number of individuals receiving dialysis has been accompanied by an increase in cases necessitating surgical intervention for mitral valve annulus calcification. In this report, we present a severe case characterized by bulky calcification of the mitral annulus, which was managed with mechanical mitral valve replacement. A 61-year-old man on dialysis presented with chest pain upon exertion that had persisted for 3 months. Cardiac echocardiography revealed severe mitral stenosis and regurgitation, accompanied by cardiac dysfunction. During surgery, an ultrasonic aspiration system was employed to remove the calcification of the mitral valve annulus to the necessary extent. Subsequently, a mechanical mitral valve was sutured into the supra-annular position. To address the regurgitation, the area surrounding the valve was sewn to the wall of the left atrium. Postoperative assessments indicated an absence of perivalvular leak and demonstrated improved cardiac function. The patient was discharged on postoperative day 22. We describe a successful mitral mechanical valve replacement in a case of extensive circumferential mitral annular calcification. Even with severe calcification extending into the left ventricular myocardium, we were able to minimize the decalcification process. This approach enabled the performance of mitral mechanical valve replacement in a high-risk patient on dialysis, thus expanding the possibilities for cardiac surgery.

Background: Calcified amorphous tumor (CAT) of the heart is a rare, non-neoplastic cardiac mass with mitral valves and annuli being the most common sites. The presence of mitral annular calcification (MAC) is associated with an increased risk of stroke or other systemic embolisms. Here, we report a case of CAT showing rapid growth with MAC and investigate the link between the two. Case presentation: A 71-year-old man presented at our hospital with dyspnea and had been undergoing hemodialysis for 26 years for chronic glomerulonephritis. Transthoracic echocardiography (TTE) revealed moderate mitral stenosis with bulky MAC. Two months later, the patient developed progressive dyspnea, and follow-up TTE revealed a highly mobile mass (8 × 5 mm) attached to the left ventricular (LV) side of the posterior MAC. He underwent surgery because of congestive heart failure and a high risk of embolization. Surgical inspection revealed that the tumor was attached beneath the P3 segment of the mitral valve on the LV side and was removed. When removing the MAC, toothpaste-like contents drained from the encapsulated mass inside the MAC at the P3 segment, where the tumor was located. After reconstructing the posterior mitral annulus defect with a bovine pericardial patch, mitral valve replacement with a mechanical prosthesis, a maze procedure, and left appendage closure were performed. Histopathological examination revealed that the excised tumor contained fibrin and calcium deposits. The mass was diagnosed as a CAT. Conclusions: CAT may be one of the causes of stroke induced by MAC. Routine follow-up echocardiography should be recommended for patients with MAC, especially those undergoing hemodialysis. [ABSTRACT FROM AUTHOR]

Mitral annular calcification (MAC) is a progressive degenerative process associated with comorbidities and increased mortality. A staging system that considers extramitral cardiac damage in MAC may help improve patient selection for mitral valve interventions. This study sought to develop a transthoracic echocardiogram (TTE)-based cardiac staging system in patients with MAC and significant mitral valve dysfunction and assess its prognostic utility. We retrospectively evaluated all adults who underwent TTE over 1 year at Mayo Clinic with MAC and significant mitral valve dysfunction defined as mitral stenosis and/or at least moderate mitral regurgitation. Patients were categorized into 5 stages according to extramitral cardiac damage by TTE. All-cause mortality and heart failure hospitalization were assessed. For the 953 included patients, the mean age was 76.2 ± 10.7 years, and 54.0% were women. Twenty-eight (2.9%) patients were classified in stages 0 to 1, 499 (52.4%) in stage 2, 115 (12.1%) in stage 3, and 311 (32.6%) in stage 4. At the 3.8-year follow-up, mortality was significantly higher in patients in stages 2 to 4 compared to stages 0 to 1 and increased with each stage. Survival differences were maintained after adjustment for age, diabetes mellitus, and glomerular filtration rate. The rate of heart failure hospitalization was significantly higher in stages 3 and 4 compared to stages 0 to 1. Similar results were observed in subgroup analysis in patients with moderate or severe MAC, predominant mitral stenosis, or predominant mitral regurgitation. Using the proposed extramitral cardiac damage staging system in patients with MAC and significant mitral valve dysfunction, more advanced stages are associated with higher mortality. [Display omitted] [ABSTRACT FROM AUTHOR]

Background Mitral annular calcification (MAC) is common in the elderly. Extensive calcification has been historically challenging for the cardiac surgeons, with traditional surgical approaches carrying significant risks. Less invasive approaches have recently been explored in an attempt to reduce this risk. Case summary We report the case of a 75-year-old woman who presented with recurrent pulmonary oedema, due to severe MAC and mitral regurgitation. Her past medical history included bioprosthetic aortic valve replacement 5 years ago. Given the extensive MAC and the patient's frailty, a minimally invasive hybrid approach with direct implantation of a transcatheter balloon expandable Sapien 3 valve was selected to manage her. Although the post-surgical result was initially excellent with elimination of the mitral regurgitation, the patient's post-operative course was marked by two serious complications, namely, acute severe aortic regurgitation, due to rupture of the bioprosthetic valve's right cusp, and severe paravalvular leak of the Sapien valve, due to posterior migration towards the left atrium. These were managed successfully with emergency valve-in-valve implantation using the 'double chimney' technique for the bioprosthetic aortic valve, as well as transeptal valve-in-valve implantation of a 2nd Sapien valve in the mitral valve, which sealed the gap between the 1st Sapien and the calcified mitral annulus. Discussion This case illustrates a less invasive approach for the management of severe MAC. Complications can still occur in this high-risk group of patients, and therefore, such cases should be managed with close collaboration between cardiac surgeons and cardiologists, in centres with high expertise. [ABSTRACT FROM AUTHOR]

