From the Guidelines
The management of massive mitral annular calcification with severe left atrial enlargement, hypertensive emergency, and acute pulmonary edema requires immediate intervention with nitroprusside or nitroglycerine, along with loop diuretics, to optimize preload and decrease afterload, as recommended by the esc council on hypertension position document 1.
Immediate Intervention
To address the hypertensive emergency and acute pulmonary edema, the following steps should be taken:
- Rapidly reduce blood pressure with intravenous antihypertensives such as nitroprusside or nitroglycerine, as they are the preferred agents for acute cardiogenic pulmonary edema 1.
- Administer intravenous loop diuretics like furosemide (40-80 mg IV bolus, followed by continuous infusion if needed) to remove excess fluid and alleviate pulmonary edema.
- Provide supplemental oxygen to maintain saturation above 92% and consider non-invasive positive pressure ventilation if respiratory distress persists.
Long-term Management
Once the patient is stabilized, the following long-term management strategies should be implemented:
- Transition to oral antihypertensives including ACE inhibitors or ARBs, beta-blockers, and diuretics to control blood pressure and reduce the risk of further cardiac complications.
- Evaluate the mitral annular calcification by echocardiography to assess for valvular dysfunction, and if significant mitral stenosis or regurgitation is present, cardiology consultation for potential intervention is warranted.
- Consider the use of ACE inhibitors, but start at a very low dose to prevent sudden decreases in blood pressure, and be prepared to correct precipitous blood pressure falls with intravenous saline infusion if necessary 1.
From the FDA Drug Label
The usual initial dose of furosemide is 40 mg injected slowly intravenously (over 1 to 2 minutes). If a satisfactory response does not occur within 1 hour, the dose may be increased to 80 mg injected slowly intravenously (over 1 to 2 minutes). Parenteral therapy with Furosemide Injection should be used only in patients unable to take oral medication or in emergency situations and should be replaced with oral therapy as soon as practical.
The medical treatment for massive mitral annular calcification with severe Left atrial enlargement and hypertensive emergency and acute pulmonary edema includes the administration of furosemide (IV) at an initial dose of 40 mg injected slowly intravenously over 1 to 2 minutes, which can be increased to 80 mg if a satisfactory response is not achieved within 1 hour 2.
- Key considerations:
- Dose adjustment: The dose may be raised by 20 mg and given not sooner than 2 hours after the previous dose until the desired diuretic effect has been obtained.
- Administration: The intravenous dose should be given slowly (1 to 2 minutes).
- Monitoring: Close medical supervision is necessary, and careful clinical observation and laboratory monitoring are particularly advisable when furosemide is given for prolonged periods 2.
- Additional therapy: If necessary, additional therapy (e.g., digitalis, oxygen) may be administered concomitantly 2.
From the Research
Medical Treatment for Massive Mitral Annular Calcification
- The management of mitral valve dysfunction in the setting of substantial mitral annular calcification (MAC) remains controversial and is one of the most challenging problems in mitral valve surgery 3.
- Mitral annular calcification (MAC) is a common and challenging pathologic condition, especially in the context of an aging society, and surgical mitral valve intervention in patients with MAC is difficult 4.
- Valve replacement, either surgical or transcatheter, is challenging because of anatomy, technical considerations, concomitant comorbidities, and advanced age 5.
Diagnosis and Classification
- Echocardiography conventionally is the first-line imaging modality for anatomic assessment, and evaluation of mitral valve function, while cardiac computed tomography (CT) has demonstrated importance as an imaging modality for the evaluation and planning of related procedures 6.
- There is no universally accepted definition or classification system of MAC severity, but a novel classification system based on qualitative and quantitative measurements derived from echocardiography and cardiac CT has been proposed 6.
Association with Hypertensive Emergency and Acute Pulmonary Edema
- Mitral annular calcification (MAC) has been associated with increased risk of ischemic stroke in general populations, and also predicts incidence of ischemic stroke in treated hypertensive patients with left ventricular hypertrophy (LVH) 7.
- Patients with MAC are older, more often women, have higher baseline systolic blood pressure, left atrial diameter, and left ventricular mass index, and include more patients with proteinuria 7.
Management Strategies
- A multidisciplinary heart team approach is necessary to minimize postoperative complications, such as left ventricular outflow tract obstruction, prosthetic paravalvular leak, valve embolization, and stroke 3.
- Advanced imaging provides the foundation for heart team discussions and management decisions concerning individual patients with MAC 4.
- Treatment options for patients with MAC include surgical or transcatheter mitral valve interventions, and a proposed grading and staging system using both anatomical and clinical features has been developed 5.