From the Guidelines
For a 67-year-old male with significant mitral annular calcification (MAC) demonstrated on fluoroscopy, the next treatment steps should prioritize medical management and close monitoring, as surgical intervention is high-risk due to the calcified tissue and the patient's age. The management of patients with MAC is complex and requires a comprehensive evaluation. According to the 2017 ESC/EACTS guidelines for the management of valvular heart disease 1, asymptomatic patients with clinically significant mitral stenosis should be followed up yearly by means of clinical and echocardiographic examinations.
Key considerations in the management of this patient include:
- Medical management focusing on heart failure symptoms with diuretics, ACE inhibitors, and beta-blockers
- Blood pressure control targeting levels below 130/80 mmHg
- Regular cardiac follow-up every 3-6 months with echocardiography to monitor disease progression
- Consideration of surgical intervention if the patient develops significant mitral regurgitation, stenosis, or heart failure symptoms despite medical therapy
- Transcatheter mitral valve procedures as potential options in specialized centers for high-risk surgical patients
It is essential to note that MAC is associated with aging, chronic kidney disease, and atherosclerosis, representing degenerative calcification of the mitral valve fibrous ring that can impair valve function over time. The 2017 ESC/EACTS guidelines also highlight that in elderly patients with degenerative mitral stenosis with severely calcified mitral annulus, surgery is very high risk, and transcatheter valve implantation of a TAVI bioprosthesis in the mitral position may be feasible in symptomatic elderly patients who are inoperable if the anatomy is suitable 1.
From the Research
Next Treatment Steps for Mitral Annular Calcification
Given the fluoroscopy demonstration of significant mitral annular calcification in a 67-year-old male, the next treatment steps would involve a comprehensive assessment of the mitral valve and left ventricular function.
- The primary non-invasive modality for anatomical and functional cardiac assessment is transthoracic echocardiography 2.
- This assessment should include morphological and functional changes indicative of the type and mechanism of the defect, as well as its stage (mild, moderate, severe) 2.
- For patients with severe mitral regurgitation and stenosis due to failed mitral annuloplasty ring, percutaneous mitral valve in ring implantation can be considered, especially in high surgical risk patients 3.
- Transesophageal echocardiography is crucial for guiding the mitral valve in ring procedure and assessing the risk of left ventricular outflow tract obstruction 3.
- Echocardiography plays a vital role in the decisional process and guidance of mitral valve repair procedures, with transthoracic echocardiography being the main investigation for diagnosis and assessment of mitral regurgitation severity 4.
- A detailed and systematic evaluation of the mitral valve apparatus is essential for proper surgical planning and screening for transcatheter-based treatment when surgery is not indicated 4.
- Standard transthoracic echocardiography and transesophageal echocardiography views are critical for assessing mitral pathology and guiding surgical decision-making 5.
- A comprehensive transthoracic echocardiogram should be performed according to the British Society of Echocardiography minimum dataset to confirm normal cardiac structure and function 6.