Transatrial transcatheter mitral valve replacement is a hybrid strategy involving placing the patient on cardiopulmonary bypass and direct implantation of a transcatheter valve in a calcified annulus for mitral annular calcification. We report a rare phenomenon of systolic anterior motion of the leaflets of a transcatheter heart valve prosthesis used for mitral valve replacement causing left ventricular outflow tract obstruction. Although reported in transcatheter mitral valve replacement, we believe this is the first report of left ventricular outflow tract obstruction after transatrial mitral valve replacement and discuss the pre-disposing risk factors. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Mitral annular calcification (MAC) is commonly observed in patients with cardiovascular diseases and has been associated with adverse clinical outcomes. This study aims to clarify the prevelance and impact of MAC on peri-procedural, in-hospital, and long-term outcomes in high-surgical-risk patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). METHODS: 403 patients underwent TAVI for severe AS was retrospectively evaluated. MAC was identified on transthoracic-echocardiography and confirmed on computed-tomography in 45.4% of patients. Clinical outcomes, including in-hospital mortality and two-year follow-up mortality, were evaluated, and potential predictors of MAC and mortality were analyzed using logistic and Cox regression models. RESULTS: MAC was more prevalent in older, female patients with atrial fibrillation. Although the presence of MAC did not correlate with increased in-hospital (unadjOR: 1.77, 95% CI (0.88-3.54), p=0.106) or long-term mortality (unadjOR: 0.73, 95% CI (0.40-1.33), p=0.311), it was associated with a higher requirement for post-TAVI permanent pacemaker implantation (PPI) and moderate-to-severe paravalvular aortic regurgitation (PVAR). Multivariate analysis revealed left ventricular ejection fraction (adjHR: 0.97, 95% CI (0.94-0.99),p=0.015), mean transvalvular gradient, (adjHR: 1.02, 95% CI (1.00-1.04), p=0.0.25) systolic pulmonary artery pressure (adjHR: 1.04, 95% CI (1.01-1.0.6), p=0.001) and severe PVAR (adjHR: 3.16, 95% CI (1.25-7.96), p=0.015) as independent predictors of long-term mortality. DISCUSSION AND CONCLUSION: In patients with severe AS undergoing TAVI, MAC is a marker of complex cardiac pathology but does not independently predict mortality. However, its presence may increase the need for PPI and the incidence of PVAR, which warrants attention in postoperative management and follow-up.

Mitral annular calcification is a chronic process involving degeneration and calcium deposition within the fibrous skeleton of the mitral valve annulus, which can lead to mitral valve dysfunction. It can be asymptomatic, or it can have pathologic sequelae leading to cardiovascular morbidity and mortality. Mitral annular calcification is increasingly recognized with the advancement of diagnostic imaging modalities, especially in an era with a growing elderly population. Its presence poses considerable challenges in terms of surgical and transcatheter management. Multiple surgical and transcatheter techniques have been developed to overcome these challenges. New transcatheter technologies are under investigation to tackle this problem. [ABSTRACT FROM AUTHOR]

Background: Mitral annular calcification (MAC) poses many challenges to the evaluation of diastolic function using standard echocardiography. Left atrial (LA) strain and left ventricular early diastolic strain rate (DSr) measured by speckle-tracking echocardiography (STE) are emerging techniques in the noninvasive evaluation of diastolic function. We aim to evaluate the utility of LA strain and early DSr in predicting elevated left ventricular filling pressures (LVFP) in patients with MAC and compare their effectiveness to ratio of mitral inflow velocity in early and late diastole (E/A). Methods: We included adult patients with MAC who presented between January 1 and December 31, 2014 and received a transthoracic echocardiogram (TTE) and cardiac catheterization with measurement of LVFP within a 24-h period. We used Spearman's rank correlation coefficient to assess associations of LA reservoir strain and average early DSr with LVFP. Receiver operating characteristic (ROC) curves were computed to assess the effectiveness of LA strain and DSr in discriminating elevated LVFP as a dichotomized variable and to compare their effectiveness with E/A ratio categorized according to grade of diastolic dysfunction. Results: Fifty-five patients were included. LA reservoir strain demonstrated poor correlation with LVFP (Spearman's rho = 0.03, p = 0.81) and poor discriminatory ability for detecting elevated LVFP (AUC = 0.54, 95% CI 0.38–0.69). Categorical E/A ratio alone also demonstrated poor discriminatory ability (AUC = 0.53, 95% CI 0.39–0.67), and addition of LA reservoir strain did not significantly improve effectiveness (AUC = 0.58, 95% CI 0.42–0.74, p = 0.56). Average early DSr also demonstrated poor correlation with LVFP (Spearman's rho = −0.19, p = 0.16) and poor discriminatory ability for detecting elevated LVFP (AUC = 0.59, 95% CI 0.44–0.75). Addition of average early DSr to categorical E/A ratio failed to improve effectiveness (AUC = 0.62, 95% CI 0.46–0.77 vs. AUC = 0.54, 95% CI 0.39–0.69, p = 0.38). Conclusions: In our sample, LA reservoir strain and DSr do not accurately predict diastolic filling pressure. Further research is required before LA strain and early DSr can be routinely used in clinical practice to assess filling pressure in patients with MAC. [ABSTRACT FROM AUTHOR]

Early studies of the Tendyne transcatheter mitral valve replacement (TMVR) showed promising results in a small selective cohort. The authors present 1-year data from the currently largest commercial, real-world cohort originating from the investigator-initiated TENDER (Tendyne European Experience) registry. All patients from the TENDER registry eligible for 1-year follow-up were included. The primary safety endpoint was 1-year cardiovascular mortality. Primary performance endpoint was reduction of mitral regurgitation (MR) up to 1 year. Among 195 eligible patients undergoing TMVR (median age 77 years [Q1-Q3: 71-81 years], 60% men, median Society of Thoracic Surgeons Predicted Risk of Mortality 5.6% [Q1-Q3: 3.6%-8.9%], 81% in NYHA functional class III or IV, 94% with MR 3+/4+), 31% had "real-world" indications for TMVR (severe mitral annular calcification, prior mitral valve treatment, or others) outside of the instructions for use. The technical success rate was 95%. The cardiovascular mortality rate was 7% at 30 day and 17% at 1 year (all-cause mortality rates were 9% and 29%, respectively). Reintervention or surgery following discharge was 4%, while rates of heart failure hospitalization reduced from 68% in the preceding year to 25% during 1-year follow-up. Durable MR reduction to ≤1+ was achieved in 98% of patients, and at 1 year, 83% were in NYHA functional class I or II. There was no difference in survival and major adverse events between on-label use and "real-world" indications up to 1 year. This large, real-world, observational registry reports high technical success, durable and complete MR elimination, significant clinical benefits, and a 1-year cardiovascular mortality rate of 17% after Tendyne TMVR. Outcomes were comparable between on-label use and "real-world" indications, offering a safe and efficacious treatment option for patients without alternative treatments. (Tendyne European Experience Registry [TENDER]; NCT04898335) [Display omitted] [ABSTRACT FROM AUTHOR]

An 83-year-old woman was admitted to our center because of heart failure. Transthoracic echocardiography revealed severe mitral annular calcification resulting in a double mitral valve lesion. After discussion by the heart team, transcatheter mitral valve replacement with Tendyne (Abbott Structural, Santa Clara, CA, USA) was performed. Despite having a predicted neo-left ventricular outflow tract (LVOT) above the cut-off value, the patient developed clinically significant LVOT obstruction (LVOTO) refractory to medical treatment. This situation is often treated before the intervention, and dealing with LVOTO afterward can be challenging. After taking the patient's anatomy into consideration, we decided to perform alcohol septal ablation. Applying a combined strategy of medical treatment and intervention led to success. In this case report, we discuss this event and the strategies available for preventing and managing the condition.

