Echocardiographic assessment of commissural calcium: A simple predictor of outcome after percutaneous mitral balloon valvotomy

C. R. Cannan, R. A. Nishimura, G. S. Reeder, D. R. Ilstrup, D. R. Larson, David Holmes, A. J. Tajik

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Abstract

Objectives. This study was undertaken to determine whether the presence of calcium in the mitral valve commissures, as demonstrated echocardiographically, could predict outcome and to compare this with an established echocardiographic scoring system. Background. Percutaneous mitral balloon valvotomy is an effective form of treatment for mitral valve stenosis. It is important to identify patients who would benefit from this procedure. Commissural splitting is the dominant mechanism by which mitral valve stenosis is relieved by this technique, and thus commissural morphology may predict outcome. Methods. One hundred forty-nine consecutive patients who underwent percutaneous mitral balloon valvotomy at the Mayo clinic were evaluated retrospectively. The morphology of the mitral valve apparatus on the baseline echocardiograms was scored in blinded manner using a semiquantitative grading system of leaflet thickening, mobility, calcification and subvalvular thickening (Abascal score). Additionally, each of the medial and lateral commissures was graded for the presence or absence of calcification. End points were death, New York Heart Association functional class, repeat percutaneous mitral balloon valvotomy and mitral valve replacement at follow-up. Results. The mean follow-up period was 1.8 years (maximum 7.9 years). Univariate predictors of death and all events combined included age, the use of a double-balloon technique, the presence of calcium in a commissure and the Abascal score, as continuous variables. Patients with an Abascal score ≤8 showed a trend toward improved survival at 36 months free of death, repeat percutaneous mitral balloon valvotomy or mitral valve replacement (78 ± 6% vs. 67 ± 8%, p = 0.07) and free of all events combined (75 ± 6% vs. 64 ± 8%, p = 0.07) versus those patients with a score >8. However, survival at 36 months free of death, repeat percutaneous mitral balloon valvotomy or mitral valve replacement (86 ± 4% vs. 40 ± 4%) and free of all events combined (82 ± 5% vs. 38 ± 10%) at follow-up was significantly different between patients without commissural calcium and those with commissural calcium (p < 0.001). In a Cox regression model with Abascal score and commissural calcium and their interaction, calcification emerged as the only significant variable (p < 0.01). Conclusions. The presence of commissural calcium is a strong predictor of outcome after percutaneous mitral balloon valvotomy. Patients with evidence of calcium in a commissure have a lower survival rate and a higher incidence of mitral valve replacement and all end points combined. Thus, the simple presence or absence of commissural calcification assessed by two-dimensional echocardiography can be used to predict outcome.

Original languageEnglish (US)
Pages (from-to)175-180
Number of pages6
JournalJournal of the American College of Cardiology
Volume29
Issue number1
DOIs
StatePublished - Jan 22 1997

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Balloon Valvuloplasty
Mitral Valve
Calcium
Mitral Valve Stenosis
Survival
Proportional Hazards Models
Echocardiography
Survival Rate
Incidence

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

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Echocardiographic assessment of commissural calcium : A simple predictor of outcome after percutaneous mitral balloon valvotomy. / Cannan, C. R.; Nishimura, R. A.; Reeder, G. S.; Ilstrup, D. R.; Larson, D. R.; Holmes, David; Tajik, A. J.

In: Journal of the American College of Cardiology, Vol. 29, No. 1, 22.01.1997, p. 175-180.

