Effects of mitral calcification in severe aortic stenosis with severe mitral regurgitation on left heart remodeling, surgical strategy, and outcomes.

OBJECTIVE: To localize and quantify mitral calcification associated with severe aortic stenosis and severe mitral regurgitation and determine its association with cardiac remodeling, operative management, and long-term survival.

METHODS: Between July 1998 and July 2010, 158 patients with severe aortic stenosis, severe mitral regurgitation, and mitral calcification underwent surgical aortic valve replacement (SAVR; n = 49) or SAVR plus mitral valve repair (SAVR+MVr; n = 67) or replacement (SAVR+MVR; n = 42) at our institution. Mitral calcium was localized and quantified by a preoperative computed tomography (CT) scan. Random forest methodology was used to correlate calcium volume with cardiac morphology and function. The median follow-up for survival was 4.1 years; 25% of patients were followed for ≥14 years.

RESULTS: Greater calcium volume was associated with degenerative mitral disease, higher ejection fraction, smaller left ventricular end-systolic volume, and SAVR+MVR (median calcium volume, 3.4 cm3) compared to SAVR (median calcium volume, 1.0 cm3) or SAVR+MVr (median calcium volume, 0.41 cm3). Ten-year mortality was higher in patients with more mitral calcification (terciles: 7.1% vs 16% vs 25%), subvalvular involvement (8.1% vs 18%), and SAVR+MVR (5.4% vs SAVR; 13% vs SAVR+MVr = 26%). Multivariable analysis showed that early postoperative mortality was strongly associated with subvalvular mitral calcification, but late mortality was not associated with calcium volume or location.

CONCLUSIONS: Greater mitral calcium volume is a marker of late-stage cardiac remodeling associated with more extensive mitral valve intervention but not with long-term mortality. Quantitative analysis of mitral calcification with CT can aid patient selection and surgical management decisions in this complex patient population.