Mitral valve annular calcification-related valvular disease is increasingly common due to the rising prevalence of age-related mitral annular calcifications. Mitral annular calcification alters the structure and function of the mitral valve annulus, which in turn causes mitral valve regurgitation, stenosis, or both. As it frequently coexists with comorbid conditions and overlapping symptoms, mitral annular calcification-related valvular disease poses significant diagnostic and therapeutic challenges. For instance, left ventricular diastolic dysfunction hinders the assessment of mitral valvular disease. Detection of mitral annular calcifications and assessment of related mitral valve disease hinge on two-dimensional echocardiography. Comprehensive assessment of mitral annular calcifications and related mitral valve disease may require multidetector computed tomography and three-dimensional echocardiography. Invasive hemodynamic testing with exercise helps identify the cause of symptoms in patients with comorbid conditions, and transcatheter interventions have emerged as a viable therapeutic option for older patients. After an outline of the normal mitral annulus, we examine how mitral annular calcifications lead to mitral valve disease and how to accurately assess mitral regurgitation and stenosis. Lastly, we review surgical and transcatheter approaches to the management of mitral annular calcification-related mitral valve regurgitation, stenosis, or both. [ABSTRACT FROM AUTHOR]

The role of assessment of mitral annular calcification (MAC) using cardiac computed tomography (CCT) in mitral transcatheter edge-to-edge repair (TEER) remains unclear. The aim of this study was to investigate the association of MAC assessed by CCT with procedural and clinical outcomes in patients undergoing TEER. We retrospectively analyzed 275 patients who underwent pre-procedural CCT prior TEER. Mitral calcium volume (MCV) and MAC score were measured by CCT. Functional procedural success was defined as residual mitral regurgitation of ≤2+ with mean transmitral gradient of <5 ​mmHg at discharge. All-cause mortality within two years after TEER was collected. MAC was present in 115 of 275 patients (41.8 %). The median MCV was 198 ​mm3 (interquartile range [IQR]: 84 to 863 ​mm3), and the median MAC score was 3 (IQR: 2 to 4). Higher MCV and MAC score were inversely related to the rate of functional procedural success, independently of anatomical features of mitral valve. Patients with moderate/severe MAC, defined as MAC score of ≥4, had a lower rate of functional procedural success than those without MAC (56.1 ​% vs. 81.3 ​%; p ​= ​0.002). Moreover, higher MCV and MAC score were associated with a higher risk of all-cause mortality within two years, irrespective of baseline characteristics and functional procedural success. The presence and burden of MAC assessed by CCT were associated with procedural and clinical outcomes in patients undergoing TEER. The CCT-based assessment of MAC may improve patient selection for TEER. [Display omitted] We retrospectively assessed mitral calcium volume (MCV) and mitral annular calcification (MAC) score using cardiac computed tomography (CT) in 275 patients undergoing mitral transcatheter edge-to-edge repair (TEER). Higher MCV and MAC score were inversely related to the rate of functional procedural success of TEER, independently of anatomical features of mitral valve. Moreover, the presence of MAC and its severity was associated with two-year all-cause mortality after TEER. The quantitative assessment of MAC using cardiac CT may improve patient selection for mitral TEER. [ABSTRACT FROM AUTHOR]

Abstract Background Appropriate management of mitral annular calcification associated with mitral valve surgery must be determined on a case-by-case basis. However, an established procedure remains uncertain. Case presentation This report describes a surgical case of severe mitral and aortic valve stenosis associated with severe mitral annular calcification in a 71-year-old woman who underwent mitral valve replacement with a collar-reinforced mitral prosthesis. The patient underwent surgical repair after the treatment for heart failure. As the present patient was deemed to be at high risk for conventional mitral valve replacement, we applied a composite prosthetic valve that was enlarged circumferentially on the ventricular side of the prosthesis with a bovine pericardial patch. First, the solid calcium bar was left untouched and only the friable calcified mass that was easily scattered was removed. Subsequently, the prosthesis was secured by two mattress sutures placed in the intra-atrial position at the region of the extended calcified myocardium. Additionally, ten mattress sutures were placed in the supra-annular position at the other regions capable of passing stitches from the ventricular side to the atrial side. Finally, a 1.5 cm wide trimmed bovine pericardial collar was sutured circumferentially from the annulus to the atrial wall using running 4–0 polypropylene for reinforcement. Although temporary hemodialysis was performed for acute renal failure, the patient remained asymptomatic. Conclusions The present case suggests that mitral valve replacement using a collar-reinforced mitral prosthesis may be an effective technique for severe mitral annular calcification. To avoid catastrophic complications associated with treatment for severely calcified annulus, it is crucial to make a prudent preoperative decision regarding the surgical strategy under circumstances where conventional mitral valve replacement is impossible.

Background and aimsSex hormones (SH) may contribute to sex differences in cardiovascular disease (CVD). High free testosterone (T) and low sex hormone binding globulin (SHBG) have been associated with progression of coronary artery calcification in women. We now examined the association of SH with extra-coronary calcification (ECC) prevalence and progression among MESA participants.MethodsWe studied 2,737 postmenopausal women and 3,130 men free of clinical CVD with baseline SH levels. ECC measurements [ascending and descending thoracic aortic calcification (ATAC, DTAC), mitral annular calcification (MAC), aortic valve calcification (AVC)] were obtained by computed tomography at baseline and after 2.4 ± 0.9 years. We used multivariable Poisson regression to evaluate associations with ECC prevalence and incidence (Agatston scores >0) and linear mixed effects models for ECC progression, per 1-SD increment in log(SH) in women and men separately.ResultsThe mean age was 65 ± 9 and 62 ± 10 years for women and men, respectively. In women, greater free T and lower SHBG were associated with MAC incidence in a demographic-adjusted model only. In men, lower free T was associated with MAC prevalence, DTAC incidence and progression, while greater SHBG was associated with MAC prevalence and DTAC progression after further adjusting for CVD risk factors.ConclusionsIn this diverse cohort free of CVD, we found some associations of SH with ECC measures. In particular, free T was inversely associated with prevalent MAC and DTAC progression in men independent of CVD risk factors. SH may influence vascular calcification, but further work is needed to understand clinical implications of these findings.