Research output: Contribution to journalArticle

Cannan, C. R. ; Nishimura, R. A. ; Reeder, G. S. ; Ilstrup, D. R. ; Larson, D. R. ; Holmes, David ; Tajik, A. J. / Echocardiographic assessment of commissural calcium : A simple predictor of outcome after percutaneous mitral balloon valvotomy. In: Journal of the American College of Cardiology. 1997 ; Vol. 29, No. 1. pp. 175-180.
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title = "Echocardiographic assessment of commissural calcium: A simple predictor of outcome after percutaneous mitral balloon valvotomy",
abstract = "Objectives. This study was undertaken to determine whether the presence of calcium in the mitral valve commissures, as demonstrated echocardiographically, could predict outcome and to compare this with an established echocardiographic scoring system. Background. Percutaneous mitral balloon valvotomy is an effective form of treatment for mitral valve stenosis. It is important to identify patients who would benefit from this procedure. Commissural splitting is the dominant mechanism by which mitral valve stenosis is relieved by this technique, and thus commissural morphology may predict outcome. Methods. One hundred forty-nine consecutive patients who underwent percutaneous mitral balloon valvotomy at the Mayo clinic were evaluated retrospectively. The morphology of the mitral valve apparatus on the baseline echocardiograms was scored in blinded manner using a semiquantitative grading system of leaflet thickening, mobility, calcification and subvalvular thickening (Abascal score). Additionally, each of the medial and lateral commissures was graded for the presence or absence of calcification. End points were death, New York Heart Association functional class, repeat percutaneous mitral balloon valvotomy and mitral valve replacement at follow-up. Results. The mean follow-up period was 1.8 years (maximum 7.9 years). Univariate predictors of death and all events combined included age, the use of a double-balloon technique, the presence of calcium in a commissure and the Abascal score, as continuous variables. Patients with an Abascal score ≤8 showed a trend toward improved survival at 36 months free of death, repeat percutaneous mitral balloon valvotomy or mitral valve replacement (78 ± 6{\%} vs. 67 ± 8{\%}, p = 0.07) and free of all events combined (75 ± 6{\%} vs. 64 ± 8{\%}, p = 0.07) versus those patients with a score >8. However, survival at 36 months free of death, repeat percutaneous mitral balloon valvotomy or mitral valve replacement (86 ± 4{\%} vs. 40 ± 4{\%}) and free of all events combined (82 ± 5{\%} vs. 38 ± 10{\%}) at follow-up was significantly different between patients without commissural calcium and those with commissural calcium (p < 0.001). In a Cox regression model with Abascal score and commissural calcium and their interaction, calcification emerged as the only significant variable (p < 0.01). Conclusions. The presence of commissural calcium is a strong predictor of outcome after percutaneous mitral balloon valvotomy. Patients with evidence of calcium in a commissure have a lower survival rate and a higher incidence of mitral valve replacement and all end points combined. Thus, the simple presence or absence of commissural calcification assessed by two-dimensional echocardiography can be used to predict outcome.",
author = "Cannan, {C. R.} and Nishimura, {R. A.} and Reeder, {G. S.} and Ilstrup, {D. R.} and Larson, {D. R.} and David Holmes and Tajik, {A. J.}",
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T1 - Echocardiographic assessment of commissural calcium

T2 - A simple predictor of outcome after percutaneous mitral balloon valvotomy

AU - Cannan, C. R.

AU - Nishimura, R. A.

AU - Reeder, G. S.

AU - Ilstrup, D. R.

AU - Larson, D. R.

AU - Holmes, David

AU - Tajik, A. J.

