Mitral annular calcification in the elderly – Quantitative assessment

Abstract

To determine the reliability of subjective and objective quantification of mitral annular calcification (MAC) in elderly patients with severe aortic stenosis, to define quantitative sex-and age-related reference values of MAC, and to correlate quantitative MAC with mitral valve disease. Methods: In this retrospective, IRB-approved study, we included 559 patients (268 females, median age 81 years, inter-quartile range 77-85 years) with severe aortic stenosis undergoing CT. Four independent readers performed subjective MAC categorization as follows: no, mild, moderate, and severe MAC. Two independent readers performed quantitative evaluation of MAC using the Agatston score method (Agatston MAC). Mitral valve disease was determined by echocardiography. Results: Subjective MAC categorization showed high inter-reader agreement for no (k = 0.88) and severe MAC (k = 0.75), whereas agreement for moderate (k = 0.59) and mild (k = 0.45) MAC was moderate. Intra-reader agreement for subjective MAC categorization was substantial (k = 0.69 and 0.62). Inter-and intra-reader agreement for Agatston MAC were excellent (ICC = 0.998 and 0.999, respectively), with minor inconsistencies in MAC involving the left ventricular outflow tract/aortic valve. There were significantly more women than men with MAC (n = 227, 85% versus n = 209, 72%; p < 0.001), with a significantly higher Agatston MAC (median 597, range 81-2055 versus median 244; range 0-1565; p < 0.001), particularly in patients ≥85 years of age. Agatston MAC showed an area-under-the-curve of 0.84 to diagnose mitral stenosis, whereas there was no association of Agatston MAC with mitral regurgitation (p > 0.05). Conclusions: Our study in elderly patients with severe aortic stenosis shows that quantitative MAC scoring is more reliable than subjective MAC assessment. Women show higher Agatston MAC scores than men, particularly in the elderly population. Agatston MAC shows high accuracy to diagnose mitral stenosis.

Mitral annular disjunction in patients with severe aortic stenosis: Extent and reproducibility of measurements with computed tomography

“…In contrast, disjunctive annulus show a paradoxical systolic expansion and flattening, even in patients with preserved left ventricular function, indicating a functional decoupling from the ventricle [ 3 ]. Severe aortic stenosis and severe mitral regurgitation frequently coexists [ 18 , 19 ]. Whether mitral valve disease is independently associated with worse outcomes after TAVR remains a matter of debate [ 33 ].…”

“…Specifically, CT allows for an assessment of the mitral valve apparatus including the leaflet/annulus complex with high accuracy [ [14] , [15] , [16] , [17] ]. In patients with aortic stenosis undergoing transcatheter aortic valve replacement (TAVR) relevant mitral valve disease frequently coexists in around one third of patients [ 18 , 19 ].…”

Clinical impact of mitral calcium volume in patients undergoing transcatheter aortic valve implantation

“…5. Calculation of the mitral Agatston score 12,13,25 has been described as an alternative. Recently, researchers suggested that quantitative MAC scoring by the Agatston method is more reliable than visual assessment and has high accuracy to diagnose MS in elderly patients with aortic stenosis.…”

“…9 Multidetector computed tomography (MDCT) is now considered the gold standard for the detection of cardiac calcification. 2,[7][8][9][10][11][12][13] Although frequently applied to the aortic valve, [14][15][16][17] quantitative assessment of mitral calcium volume (MCV) has not been well studied and MAC as a disease has been poorly described. We assess the impact of MAC quantified by MCV on MV function and clinical outcomes after TAVI.…”

Current methods to assess mitral annular calcification and its risk factors

“…Additionally, contrast CT images enable the evaluation of other anatomical cardiac structures (coronary arteries and aorta), peri coronary fat attenuation index, cardiac volumes, ejection fraction, wall motion and intracardiac thrombus without additional imaging [32]. However, it is not possible to obtain the trans mitral gradients and associated MR with CT. [46]. The association between MAC and aging is proven by the fact that it is present in 90years of adults at the time of autopsy (17% men and 43% women) [47].…”