Mitral annular calcification in patients with hypertrophic obstructive cardiomyopathy: risk factors and prognosis

doi:10.21203/rs.3.rs-4578718/v1

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Mitral annular calcification in patients with hypertrophic obstructive cardiomyopathy: risk factors and prognosis

https://doi.org/10.21203/rs.3.rs-4578718/v1

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Objective

This research aimed to ascertain the risk factors for the development of mitral annular calcification (MAC) in patients with hypertrophic obstructive cardiomyopathy (HOCM) and the impact of MAC on prognosis.

Methods

HOCM patients underwent interventricular diaphragmatic myectomy were collected and examined by echocardiography and CT to test whether MAC occurred or not. General data and risk factors affecting MAC development in HOCM patients were observed. Differences in cardiac function indicators and perioperative clinical data were compared between patients with MAC and those without MAC. After surgery, patients were followed up until December 2022, with the primary endpoint being postoperative all-cause mortality and the secondary endpoint being major adverse cardiovascular and cerebrovascular events (MACCE). Prognosis and MACCE occurrence were analyzed, and differences in brain natriuretic peptide (BNP), Apelin, and Galectin-3 levels were assessed between patients with MAC and patients without MAC, and the correlation between factor levels and cardiac function indicators were explored.

Results

There were 24 patients with MAC (7.74%) and 286 patients without MAC (92.26%). Female and older patients were more common in the MAC group. The MAC group had a higher incidence of SAM sign, aortic annular calcification, aortic calcification, coronary artery calcification, mitral leaflet thickening, and moderate and severe tricuspid regurgitation. Gender, age, aortic calcification, aortic annular calcification, SAM sign, and mitral leaflet thickening were independent risk factors for MAC development. The MAC group had higher LVEDD, lower LVEF and heavier LVMM than the no-MAC group. Patients in the no-MAC group had a better prognosis and better MACCE incidence than patients in the MAC group.

Conclusion

Independent risk factors affecting MAC development in HOCM patients are gender, age, aortic calcification, aortic annular calcification, SAM sign, and mitral leaflet thickening. MAC development may lead to a poor prognosis in HOCM patients.

Hypertrophic obstructive cardiomyopathy

Mitral annular calcification

Risk factors

Prognosis

Cardiac function

Hypertrophic obstructive cardiomyopathy (HOCM) refers to an inherited myocardial disorder that is defined by cardiac hypertrophy (wall thickness ≥ 15 mm) and left ventricular obstruction ≥ 30 mm Hg, with typical symptoms including dyspnoea, palpitations, syncope, and chest pain [1]. HOCM influences approximately 1 in 500 people around the world, which can lead to interventricular septum hypertrophy and left ventricular wall thickening [2]. Mitral annular calcification (MAC) is common among hypertrophic cardiomyopathy (HCM) patients [3], and it is defined as calcium deposition in the fibrous skeleton of mitral valve, which is associated with mitral valve dysfunction, increased cardiovascular risk, endocarditis and arrhythmias in the cardiovascular level. Conventionally, echocardiography is utilized as the first-line imaging method for anatomic assessment and mitral valve function evaluation. Cardiac computed tomography (CT) is also an important imaging tool in evaluating and planning relevant procedures [4]. Generally, MAC is recognized by the characteristic density, shape and location on echocardiography and CT [5].

MAC, a challenging pathological condition, is particularly common in an aging society [6]. MAC is reported to be a common finding in older patients with HOCM, and it is more likely to be found in females. In addition, it is also involved in higher rates of concomitant mitral valve replacement [7]. Increasing evidence has revealed that it is challenging to manage patients with HOCM and serious MAC [8]. It is also reported that MAC can influence the results of cardiac surgery and interventions [9]. Furthermore, MAC is a degenerative process with multiple etiologies, and those with MAC possess an elevated prevalence of left ventricular enlargement, left atrial enlargement, atrial fibrillation, mitral regurgitation and stenosis, and hypertrophic cardiomyopathy as well as a raised incidence of cardiovascular events [10]. In a previous study, it has demonstrated that pulse pressure, left ventricular ejection fraction (LVEF), MAC angle, and mean diastolic pressure gradient at baseline are involved in the progression of MAC [11]. Growing evidence has also demonstrated that age, female, aortic annular calcification, aortic calcification, systolic anterior motion (SAM) sign, mitral valve thickening, and tricuspid regurgitation are independent predictors for MAC [12]. In our paper, the study focused on the risk factors for the development of MAC in patients with HOCM. Consequently, this study aimed to ascertain the risk factors for MAC development in patients with HOCM and the effects of MAC on prognosis.

