- This study investigated the effect of systolic pulmonary artery pressure (SPAP) on mortality in 4,384 patients with mitral valve (MV) dysfunction related to mitral annular calcium (MAC) and identified determinants of SPAP in those patients
- SPAP was associated with an increased risk of all-cause mortality (adjusted HR, 1.22 per 10 mm Hg increase in SPAP; 95% CI, 1.17–1.27) independently of traditional cardiovascular risk factors, the transmitral gradient, and severity of mitral regurgitation
- A high rate of mortality was observed at SPAP ≥50 mm Hg that was consistent across the spectrum of transmitral gradients (<5, 5 to 10, and >10 mm Hg)
- SPAP in MAC is strongly related to left-sided valvular disease, although the impact of concomitant mitral regurgitation on SPAP decreased at higher transmitral gradients and was no longer significant at gradients ≥10 mm Hg
- These findings strongly imply SPAP should be considered during the risk assessment of individuals with MAC-related MV dysfunction
Patients with mitral valve (MV) dysfunction related to mitral annular calcium (MAC), a common age-related degenerative process, are at substantially increased risk of all-cause and cardiovascular mortality. Researchers at Massachusetts General Hospital recently linked mean transmitral gradient ≥3 mm Hg to mortality in this population, as they reported in the European Heart Journal.
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Extending those findings in a subset of the same cohort, the group recently found that pulmonary hypertension—specifically, echocardiographic assessment of systolic pulmonary artery pressure (SPAP)—adds incremental prognostic value in patients with MAC-related MV dysfunction.
Timothy W. Churchill, MD, a cardiologist in the Division of Cardiology at Mass General, and colleagues explain in The American Journal of Cardiology that the association was independent of both MAC-related risk factors and the extent of MV dysfunction.
The study included 4,384 patients who had extensive MAC with MAC-related MV dysfunction (mean transmitral gradient ≥3 mm Hg) documented on echocardiography between 2001 and 2019. The mean patient age was 78, and 69% were female.
2,346 patients died during a median follow-up of 1.3 years. SPAP was strongly associated with an increased risk of all-cause mortality (adjusted HR, 1.22 per 10 mm Hg increase of SPAP; 95% CI, 1.17–1.27).
The association was independent of traditional cardiovascular risk factors, mean transmitral gradient and the severity of mitral regurgitation.
Patients with SPAP ≥50 mm Hg had a substantially higher risk of all-cause mortality than those with lower SPAP (P<0.001). That finding was consistent across prespecified subgroups of the transmitral gradient (<5, 5 to 10, and >10 mm Hg).
Determinants of SPAP
In multivariate analysis, factors independently associated with SPAP were:
- History of atrial fibrillation (standardized β, 0.114)
- Left atrial dimension (β, −0.073)
- Left ventricle ejection fraction (β, −0.069)
- Mean transmitral gradient (β, 0.282)
- The severity of mitral regurgitation (β, 0.224)
- More than moderate aortic stenosis (β, 0.057)
The impact of concomitant mitral regurgitation on SPAP decreased at higher transmitral gradients and was no longer significant at gradients ≥10 mm Hg.
The Importance of Risk Stratification
In the past, direct valvular interventions for patients with MAC or MAC-related MV dysfunction were relatively uncommon because of the comorbidity burden and high surgical risk. Over the past decade, though, a number of new valve-in-MAC procedures have been developed.
Therefore, refinement of risk stratification is becoming vitally important to define thresholds for intervention. The present study suggests SPAP should be considered in the risk assessment of patients with MAC-related MV dysfunction so treatment options can be targeted appropriately.
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