Background and aimsBone and mineral metabolism has been implicated in the pathophysiology of cardiac valve calcification. Whether bone demineralization, a common aging-related disorder, promotes calcific valve disease remains uncertain. We tested the hypothesis that low bone mineral density (BMD) is associated with greater incidence/progression of cardiac valve calcification in the Multi-Ethnic Study of Atherosclerosis.MethodsUsing linear mixed-effects models, we related baseline measurement of BMD of the thoracic vertebrae by computed tomography (CT) in 6768 participants to serial CT assessments of aortic valve calcification (AVC) and mitral annular calcification (MAC) obtained over a >10-year period.ResultsAfter multivariable adjustment, lower BMD (per SD decrement) was associated with accelerated increase in AVC over time in women (0.76 [95% CI 0.42,1.09] Agatston -units [AU]/year) and men (1.41 [95% CI 0.48,2.33] AU/year), as well as for MAC in women (3.22 [95% CI 1.16,5.28] AU/year) and men (3.59 [95% CI 2.09,5.09] AU/year). Significant effect modification was observed, with more pronounced BMD-related acceleration of AVC and MAC progression in older or white participants of one or both sexes, as well as by estimated glomerular filtration rate, though the latter differed by sex for AVC and MAC.ConclusionsIn this multi-ethnic cohort, low thoracic BMD was significantly, but modestly, associated with increased AVC and MAC progression. This suggests that altered bone mineral metabolism does not have a major impact on calcific valve disease in the general population, but the possibility of a more meaningful influence in higher-risk individuals with osteoporosis will require further investigation.

Background Aortic valve calcium score is associated with hemodynamic severity of aortic stenosis. Whether this association is present in calcific mitral stenosis remains unknown. Methods and Results This study was a retrospective analysis of consecutive patients with mitral stenosis secondary to mitral annular calcification (MAC) undergoing transseptal catheterization. All patients underwent invasive mitral valve assessment via direct left atrial and left ventricular pressure measurement. Computed tomography within 1 year of cardiac catheterization and with adequate visualization of the mitral annulus was included. MAC calcium score quantification by Agatston method was obtained offline using dedicated software (Aquarius, TeraRecon, V.4). Median patient age was 66.9±11.2 years, 47% of patients were women, 50% had coronary artery disease, 40% had atrial fibrillation, 47% had prior cardiac surgery, and 33% had prior chest radiation. Median diastolic mitral valve gradient was 9.4±3.4 mm Hg on echocardiography and 8.5±4 mm Hg invasively. Invasive median mitral valve area using the Gorlin formula was 1.87±0.9 cm2. Median MAC calcium score for the cohort was 7280±7937 Hounsfield units. MAC calcium score correlated with the presence of atrial fibrillation (P=0.02) but was not associated with other comorbidities. There was no correlation between MAC calcium score and mitral valve area (r=0.07; P=0.6) or mitral valve gradient (r=−0.03; P=0.8). Conclusions MAC calcium score did not correlate with invasively measured mitral valve gradient and mitral valve area in patients with MAC‐related mitral stenosis, suggesting that calcium score should not be used as a surrogate for invasive hemodynamic parameters.

Background: Appropriate management of mitral annular calcification associated with mitral valve surgery must be determined on a case-by-case basis. However, an established procedure remains uncertain. Case presentation: This report describes a surgical case of severe mitral and aortic valve stenosis associated with severe mitral annular calcification in a 71-year-old woman who underwent mitral valve replacement with a collar-reinforced mitral prosthesis. The patient underwent surgical repair after the treatment for heart failure. As the present patient was deemed to be at high risk for conventional mitral valve replacement, we applied a composite prosthetic valve that was enlarged circumferentially on the ventricular side of the prosthesis with a bovine pericardial patch. First, the solid calcium bar was left untouched and only the friable calcified mass that was easily scattered was removed. Subsequently, the prosthesis was secured by two mattress sutures placed in the intra-atrial position at the region of the extended calcified myocardium. Additionally, ten mattress sutures were placed in the supra-annular position at the other regions capable of passing stitches from the ventricular side to the atrial side. Finally, a 1.5 cm wide trimmed bovine pericardial collar was sutured circumferentially from the annulus to the atrial wall using running 4–0 polypropylene for reinforcement. Although temporary hemodialysis was performed for acute renal failure, the patient remained asymptomatic. Conclusions: The present case suggests that mitral valve replacement using a collar-reinforced mitral prosthesis may be an effective technique for severe mitral annular calcification. To avoid catastrophic complications associated with treatment for severely calcified annulus, it is crucial to make a prudent preoperative decision regarding the surgical strategy under circumstances where conventional mitral valve replacement is impossible. [ABSTRACT FROM AUTHOR]

Background and Aims: Mitral annular calcification (MAC) by computed tomography (CT) is reported as an independent predictor of poor outcomes. However, it currently remains unclear if quantitative MAC parameters provide more value for mitral valve disease (MVD) management, therefore, we examined the prognostic value of MAC scores using noncontrast cardiac‐CT in MVD patients. Methods: Between January 2020 and December 2021, we prospectively enrolled 300 consecutive patients with MVD (MAC‐present = 80 and MAC‐absent = 220) undergoing preoperative cardiac‐CT and mitral valve (MV) surgery. Noncontrast cardiac‐CT images were used to qualitatively detect MAC (present or absent) and evaluate MAC scores. For analyses, we also collected baseline clinical data, intraoperative conversion (from MV repair to MV replacement), and follow‐up arrhythmia data. Results: Compared with the MAC‐absent group, MAC‐present patients were older (62 ± 7 vs. 58 ± 9 years, p <.001), mostly women (55% vs. 39.5%, p =.017), and also had aortic valve calcification (57.5% vs. 23.2%, p <.001), mitral stenosis (82.5% vs. 61.8%, p <.001), atrial fibrillation (30% vs. 11.8%, p <.001), and larger left atrial end‐diastolic dimension (LADD, 49 [44–56] versus 46 [41–50], p =.001]. Furthermore, MAC‐present patients underwent more MV replacements (61.8% vs. 82.5%, p =.001) and experienced a higher intraoperative conversion prevalence (11.8% vs. 61.3%, p <.001). Multiple logistic regression analyses showed that the female gender (odds ratio [OR]/95% confidence interval [CI]/p = 2.001/1.042–3.841/0.037) and MAC scores (OR/95% CI/p = 10.153/4.434–23.253/p <.001) were independent predictors of intraoperative conversion. During a follow‐up of 263 ± 134 days, MAC‐present patients had more arrhythmias (42.5% vs. 9.5%, p <.001). Also, MAC‐scores (hazard ratio [HR]/95% CI/p = 6.841/3.322–14.089/p <.001) and LADD (HR/95% CI/p = 1.039/1.018–1.060/p <.001) were independently associated with arrhythmias by Cox regression analyses. Conclusions: Noncontrast cardiac CT‐derived MAC‐scores showed a high risk for intraoperative conversion and follow‐up arrhythmias in MVD‐patients. [ABSTRACT FROM AUTHOR]