Ethics statement

The study was under the approval of the Ethic Committee of Beijing Anzhen Hospital, and all patients and their families signed written informed consent.

Study subjects

HOCM patients who underwent interventricular diaphragmatic myectomy from February 2018 to October 2021 at Beijing Anzhen Hospital were included. Exclusion criteria: patients with a history of previous surgical procedures; patients below 20 years old; patients without complete clinical data; patients combined with other cardiac diseases; patients without left ventricular outflow tract gradient (LVOTG ≤ 50 mmHg); patients lacking preoperative CT data. Finally, 310 cases were included in the analysis.

Observation indicators

(1) Echocardiography and CT in combination were applied to determine whether MAC occurred in patients with HOCM. MAC was defined as dense calcified deposits in the root of the mitral valve leaflets with a CT value higher than 130 Hu. CT examination for MAC diagnosis was performed by electrocardiogram-gated multi-detector CT angiography (Somatom Definition Flash, Siemens Healthineers, Forchheim, Germany) on a second-generation dual-source CT scanner. Patients’ baseline data were collected, including age, gender, past history, chronic disease history, and poor lifestyle habits, for observing differences between patients with MAC and patients without MAC.

(2) Echocardiography was performed to monitor and calculate left atrial diameter (LA diameter), left ventricular end-diastolic diameter (LVEDD), left ventricular myocardial mass (LVMM), and LVEF in each patient. Perioperative clinical data including ventilator time, ICU duration, and postoperative hospitalization were recorded. Differences in cardiac function indicators and perioperative clinical data were compared among patients with and without MAC.

(3) Follow-up was conducted by telephone or home visit and it ended in December 2022, with the primary endpoint being postoperative all-cause mortality and the secondary endpoint being major adverse cardiovascular and cerebrovascular events (MACCE), including those due to heart failure, myocardial infarction, arrhythmia, and stroke/embolic events. Prognostic information and the occurrence of MACCE in patients with and without MAC were analyzed.

(4) Fasting venous blood (10 mL) was drawn from patients with or without MAC in the early morning prior to surgery, rested for 20 min and centrifuged utilizing a centrifuge (10 ×g at 4˚C for 15 min, BMH Instrument Co., Ltd., Beijing, China) to separate the serum, and then the serum was frozen in liquid nitrogen, and stored at -80℃. Serum brain natriuretic peptide (BNP), Apelin, and Galectin-3 levels were measured by enzyme-linked immunosorbent assay (ELISA, Suzhou Elisa Biotechnology Co., Ltd., Suzhou, China). Differences in BNP, Apelin, and Galectin-3 levels between patients with MAC and without MAC were observed.

Statistics

Statistical analysis was performed utilizing SPSS 24.0 (SPSS, Inc., Chicago, IL, USA) and GraphPad Prism 8.0 software (Graph Pad Inc., La Jolla, CA, USA). Measurement data were depicted as \(\overline{x}\) ± standard deviation, and t-test was implemented for comparison between groups. Numeration data were depicted as [n(%)], and chi-square test was utilized for comparison between groups. KM survival curves revealed the prognosis, and logistic regression analysis was performed to observe the independent risk factors affecting MAC. Pearson correlation coefficient method was employed to analyze the correlation of BNP, Apelin, and Galectin-3 with related indicators. P < 0.05 indicated that the difference was statistically significant.

Baseline data in patients with and without MAC

Based on CT data, it was found that there were 24 patients with MAC (7.74%), and 286 patients without MAC (92.26%). Related information such as age, gender, BMI, history of previous diseases, and presence or absence of aortic annulus calcification, aortic calcification, SAM sign, mitral leaflet thickening, and tricuspid regurgitation in both groups were collected. The mean age of the patients with MAC was 56.94 ± 7.45 years old, while the mean age of the patients without MAC was 45.68 ± 9.51 years old. The results displayed that in the MAC group, there was a higher percentage of female and older patients (P < 0.05). Moreover, the MAC group also had a higher incidence of SAM sign, aortic annular calcification, aortic calcification, coronary artery calcification, mitral leaflet thickening, and moderate and severe tricuspid regurgitation (P < 0.05) (Table 1).

