Author + information
- Received December 19, 2019
- Revision received March 2, 2020
- Accepted March 6, 2020
- Published online May 21, 2020.
- Mayra Guerrero, MDa,∗ ( )(, )@MayraGuerreroMD,
- Dee Dee Wang, MDb,
- Amit Pursnani, MDc,
- Mackram Eleid, MDa,
- Omar Khalique, MDd,
- Marina Urena, MDe,
- Michael Salinger, MDc,
- Susheel Kodali, MDd,
- Tatiana Kaptzan, PhDf,
- Bradley Lewis, MSg,
- Nahoko Kato, MDa,
- Hector M. Cajigas, BAh,
- Olaf Wendler, MDi,
- David Holzhey, MDj,
- Ashish Pershad, MDk,
- Christian Witzke, MDl,
- Sami Alnasser, MDm,n,
- Gilbert H.L. Tang, MD, MSc, MBAo,
- Kendra Grubb, MDp,
- Mark Reisman, MDq,
- Philipp Blanke, MDr,
- Jonathon Leipsic, MDr,
- Eric Williamson, MDs,
- Patricia A. Pellikka, MDa,
- Sorin Pislaru, MDa,
- Juan Crestanello, MDt,
- Dominique Himbert, MDe,
- Alec Vahanian, MDu,
- John Webb, MDq,
- Rebecca T. Hahn, MDd,
- Martin Leon, MDd,
- Isaac George, MDv,
- Vinayak Bapat, MDv,
- William O’Neill, MDb and
- Charanjit Rihal, MDa
- aDepartment of Cardiovascular Medicine, Mayo Clinic Hospital, Rochester, Minnesota
- bCenter for Structural Heart Disease, Henry Ford Hospital, Detroit, Michigan
- cDivision of Cardiology, NorthShore University HealthSystem, Evanston, Illinois
- dDivision of Cardiology, Columbia University Medical Center, New York, New York
- eDepartment of Cardiology, Bichat Hospital, Paris, France
- fCardiovascular Research Unit, Mayo Clinic Hospital, Rochester, Minnesota
- gDepartment of Health Sciences Research, Mayo Clinic Hospital, Rochester, Minnesota
- hUniversity of Illinois College of Medicine, Chicago, Illinois
- iDepartment of Surgery, King’s College Hospital, London, United Kingdom
- jDepartment of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
- kDivision of Cardiology, Banner University Medical Center, Phoenix, Arizona
- lDivision of Cardiology, Einstein Medical Center, Philadelphia, Pennsylvania
- mDivision of Cardiology, St. Michael’s Hospital, Toronto, Ontario, Canada
- nNorthern Ontario School of Medicine, Health Sciences North, Sudbury, Ontario
- oDepartment of Cardiovascular Surgery, Mount Sinai Health System, New York, New York
- pDivision of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
- qDivision of Cardiology, University of Washington Medical Center, Seattle, Washington
- rCenter for Heart Valve Innovation, St. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada
- sDepartment of Radiology, Mayo Clinic Hospital, Rochester, Minnesota
- tDepartment of Cardiac Surgery, Mayo Clinic Hospital, Rochester, Minnesota
- uUniversite de Paris, Paris, France
- vDivision of Cardiothoracic Surgery, Columbia University Medical Center, New York, New York
- ↵∗Address for correspondence:
Mayra Guerrero, MD, Mayo Clinic College of Medicine, Department of Cardiovascular Medicine, Mayo Clinic Hospital, 1216 2nd Street SW, Rochester, Minnesota 55905.
Objectives This study aims to establish a computed tomography (CT)–based scoring system for grading mitral annular calcification (MAC) severity and potentially aid in predicting valve embolization during transcatheter mitral valve (MV) replacement using balloon-expandable aortic transcatheter heart valves.
Background Transcatheter MV replacement is emerging as an alternative treatment for patients with severe MAC who are not surgical candidates. Although cardiac CT is the imaging modality of choice in the evaluation of candidates for valve-in-MAC (ViMAC), a standardized grading system to quantify MAC severity has not been established.
Methods We performed a multicenter retrospective review of cardiac CT and clinical outcomes of patients undergoing ViMAC. A CT-based MAC score was created using the following features: average calcium thickness (mm), degrees of annulus circumference involved, calcification at one or both fibrous trigones, and calcification of one or both leaflets. Features were assigned points according to severity (total maximum score = 10) and severity grade was assigned based on total points (mild ≤3, moderate 4 to 6, and severe ≥7 points). The association between MAC score and device migration/embolization was evaluated.