Purposes: Predicting hemodynamic changes of stenotic mitral valve (MV) lesions with mitral annular calcification (MAC) following transcatheter aortic valve implantation (TAVI) may inform clinical decision-making. This study aimed to investigate the association between the MAC severity quantified by computed tomography (CT) and changes in mean transmitral gradient (mTMG), mitral valve area (MVA) and stroke volume index (SVi) following TAVI. Methods and results: A total of 708 patients (median age 81, 52% male) with severe aortic stenosis (AS) underwent pre-procedural CT and pre- and post-TAVI transthoracic echocardiography. According to the classification of MAC severity determined by CT, 299 (42.2%) patients had no MAC, 229 (32.3%) mild MAC, 102 (14.4%) moderate MAC, and 78 (11.0%) severe MAC. After adjusting for age and sex, there was no significant change in mTMG following TAVI (Δ mTMG = 0.07 mmHg, 95% CI -0.10 to 0.23, P = 0.92) for patients with no MAC. In contrast, patients with mild MAC (Δ mTMG = 0.21 mmHg, 95% CI 0.01 to 0.40, P = 0.018), moderate MAC (Δ mTMG = 0.31 mmHg, 95% CI 0.02 to 0.60, P = 0.019) and severe MAC (Δ mTMG = 0.43 mmHg, 95% CI 0.10 to 0.76, P = 0.0012) had significant increases in mTMG following TAVI, with greater changes associated with increasing MAC severity. In contrast, there was no significant change in MVA or SVi following TAVI. Conclusion: In patients with severe AS undergoing TAVI, MAC severity was associated with greater increases in post-procedural mTMG whereas MVA or SVi remained unchanged. MAC severity should be considered for potential subsequent MV interventions if TAVI does not improve symptoms. [ABSTRACT FROM AUTHOR]

Background: This study aimed to examine the clinical outcomes of mitral valve replacement (MVR) in patients with severe mitral annular calcification (MAC) who required extensive decalcification and mitral annular reconstruction. Methods: We reviewed 15 patients with severe MAC who underwent MVR between January 2016 and May 2022. In all cases, the calcified mitral annulus was resected completely using a Cavitron Ultrasound Surgical Aspirator, and a new annulus was created using bovine pericardium. In the acute postoperative phase, strict afterload reduction therapy using an intra-aortic balloon pump (IABP) was administered. Results: The mean age of patients was 73 ± 8 years, and 13 (86.7%) were women. Concomitant aortic valve replacement was performed in 11 (73.3%) patients, tricuspid annuloplasty in 9 (60.0%), coronary artery bypass grafting in 1 (6.7%), and arrhythmia surgery in 7 (46.7%). The mean aortic cross-clamp and cardiopulmonary bypass times were 143 ± 32 min and 175 ± 34 min, respectively. In 13 patients, an IABP was used for 2 or 3 days postoperatively. There were no in-hospital deaths, left ventricular ruptures, or other MAC-related complications. Postoperative echocardiography revealed no paravalvular leakages. Conclusion: Our strategy for managing severe MAC is safe and reproducible even in relatively high-risk patients. Afterload reduction using an IABP in the acute postoperative phase may reduce the risk of fatal complications after extensive decalcification and mitral annular reconstruction. [ABSTRACT FROM AUTHOR]

Surgical treatment of mitral valve disease with severe mitral annular calcifications (MACs) is challenging, with reported high morbidity and mortality. Transcatheter treatment options are feasible, however, still far from being optimal alternatives. We report our positive experience with the off-label implant of a BioIntegral Injectable BioPulmonic valve fitted on a circumferential pericardial skirt for the treatment of severe MAC. [ABSTRACT FROM AUTHOR]

The MITRAL (Mitral Implantation of Transcatheter Valves) trial is the first prospective trial to evaluate the safety and feasibility of balloon-expandable aortic transcatheter heart valves in patients with failed surgical bioprostheses or annuloplasty rings and severe mitral annular calcification treated with mitral valve-in-valve (MViV), valve-in-ring (MViR), or valve–in–mitral annular calcification (ViMAC). The aim of this study was to evaluate 5-year outcomes among these patients. A multicenter prospective study was conducted among patients at high surgical risk at 13 U.S. sites. Patients underwent MViV (n = 30), MViR (n = 30), or ViMAC (n = 31) and were followed annually for 5 years. Kansas City Cardiomyopathy Questionnaire scores were obtained at baseline and follow-up visits. Echocardiograms were analyzed at independent core laboratories. A total of 91 patients underwent transcatheter mitral valve replacement (February 2015 to December 2017). The mean age was 74.3 ± 8.9 years. At 5-year follow-up, the lowest all-cause mortality was observed in the MViV group (21.4%), 94.7% of patients were in NYHA functional class I or II, and the mean mitral gradient was 6.6 ± 2.5 mm Hg. The MViR and ViMAC groups had higher all-cause mortality (65.5% and 67.9%), most survivors were in NYHA functional classes I and II (50% and 55.6%), and mean mitral gradients remained stable (5.8 ± 0.1 and 6.7 ± 2.5 mm Hg). Significant improvements in Kansas City Cardiomyopathy Questionnaire scores were observed when all 3 arms were pooled. MViV, MViR, and ViMAC procedures were associated with sustained improvement of heart failure symptoms and quality of life among survivors at 5 years. Transcatheter heart valve function remained stable in all 3 groups. Patients treated with MViV had excellent survival at 5 years, whereas survival was lower in the MViR and ViMAC groups, consistent with underlying disease severity. Patients with more residual mitral regurgitation had higher mortality. [Display omitted] [ABSTRACT FROM AUTHOR]

Mitral valve replacement in the setting of extensive mitral annular calcification is technically challenging and associated with high mortality and morbidity, including stroke. This is the first published report of direct surgical transcatheter valve implantation with use of a cerebral embolic protection device. (Level of Difficulty: Intermediate.)

