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Long-Term Outcomes After Primary, Isolated Mitral Valve Repair in Patients with Mitral Annular Calcification: A Propensity Score-Matched Analysis
Behrooz Banivaheb, Hartzell Schaff, Joseph Dearani, Juan Crestanello, Kevin Greason, Mauricio Villavicencio, Arman Arghami
Cardiovascular Surgery Department, Mayo Clinic Minnesota, Rochester, MN
Objective: Mitral annular calcification (MAC) is increasingly prevalent in elderly patients and complicates mitral valve repair (MVr), with adverse effects on prognosis. However, evidence on long-term outcomes in this group remains scarce. This study aimed to compare long-term surgical outcomes after MVr in patients with and without MAC.
Methods: We identified patients with MAC who underwent primary, isolated MVr between 2000 and 2024 and matched them 1:1 with patients without MAC using propensity score analysis. Primary endpoints were long-term all-cause mortality, hospital readmission, and reintervention. Statistical analyses were conducted in R (version 4.1.3). Data were appropriately summarized using median, mean, and frequency percentages; long-term survival was analyzed using the Kaplan-Meier method.
Results: Among 317 patients in the MAC group, mean age was 68.3±10.9 years, and 49.5% were female. Comorbidities were common, including NYHA class ≥ III in 29.3%, atrial fibrillation in 25.5%, chronic heart failure in 14.5%, cerebrovascular disease in 11.0%, diabetes mellitus in 4.4%, renal failure in 2.2%, and peripheral vascular disease in 4.7%. Moderate or greater tricuspid regurgitation was present in 31.8% (n=100). A robotic approach was used in 36.5% of cases. Cross-clamp time (52 vs. 49 minutes, p=0.289) and perfusion time (75 vs. 70 minutes, p=0.268) did not differ significantly between groups. Mitral valve annuloplasty was less frequently done in the MAC group (72.4% vs. 84.0%, p=0.003). Postoperative atrial fibrillation (31.9% vs. 33.4%, p = 0.733), cerebrovascular events (1.3% vs. 0.3%, p = 0.371), ICU stay (24.0 vs. 23.5 h, p = 0.722), hospital stay (5 vs. 5 days, p = 0.057), thirty-day readmission (9.1% vs. 7.1%, p = 0.310), and early reoperation for valve dysfunction (5 vs. 2 cases, p = 0.450) did not differ significantly between groups. Operative mortality was low and not significantly different (1.0% vs. 0.6%, p=1.000). Ten-year survival was comparable between groups (71.4% vs. 73.4%). Durability was excellent, with similar 10-year freedom from reoperation (93.5% in the MAC group vs. 96.2% in controls, p=0.11).
Conclusions: These results suggest that isolated mitral valve repair, when technically feasible in patients with mitral annular calcification, is associated with perioperative and long-term outcomes comparable to those of patients without MAC.
Fig 1. Long-term Survival of patients with mitral annular calcification who underwent mitral valve repair compared to propensity score matched control group.
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