PY - 1997/1/22

Y1 - 1997/1/22

N2 - Objectives. This study was undertaken to determine whether the presence of calcium in the mitral valve commissures, as demonstrated echocardiographically, could predict outcome and to compare this with an established echocardiographic scoring system. Background. Percutaneous mitral balloon valvotomy is an effective form of treatment for mitral valve stenosis. It is important to identify patients who would benefit from this procedure. Commissural splitting is the dominant mechanism by which mitral valve stenosis is relieved by this technique, and thus commissural morphology may predict outcome. Methods. One hundred forty-nine consecutive patients who underwent percutaneous mitral balloon valvotomy at the Mayo clinic were evaluated retrospectively. The morphology of the mitral valve apparatus on the baseline echocardiograms was scored in blinded manner using a semiquantitative grading system of leaflet thickening, mobility, calcification and subvalvular thickening (Abascal score). Additionally, each of the medial and lateral commissures was graded for the presence or absence of calcification. End points were death, New York Heart Association functional class, repeat percutaneous mitral balloon valvotomy and mitral valve replacement at follow-up. Results. The mean follow-up period was 1.8 years (maximum 7.9 years). Univariate predictors of death and all events combined included age, the use of a double-balloon technique, the presence of calcium in a commissure and the Abascal score, as continuous variables. Patients with an Abascal score ≤8 showed a trend toward improved survival at 36 months free of death, repeat percutaneous mitral balloon valvotomy or mitral valve replacement (78 ± 6% vs. 67 ± 8%, p = 0.07) and free of all events combined (75 ± 6% vs. 64 ± 8%, p = 0.07) versus those patients with a score >8. However, survival at 36 months free of death, repeat percutaneous mitral balloon valvotomy or mitral valve replacement (86 ± 4% vs. 40 ± 4%) and free of all events combined (82 ± 5% vs. 38 ± 10%) at follow-up was significantly different between patients without commissural calcium and those with commissural calcium (p < 0.001). In a Cox regression model with Abascal score and commissural calcium and their interaction, calcification emerged as the only significant variable (p < 0.01). Conclusions. The presence of commissural calcium is a strong predictor of outcome after percutaneous mitral balloon valvotomy. Patients with evidence of calcium in a commissure have a lower survival rate and a higher incidence of mitral valve replacement and all end points combined. Thus, the simple presence or absence of commissural calcification assessed by two-dimensional echocardiography can be used to predict outcome.

AB - Objectives. This study was undertaken to determine whether the presence of calcium in the mitral valve commissures, as demonstrated echocardiographically, could predict outcome and to compare this with an established echocardiographic scoring system. Background. Percutaneous mitral balloon valvotomy is an effective form of treatment for mitral valve stenosis. It is important to identify patients who would benefit from this procedure. Commissural splitting is the dominant mechanism by which mitral valve stenosis is relieved by this technique, and thus commissural morphology may predict outcome. Methods. One hundred forty-nine consecutive patients who underwent percutaneous mitral balloon valvotomy at the Mayo clinic were evaluated retrospectively. The morphology of the mitral valve apparatus on the baseline echocardiograms was scored in blinded manner using a semiquantitative grading system of leaflet thickening, mobility, calcification and subvalvular thickening (Abascal score). Additionally, each of the medial and lateral commissures was graded for the presence or absence of calcification. End points were death, New York Heart Association functional class, repeat percutaneous mitral balloon valvotomy and mitral valve replacement at follow-up. Results. The mean follow-up period was 1.8 years (maximum 7.9 years). Univariate predictors of death and all events combined included age, the use of a double-balloon technique, the presence of calcium in a commissure and the Abascal score, as continuous variables. Patients with an Abascal score ≤8 showed a trend toward improved survival at 36 months free of death, repeat percutaneous mitral balloon valvotomy or mitral valve replacement (78 ± 6% vs. 67 ± 8%, p = 0.07) and free of all events combined (75 ± 6% vs. 64 ± 8%, p = 0.07) versus those patients with a score >8. However, survival at 36 months free of death, repeat percutaneous mitral balloon valvotomy or mitral valve replacement (86 ± 4% vs. 40 ± 4%) and free of all events combined (82 ± 5% vs. 38 ± 10%) at follow-up was significantly different between patients without commissural calcium and those with commissural calcium (p < 0.001). In a Cox regression model with Abascal score and commissural calcium and their interaction, calcification emerged as the only significant variable (p < 0.01). Conclusions. The presence of commissural calcium is a strong predictor of outcome after percutaneous mitral balloon valvotomy. Patients with evidence of calcium in a commissure have a lower survival rate and a higher incidence of mitral valve replacement and all end points combined. Thus, the simple presence or absence of commissural calcification assessed by two-dimensional echocardiography can be used to predict outcome.

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