Background The clinical significance of mitral annular calcification (MAC) in patients undergoing mitral transcatheter edge‐to‐edge repair is not well understood. There is limited evidence regarding the feasibility, durability of repair, and the prognostic value of MAC in this population. We sought to examine the prognostic value of MAC, its severity, and its impact on procedural success and durability of mitral transcatheter edge‐to‐edge repair. Methods and Results We reviewed the records of 280 patients with moderate–severe or severe mitral regurgitation who underwent mitral transcatheter edge‐to‐edge repair with MitraClip from March 2014 to March 2022. The primary end point was cumulative survival at 1 year. Independent factors associated with the primary end point were identified using multivariable Cox regression. Among 280 patients included in the final analysis, 249 had none/mild MAC, and 31 had moderate/severe MAC. Median follow‐up was 23.1 months (interquartile range: 11.1–40.4). Procedural success was comparable in the MAC and non‐MAC groups (92.6% versus 91.4%, P=0.79) with similar rates of residual mitral regurgitation ≤2 at 1 year (86.7% versus 93.2%, P=0.55). Moderate/severe MAC was associated with less improvement in New York Heart Association III/IV at 30 days when compared with none/mild MAC (45.8% versus 14.3%, P=0.001). The moderate/severe MAC group had lower cumulative 1‐year survival (56.8% versus 80.0%, hazard ratio [HR], 1.98 [95% CI, 1.27–3.10], P=0.002). Moderate/severe MAC and Society of Thoracic Surgeons predicted risk of mortality for mitral valve repair were independently associated with the primary end point (HR, 2.20 [1.10–4.41], P=0.02; and HR, 1.014 [1.006–1.078], P=0.02, respectively). Conclusions Mitral TEER is a safe and feasible intervention in selected patients with significant MAC and associated with similar mitral regurgitation reduction at 1 year compared with patients with none/mild MAC. Patients with moderate/severe MAC had a high 1‐year mortality and less improvement in their symptoms after TEER.

Mitral regurgitation (MR) associated with mitral annular calcification (MAC) is surgically challenging, and valve-in-MAC procedures using transcatheter aortic valve replacement (TAVR) devices have poor outcomes. Transcatheter mitral valve replacement (TMVR) may be an option. Concomitant TAVR and TMVR are limited to 2 reports. We describe the first case of concomitant TAVR and TMVR-in-MAC procedures. (Level of Difficulty: Advanced.)

Background Mitral annular calcification (MAC) is a chronic degenerative process that may progress. This study aimed to investigate associating factors and clinical implications of MAC progression. Methods and Results Among 560 patients with MAC identified by transthoracic echocardiography between January 2012 and June 2016, 138 patients (mean±SD age 72.7±10.2 years, 73 women) with mild or moderate MAC who received follow‐up examination within 18 to 36 months were retrospectively analyzed. Progressive MAC was defined as hemodynamic or structural profiles that had worsened by more than 1 grade. Hemodynamic features were assessed by the transmitral mean diastolic pressure gradient (MDPG), and structural features were assessed by the MAC angle in the parasternal short‐axis view. The clinical outcome was defined as a composite of all‐cause mortality, hospitalization for heart failure, and occurrence of ischemic stroke. Forty‐three patients (31.2%) showed progressive MAC. Patients with progressive MAC had higher systolic blood pressure, pulse pressure, MAC angle, and MDPG than those with stable MAC. Patients with progressive MAC had smaller left ventricular (LV) end‐systolic dimensions and higher LV ejection fractions compared with those with stable MAC. In multivariate analysis, pulse pressure, LV ejection fraction, MAC angle, and MDPG at baseline were significantly associated with MAC progression. During a median of 39.2 months' follow‐up, patients with progressive MAC showed poorer clinical outcomes than those with stable MAC (log‐rank P=0.015). Conclusions MAC progression is not rare and is associated with structural substrate and hemodynamic loads that result in mechanical stress. Patients with progressive MAC have poor outcomes.

Key Clinical Message: Extensive resection of the infected calcified annulus and the reconstruction with a pericardial patch for the debrided annulus is an effective surgical option for the treatment of infectious endocarditis in patients with mitral annular calcification. A 78‐year‐old woman was referred to our hospital because of left‐sided hemiparesis. During the treatment for cerebral infarction, the patient became feverish and lost consciousness. Transthoracic echocardiography revealed mitral annular calcification and a tumor‐like mass on the posterior leaflet despite no findings of mitral regurgitation. She underwent successful mitral valve replacement with debridement of the infected mitral annulus and reconstruction of the posterior annulus (annuloplasty) with bovine pericardium after removal of the mitral annular calcification. [ABSTRACT FROM AUTHOR]

Transcatheter mitral valve replacement (TMVR) using the SAPIEN platform has been performed in failed bioprosthetic valves (valve-in-valve), surgical annuloplasty rings (valve-in-ring), and native valves with mitral annular calcification (MAC) (valve-in-MAC). Experience over the past decade has identified important challenges and solutions to improve clinical outcomes. In this review, we discuss the indication, trend in utilization, unique challenges, procedural planning, and clinical outcomes of valve-in-valve, valve-inring, and valve-in-MAC TMVR. [ABSTRACT FROM AUTHOR]

AimsThe detection of cardiac valvular calcification on routine imaging may provide an opportunity to identify individuals at increased risk for peripheral artery disease (PAD). We investigated the associations of aortic valvular calcification (AVC) and mitral annular calcification (MAC) with risk of developing clinical PAD or a low ankle-brachial index (ABI).Methods and resultsAVC and MAC were measured on cardiac computed tomography in 6778 Multi-Ethnic Study of Atherosclerosis participants without baseline PAD between 2000 and 2002. Clinical PAD was ascertained through 2015. Incident low ABI, defined as ABI 0.9 at baseline and at least one follow-up ABI measurement 3-10 years later. Adjusted Cox proportional hazards and Poisson regression modelling were used to determine the association of valvular calcification with clinical PAD and low ABI, respectively. There were 117 clinical PAD and 198 low ABI events that occurred over a median follow-up of 14 years and 9.2 years, respectively. The presence of MAC was associated with an increased risk of clinical PAD [hazard ratio 1.79; 95% confidence interval (CI) 1.04-3.05] but not a low ABI (rate ratio 1.28; 95% CI 0.75-2.19). No significant associations were noted for the presence of AVC and risk of either clinical PAD.ConclusionMAC is associated with an increased risk of developing clinical PAD. Future studies are needed to corroborate our findings and better understand whether MAC holds any predictive value as a risk marker for PAD.

