What is the significance of fluoroscopy demonstrating significant mitral annular calcification in a 67-year-old male who underwent Right Heart Catheterization (RHC)?

From the Guidelines

The patient with significant mitral annular calcification (MAC) should be managed conservatively with regular echocardiographic follow-up every 6-12 months to assess for progression and development of mitral valve dysfunction, as intervention should be delayed until symptoms are severely limiting and cannot be managed with diuresis and heart rate control 1. The finding of significant MAC on fluoroscopy during right heart catheterization in this 67-year-old male requires clinical monitoring and potential management.

Key Considerations

• The patient should be evaluated for symptoms of heart failure, such as dyspnea, fatigue, or decreased exercise tolerance.
• If mitral stenosis or regurgitation develops, medical therapy with diuretics (such as furosemide 20-40mg daily) may be needed for symptom management.
• Risk factor modification is essential, including blood pressure control (target <130/80 mmHg), lipid management (statin therapy if indicated), and diabetes control if applicable.
• MAC is a degenerative process involving calcium deposition in the mitral valve annulus, often associated with aging, chronic kidney disease, and atherosclerotic risk factors.
• While MAC itself doesn't typically require specific treatment, it can lead to mitral valve dysfunction, conduction abnormalities, or serve as a marker for increased cardiovascular risk.

Potential Complications

• Significant valve dysfunction may develop despite medical therapy, and referral for cardiology consultation regarding potential interventional options may be necessary.
• Calcification can complicate valve procedures, and alternative techniques such as supra-annular insertion or left atrial to ventricular bypass with a valved conduit may be considered in extreme cases 1.
• The risk of thromboembolism and cerebral ischemic events should also be considered, although the incidence is not clear 1.

From the Research

Mitral Annular Calcification Diagnosis and Treatment

The patient's Right Heart Catheterization (RHC) results showing significant mitral annular calcification are consistent with the findings of several studies 2, 3, 4, 5, 6.

• Mitral annular calcification (MAC) is a chronic process involving the mitral valve annulus, linked with increased cardiovascular mortality and morbidity 2.
• Cardiac computed tomography (CT) scan is considered the gold standard in MAC detection and classification 2, 3.
• The treatment of significant mitral valve disease in patients with annular calcifications is challenging due to the increased risk of complications such as atrioventricular groove rupture, circumflex artery injury, or embolism 2, 6.

Treatment Options

Several treatment options are available for patients with MAC, including:

• Transcatheter mitral valve replacement (TMVR) which has emerged as a valid alternative to surgery in high-risk patients 2.
• Surgical techniques such as hybrid transatrial, transfemoral, or transapical approaches to deliver balloon-expandable or self-expanding aortic transcatheter valves into the calcified annulus 2.
• Tendyne (Abbott Structural Heart, Santa Clara, CA, USA) is a promising transapical-delivered option that has shown effectiveness and safety in patients with MAC and severe mitral valve disease 2.

Management Strategies

A multidisciplinary heart team approach is recommended for the management of patients with mitral valve dysfunction and significant MAC 4, 6.

• A proposed grading and staging system using both anatomical and clinical features can help guide treatment decisions 4.
• Point-of-care ultrasound (POCUS) can play a role in identifying mitral valve pathology in the emergency department, leading to appropriate disposition and management 5.