Table 1

Baseline data of patients with and without MAC
	The MAC group (n = 24)	The no-MAC group (n = 286)	P value
Gender			0.028
Male	9 (37.5%)	177 (61.89%)
Female	15 (62.5%)	109 (38.11%)
Age	56.94 ± 7.45	45.68 ± 9.51	< 0.001
Body mass index (kg/m²)	25.75 ± 3.84	24.78 ± 3.41	0.186
Diabetes			0.338
Yes	4 (16.67%)	78 (27.27%)
No	20 (83.33%)	208 (72.73%)
Hypertension			0.287
Yes	16 (66.67%)	154 (53.85%)
No	8 (33.33%)	132 (46.15%)
Hyperlipidemia			0.281
Yes	7 (29.17%)	121 (42.31%)
No	17 (70.83%)	165 (57.69%)
Atrial fibrillation			0.465
Yes	3 (12.50%)	25 (8.74%)
No	21 (87.50%)	261 (91.26%)
Smoking history			0.258
Yes	19 (79.17%)	188 (65.73%)
No	5 (20.83%)	98 (34.27%)
Drinking history			0.374
Yes	6 (25.00%)	102 (35.66%)
No	18 (75.00%)	184 (64.34%)
Coronary heart disease			0.665
Yes	10 (41.67%)	106 (37.06%)
No	14 (58.33%)	180 (62.94%)
SAM sign			0.002
Yes	11 (45.83%)	50 (17.48%)
No	13 (54.17%)	236 (82.52%)
Aortic calcification			0.027
Yes	15 (62.50%)	107 (37.41%)
No	9 (37.50%)	179 (62.59%)
Aortic annulus calcification			0.012
Yes	7 (29.17%)	29 (10.14%)
No	17 (70.83%)	257 (89.86%)
Coronary artery calcification			0.041
Yes	12 (50.00%)	84 (29.37%)
No	12 (50.00%)	202 (70.63%)
Peripheral vascular calcification			0.169
Yes	10 (41.67%)	81 (28.32%)
No	14 (258.33%)	205 (71.68%)
Moderate and severe mitral regurgitation			0.286
Yes	16 (66.67%)	152 (53.15%)
No	8 (33.33%)	134 (46.85%)
Moderate and severe tricuspid regurgitation			0.044
Yes	3 (12.50%)	8 (2.80%)
No	21 (87.50%)	278 (97.20%)
Mitral leaflet thickening			0.037
Yes	9 (37.50%)	54 (18.88%)
No	15 (62.50%)	232 (81.12%)

Cardiac function indicators in patients with and without MAC

Echocardiography was employed to observe LA diameter, LVEDD, LVMM, and LVEF in patients with and without MAC. The results unearthed that there was no significant difference in LV diameter between the two groups (P > 0.05); patients in the MAC group possessed higher LVEDD, lower LVEF and heavier LVMM versus those in the no-MAC group (P < 0.05) (Table 2).

Table 2

Cardiac function indicators between the two groups
	The MAC group (n = 24)	The no-MAC group (n = 286)	P value
LA diameter (mm)	48.12 ± 5.95	47.82 ± 6.12	0.817
LVMM (g)	126.74 ± 7.98	105.62 ± 9.41	< 0.001
LVEDD (mm)	45.82 ± 5.48	43.41 ± 5.16	0.029
LVEF (%)	60.14 ± 5.52	62.86 ± 5.14	0.013

Multivariate logistic regression analysis of MAC

The univariate results based on baseline data unraveled that there were significant differences between patients with and without MAC in terms of gender, age, and presence or absence of SAM sign, aortic calcification, aortic annular calcification, coronary artery calcification, moderate and severe tricuspid regurgitation, and mitral leaflet thickening. These relevant risk factors were analyzed by multivariate logistic regression analysis and the results unearthed that gender, age, aortic calcification, aortic annular calcification, SAM sign, and mitral leaflet thickening were independent risk factors for MAC development (P < 0.05) (Table 3).

Table 3

Multivariate logistic regression analysis of MAC
Factors	β	SE	Wald	P	Exp(β)	95% CI
Factors	β	SE	Wald	P	Exp(β)	Lower limit	Upper limit
Gender	1.362	0.579	5.526	0.019	3.904	1.254	12.154
Age	0.164	0.037	19.692	< 0.001	1.178	1.096	1.266
Aortic calcification	1.144	0.56	4.17	0.041	3.14	1.047	9.414
Aortic annulus calcification	1.591	0.669	5.653	0.017	4.91	1.322	18.228
Coronary artery calcification	0.542	0.578	0.881	0.348	1.719	0.554	5.334
Mitral leaflet thickening	1.388	0.587	5.584	0.018	4.008	1.267	12.675
Moderate and severe tricuspid regurgitation	2.257	1.169	3.725	0.054	9.555	0.966	94.536
SAM sign	1.4	0.563	6.182	0.013	4.057	1.345	12.236

Surgical information and perioperative information

All patients underwent modified enlarged septal myotomy, and septal myotomy was operated through an ascending aortic incision. If mitral valve replacement, mitral annular placement, or posterior leaflet plication was required, a concomitant left atrial incision was utilized. The two groups had similar duration of extracorporeal circulation and aortic block. Surgical information displayed a higher percentage of valve annuloplasty in the MAC group, and the results of perioperative information presented that patients in the MAC group possessed longer ICU stay, hospitalization, and ventilation time (P < 0.05) (Table 4).