Background and aimsPrevalent valvular calcification (VC) is associated with stroke but little is known about associations of VC progression with stroke.MethodsProgression (interval increase >0 Agatston units/year) of aortic valvular calcification (AVC) and mitral annular calcification (MAC) was assessed by two cardiac CTs over a median of 2.4 years. We determined the risk of adjudicated total and ischemic stroke using Cox regression adjusted for cardiovascular disease (CVD) risk factors.ResultsWe studied 5,539 MESA participants free of baseline CVD and atrial fibrillation. Baseline mean ± SD age was 62 ± 10 years; 53% were women; 83% had no progression of VC; 15%, progression at one site (AVC or MAC), and 3%, progression at both sites. Over a median of 12 years, 211 total and 167 ischemic strokes occurred. The number of sites with VC progression (range 0-2) was not associated with total and ischemic stroke (all p > 0.05). We found MAC progression to be associated with increased risk of total stroke [adjusted hazard ratio (95% CI) 1.59 (1.11, 2.28)] and ischemic stroke [1.64 (1.10, 2.45)]. Results remained significant after further adjustment for baseline coronary artery calcification. After excluding participants with interim atrial fibrillation and coronary heart disease, findings were no longer statistically significant in fully-adjusted models. There was no interaction by age, sex, or race/ethnicity. There was no association with AVC progression and stroke.ConclusionsProgression of MAC but not AVC over 2.4 years is associated with increased risk of total and ischemic stroke.

Abstract Background In the latest reports, atherogenic indices have been related to acute coronary syndromes, stable coronary artery disease, heart failure and future cardiac events. Conventional atherosclerosis risk factors have been associated with mitral annular calcification (MAC), but data on the relationship between atherogenic indices and MAC are lacking. We aimed to investigate a possible relationship between MAC and atherogenic indices. Methods In total 741 patients (n = 427 with MAC and n = 314 without MAC) who were examined in our cardiology clinic from February 2016 to October 2021 were recruited in the study. Mitral annular calcification was diagnosed by transthoracic 2-dimensional echocardiography. The atherogenic coefficient (AC), Castelli risk index 1 (CRI-1), Castelli risk index 2 (CRI-2) and atherogenic index of plasma (AIP) were calculated by utilizing standard lipid test values. Results There was no statistically significant difference in sex, age, diabetes and hypertension status between the patient and the control groups. Serum triglyceride level, AIP, Hs-CRP, smoking and BMI were independently significantly associated with MAC in multiple regression analysis (p

Objective: Coronavirus disease-2019 (COVID-19) can particularly affect the respiratory and cardiovascular systems and cause serious mortality. Mitral annular calcification (MAC) is a mitral valve pathology associated with cardiac mortality. We aimed to evaluate the effect of MAC on myocardial injury (MI) and mortality, which can develop secondary to COVID-19 infection. Materials and Methods: After applying the exclusion criteria, thorax computed tomography (CT) images of the remaining 1151 consecutive COVID-19 patients were evaluated. Calculation of MAC scores was done by two expert radiologists blinded to the study data. MI was defined as those with hs-TnI level (≥34 ng/dl). Patients included in the study were classified as having mortality and not occurring. Results: Male gender, advanced age (>65), hypertension, diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease (CKD), coronary artery disease, heart failure and atrial fibrillation rates were statistically higher in the mortality group (p

Background: Surgical management of severe mitral annular calcification (MAC) presents a challenging problem for even the most experienced surgeons. Preoperative planning is the most effective strategy to mitigate risk in these scenarios. MAC alone should not disqualify a patient from consideration for mitral valve repair, although the presence of concurrent greater than moderate stenosis warrants consideration of mitral valve replacement. Methods: While repair and replacement techniques for mitral regurgitation in the setting of MAC overlap with those used to repair a non-calcified mitral apparatus, there are unique considerations to the surgical conduct of these procedures. Specifically, this article describes techniques that may be employed when the severity of MAC precludes typical repair or replacement strategies. Results: Between 2014 and 2021, 77 patients were operated on by a single surgeon for mitral valve disease complicated by severe MAC. Using the systematic approach described herein, 1-year mortality was 7.8% and overall mortality over a follow-up period extending 1 to 8 years was 9.1%. Conclusions: Despite the inherent challenges of mitral valve repair or replacement in the setting of severe MAC, a systematic approach beginning with preoperative planning, modification of annular suture placement, and techniques to mitigate severe complications have, in our experience, resulting in a reliable methodology for managing severe MAC with excellent outcomes. [ABSTRACT FROM AUTHOR]

Data regarding mitral regurgitation (MR) in extremely elderly patients are limited. The aim of the present study was to assess symptomatic status, frailty, etiology and outcomes for nonagenarians with severe MR. Single-center cohort study of patients ≥90 years of age with at least 3+ MR on echocardiography between September 2010 and August 2018. Out of a total of 11,998 patients with at least 3+ MR, 267 patients were included in the present study. The average age was 93.5 ± 2.6 years, and 57% were female. At baseline, 88% were symptomatic, with mean Charlson co-morbidity index of 6 ± 2 points, and mean frailty score of 2.9 ± 1.4 points. Primary MR was present in 50%, secondary in 47%, and prosthetic valve dysfunction in 3%. Among patients with primary MR, the most common etiology was mitral annular calcification (58%). In comparison, the most common etiology of secondary MR was atrial functional MR (52%). Of all, 95% were treated conservatively, and 5% underwent interventional management. Among 253 patients who had follow-up data with a median follow-up of 14 months (25th–75th interquartile range: 3–31 months), 191 patients (75%) died. Mortality trended higher in the conservative group versus the interventional group (60% vs. 22%, log-rank P = 0.063). Most nonagenarians with significant MR were symptomatic at presentation, had elevated Charlson co-morbidity index and frailty scores. Etiologies of MR were almost equally distributed between primary and secondary causes. The vast majority of nonagenarians with significant MR were conservatively managed. • Etiology of MR is an important decision-making factor when determining treatment strategies. • The majority of nonagenarians with significant MR had elevated CCI and frailty scores. • Distributions of DMR and SMR in nonagenarians differed from younger patients. • The vast majority of nonagenarians were conservatively managed. • There may be a subset of nonagenarians who may benefit from appropriate intervention for severe MR. [ABSTRACT FROM AUTHOR]