Results Of 117 patients in the TMVR in MAC registry, 87 had baseline cardiac CT of adequate quality. Of these, 15 were treated with transatrial access and were not included. The total cohort included 72 (trans-septal = 37, transapical = 35). Mean patient age was 74 ± 12 years, 66.7% were female, and the mean Society of Thoracic Surgery risk score was 15.4% ± 10.5. The mean MAC score was 7.7 ± 1.4. Embolization/migration rates were lower in higher scores: Patients with a MAC score of 7 had valve embolization/migration rate of 12.5%, MAC score ≥8 had a rate of 8.7%, and a MAC score of ≥9 had zero (p = 0.023). Patients with a MAC score of ≤6 had 60% embolization/migration rate versus 9.7% in patients with a MAC score ≥7 (p < 0.001). In multivariable analysis, a MAC score ≤6 was in independent predictor of valve embolization/migration (odds ratio [OR]: 5.86 [95% CI: 1.00 to 34.26]; p = 0.049).
Conclusions This cardiac CT–based score provides a systematic method to grade MAC severity which may assist in predicting valve embolization/migration during trans-septal or transapical ViMAC procedures.
- mitral annular calcification
- mitral valve replacement
- transcatheter mitral valve replacement
- valve embolization
- valve migration
Dr. Guerrero has received grants from Abbott Vascular and Edwards Lifesciences; and has served as consultant for Tendyne Holdings and Abbott Vascular. Dr. Wang has received grants from Boston Scientific; and served as consultant for Edwards Lifesciences, Boston Scientific, Materialise, and HighLife Medical. Dr. Khalique served as consultant for from Edwards Lifesciences, Cephea Valve, Abbott Structural, and Boston Scientific. Dr. Salinger served as consultant for from Boston Scientific and Edwards Lifesciences. Dr. Kodali has received grants from Edwards Lifesciences, Medtronic, Abbott Vascular, Boston Scientific, and JenaValve; served as consultant for Admedus, Meril Lifesciences, Abbott Vascular, Jena Valve, and Claret Medical; and has ownership interest in Dura Biotech, Thubrikar Aortic Valve, Microinterventional Devices, and Supira Medical. Dr. Holzhey served as consultant for Edwards Lifesciences, Medtronic, and Symetis. Dr. Tang served as consultant for from Abbott Structural Heart, W.L. Gore and Associates, Medtronic, and Edwards Lifesciences. Dr. Grubb served as consultant for Medronic, Edwards, and Boston Scientific. Dr. Reisman served as consultant for Anocra Medical and Boston Scientific. Dr. Blanke served as consultant for Edwards Lifesciences, Tendyne, Neovasc, Circel Cardiovascular Imaging, and Gore. Drs. Blanke and Dr. Leipsic provide CT-Core Lab services to Neovasc, Edwards Lifesciences, and Tendyne Holdings. Dr. Leipsic received institutional core lab for CT services from Edwards, Medtronic, Abbott and unrestricted grants from GE Healthcare and Edwards; and served as consultant for Circle CVI and HeartFlow. Dr. Himbert served as consultant for Edwards Lifesciences and Medtronic. Dr. Vahanian served as consultant for CardioValve. Dr. Webb served as consultant for Edwards Lifesciences. Dr. Hahn served as consultant for Abbott Structural, Edwards Lifesciences, Gore & Associates, Medtronic, Navigate, Boston Scientific, Bayliss Medical, and Philips Healthcare; has stock options with Navigate; has received nonfinancial support from 3mensio; and is Chief Scientific Officer for the Echocardiography Core Laboratory at the Cardiovascular Research Foundation for multiple industry-sponsored trials, for which she receives no direct industry compensation. Dr. George served as consultant for Medtronic, W.L. Gore and Associates; MitreMedical, Boston Scientific, CardioMech, and Atricure. Dr. Bapat served as consultant for Medtronic, Boston Scientific, 4C, Edwards Lifesciences, and Sorin. Dr. O’Neill served as consultant for Abiomed, Boston Scientific, Edwards Lifesciences, and Abbott. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Cardiovascular Imaging author instructions page.
- Received December 19, 2019.
- Revision received March 2, 2020.
- Accepted March 6, 2020.
- 2020 American College of Cardiology Foundation
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