Clinical outcomes of mitral valve intervention in patients with mitral annular calcification: A systematic review and meta-analysis

Roberto V P Ribeiro; Bobby Yanagawa; Jean-François Légaré; Ansar Hassan; Maral Ouzounian; Subodh Verma; Jan O Friedrich

doi:10.1111/jocs.14325

Clinical outcomes of mitral valve intervention in patients with mitral annular calcification: A systematic review and meta-analysis

J Card Surg. 2020 Jan;35(1):66-74. doi: 10.1111/jocs.14325. Epub 2019 Nov 6.

Authors

Roberto V P Ribeiro^{1

2}, Bobby Yanagawa¹, Jean-François Légaré³, Ansar Hassan³, Maral Ouzounian², Subodh Verma¹, Jan O Friedrich^{4

5}

Affiliations

¹ Division of Cardiovascular Surgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
² Division of Cardiovascular Surgery, Department of Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada.
³ Division of Cardiovascular Surgery, New Brunswick Heart Centre, Dalhousie University, Saint John, New Brunswick, Canada.
⁴ Critical Care and Medicine Department, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
⁵ Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.

PMID: 31692124
DOI: 10.1111/jocs.14325

Abstract

Background: Mitral valve (MV) disease with mitral annular calcification (MAC) poses a surgical challenge and the clinical outcomes of MV surgery as well as transcatheter mitral valve replacement (TMVR) remain relatively unexplored. We performed a systematic review and meta-analysis to assess the effects of MAC on clinical outcomes following MV surgery and TMVR.

Methods: We searched MEDLINE and EMBASE databases until February 2019 for studies comparing clinical outcomes of MV surgery or TMVR in patients with and without MAC. Data were extracted by two independent investigators. Outcomes were perioperative and midterm complications and mortality.

Results: Seven observational studies enrolling 2902 patients were included. MAC patients were older, more likely to be female with greater chronic lung disease and kidney failure. Perioperative mortality was similar between patients with and without MAC undergoing MV surgery (risk ratio [RR], 1.15; 95% confidence interval [CI], 0.50-2.65; P = .74). MAC was associated with a higher risk of bleeding, permanent pacemaker implantation, and periprosthetic leak. Midterm mortality was greater in MAC patients undergoing MV surgery (incident rate ratio [IRR], 1.32; 95% CI, 1.05-1.67; P = .02). MAC patients undergoing TMVR had higher perioperative (RR, 4.65; 95% CI, 2.93-7.38; P < .01) and 1-year (RR, 5.44; 95% CI, 3.49-8.49; P < .01) mortality, decreased procedural success, greater left ventricular outflow tract obstruction and need for conversion to surgery when compared with patients undergoing TMVR for dysfunction of a bioprosthetic valve or annuloplasty ring.

Conclusion: MV procedures in patients with MAC are associated with higher mortality and morbidity. This is largely driven by the high-risk patient profile associated with MAC. TMVR holds promise but has important limitations and should be reserved for select patients.

Keywords: meta-analysis; mitral annular calcification; mitral valve surgery; transcatheter mitral valve replacement; valve repair/replacement.

Publication types

Meta-Analysis
Systematic Review

MeSH terms

Calcinosis*
Female
Heart Valve Diseases / mortality
Heart Valve Diseases / surgery*
Heart Valve Prosthesis Implantation / methods*
Humans
Male
Mitral Valve / pathology*
Mitral Valve / surgery*
Risk
Survival Rate