Among masses involving the mitral valve and annulus, caseous calcification of the mitral annulus (CCMA) is a rare disease. CCMA accounts for.63% of all mitral annular calcification (MAC) cases. The pathophysiology is still unknown. The correct diagnosis and treatment of this disease is very important to prevent complications. We present a case of giant CCMA with advanced mitral stenosis and hypertrophic cardiomyopathy, presenting with symptoms of infection and therefore a preliminary diagnosis of infective endocarditis. Because of these features, we wanted to share our case as it is the 1st case in the literature. [ABSTRACT FROM AUTHOR]

Key Clinical Message Extensive resection of the infected calcified annulus and the reconstruction with a pericardial patch for the debrided annulus is an effective surgical option for the treatment of infectious endocarditis in patients with mitral annular calcification. Abstract A 78‐year‐old woman was referred to our hospital because of left‐sided hemiparesis. During the treatment for cerebral infarction, the patient became feverish and lost consciousness. Transthoracic echocardiography revealed mitral annular calcification and a tumor‐like mass on the posterior leaflet despite no findings of mitral regurgitation. She underwent successful mitral valve replacement with debridement of the infected mitral annulus and reconstruction of the posterior annulus (annuloplasty) with bovine pericardium after removal of the mitral annular calcification.

Mitral annulus calcification is a common incidental finding in echocardiography examination of predisposed populations. On the other hand, caseous calcification of the mitral annulus is a rare variant that challenges the physician to differentiate it from different causes of cardiac masses. We describe a case of incidentally discovered caseous calcification confirmed with CT cardiac and cardiac magnetic resonance.

Background and aimsGlycA is a novel composite biomarker of systemic inflammation reflecting posttranslational glycosylation of acute phase reactants. GlycA has been associated with coronary artery calcium, cardiovascular disease (CVD) events and mortality. Vascular calcifications outside of the coronary arteries are risk markers of CVD and mortality. Whether GlycA is linked to extra-coronary calcifications (ECC) is not well established.MethodsWe studied 6462 MESA participants free of clinical CVD who had plasma GlycA measured at baseline. ECCs [calcification in aortic valve (AVC), mitral annulus (MAC), ascending and descending thoracic aorta (ATAC, DTAC)] were ascertained at baseline and follow-up visit (median 2.3-yrs later) by cardiac CT. Poisson regression models with robust variance estimation assessed associations of GlycA with prevalent and incident ECC. Linear mixed models assessed the cross-sectional and 2-year change in ECC. Models were adjusted for demographic and lifestyle factors.ResultsIn cross-sectional analysis, GlycA (per SD increment) was positively associated with prevalent AVC, ATAC and DTAC with adjusted prevalence ratios (95% CI) of 1.08 (1.01-1.14), 1.18 (1.03-1.34) and 1.10 (1.06-1.14), respectively. There was also a significant association between GlycA and baseline extent of both ATAC and DTAC. Longitudinally, GlycA was positively associated with incident MAC and DTAC, with adjusted incidence ratios of 1.18 (1.03-1.37) and 1.17 (1.07-1.28), respectively. GlycA was also associated with 2-year change in MAC and DTAC extent.ConclusionsIn this diverse cohort free from clinical CVD, we found GlycA was positively associated with prevalent and incident ECC measures, in particular for progression of MAC and DTAC.

Mitral annular calcification (MAC) is a common chronic degenerative process of the mitral valve fibrous support ring. MAC increases the risk of mitral valve dysfunction, all-cause and cardiovascular mortality, and worse outcomes in cardiac interventions. Echocardiography represents the first imaging modality for MAC assessment, but it has low specificity compared to cardiac CT in terms of distinguishing between calcium and dense collagen. Novel three-dimensional transesophageal maximal intensity projection (MIP) mapping allows for the real-time MAC distribution and depth visualization of the cardiac anatomy and represents a useful and promising tool for pre-procedural assessment and intra-procedural guidance of cardiac interventions. [ABSTRACT FROM AUTHOR]

Mitral annular calcification is a chronic and degenerative process of the fibrous base of the mitral valve. Surgical management of mitral valve dysfunction with severe annular calcification remains technically demanding and, to date, the preferred approach is still a standard full sternotomy. We aimed to analyze and report our experience with mitral valve surgery addressing annular calcification via the minimally invasive approach through a right mini-thoracotomy. Data of patients with mitral valve disease and underlying annular calcification undergoing minimally invasive surgery from 2018 to 2022 were prospectively collected and retrospectively analyzed. The severity of mitral annular calcification was categorized with an angio-computerized tomography scan analysis as mild, moderate or severe according to calcium thickness, calcium distribution, and trigone and leaflet involvement using the Mitral Annular Calcification Computerized Tomography-score. During the study period, 27 patients with mitral valve disease and associated mitral annular calcification were enrolled. The most common etiology was advanced Barlow's disease, which was encountered in 18 cases (67%). Mitral valve replacement was performed in 21 patients (78%). No intraoperative death, atrioventricular disruption, or circumflex coronary artery injury occurred. Conversion to sternotomy was necessary in a single case. Residual moderate periprosthetic leak requiring early reoperation and permanent heart block mandating permanent pacemaker implantation were reported in one and in three patients, respectively. No cases of stroke were reported. Two patients died, accounting for a 7.4% perioperative mortality. At a median follow-up of 9 months, one patient had residual moderate mitral regurgitation, whereas two patients required short-term reoperation and prosthetic valve (re)replacement. Minimally invasive mitral valve surgery via right mini-thoracotomy should be considered an and effective approach to be indicated also in patients with mild-to-severe mitral annular calcification. Routine angio-computerized tomography scan during work-up is a mandatory step to stratify the anatomical extension and severity of the mitral annular calcification. [ABSTRACT FROM AUTHOR]