Table 4

Surgical information and perioperative information
Surgical information	The MAC group (n = 24)	The no-MAC group (n = 286)	P value
Mitral valve replacement			0.479
Yes	1 (4.17)	7 (2.45)
No	23 (95.83)	279 (97.55)
Mitral valve repair			0.742
Yes	3 (12.50)	32 (11.19)
No	21 (87.50)	254 (88.81)
Flap ring repair			0.044
Yes	3 (12.50)	8 (2.80)
No	21 (87.50)	278 (97.20)
Leaflet repair
Yes	2 (8.33)	19 (6.64)	0.670
No	22 (91.67)	267 (93.36)
Aortic annuloplasty
Yes	1 (4.17)	5 (1.75)	0.386
No	23 (95.83)	281 (98.25)
Ventilator time (h)	21.65 ± 3.15	19.51 ± 3.84	0.008
ICU duration (h)	53.91 ± 4.16	46.86 ± 4.65	< 0.001
Postoperative hospitalization (d)	9.49 ± 1.48	8.16 ± 1.11	< 0.001

Follow-up results

Follow-up was ended in December 2022. At the follow-up endpoint, 3 patients without MAC (1.05%) and 2 patients with MAC (8.33%) died, indicating that MAC patients had a higher proportion of deaths and experienced heart failure as well as MACCE events more commonly (P < 0.05), as displayed in Table 5. Survival curves also revealed that patients in the no-MAC group possessed a better prognosis and a better incidence of MACCE versus those in the MAC group (P < 0.05) (Fig. 1).

Table 5

Adverse events between the two groups
	The MAC group (n = 24)	The no-MAC group (n = 286)	P value
All-cause mortality	2 (8.33)	3 (1.05)	0.04
Heart failure	4 (16.67)	13 (4.55)	0.03
LVEF < 50%	2 (8.33)	4 (1.40)	0.07
MACCE	6 (25.00)	21 (7.34)	0.011

Differences in BNP, Apelin, and Galectin-3 levels between patients with MAC and those without MAC

In this study, we examined the levels of BNP, Apelin, and Galectin-3 in the preoperative serum of patients with and without MAC, and the results unearthed that there was no significant difference in BNP between the two groups (P > 0.05); Apelin levels were lower and Galectin-3 levels were higher in patients with MAC versus those without MAC (P < 0.05) (Table 6).

Table 6

Differences in BNP, Apelin, and Galectin-3 levels between patients with MAC and those without MAC
	The MAC group (n = 24)	The no-MAC group (n = 286)	P value
BNP (pg/dL)	1638.96 ± 566.64	1637.51 ± 753.92	0.993
Apelin (pg/mL)	1.17 ± 0.15	1.39 ± 0.07	< 0.001
Galectin−3 (ng/mL)	3.18 ± 0.11	3.05 ± 0.09	< 0.001

Correlation of BNP, Apelin, and Galectin-3 with cardiac function indicators

Furthermore, we analyzed the correlation of BNP, Apelin, and Galectin-3 with LA diameter, LVEDD, and LVEF by implementing the Pearson correlation coefficient method. The findings showed that no significant correlation presented between preoperative BNP levels and LA diameter, LVEDD, and LVEF (P > 0.05); there was a negative correlation between Apelin levels and LVMM (R = -0.34, P < 0.001); there was a positive correlation between Galectin-3 and LVMM (R = 0.218, P < 0.001), and no significant correlation with any other relevant indicator was found (Table 7).

Table 7

Correlation of BNP, Apelin, and Galectin-3 with cardiac function indicators
	BNP		Apelin		Galectin−3
	R	P	R	P	R	P
LA diameter (mm)	−0.085	0.136	−0.011	0.835	0.009	0.874
LVMM (g)	0.056	0.321	−0.340	< 0.001	0.218	< 0.001
LVEDD (mm)	−0.004	0.932	−0.067	0.242	0.016	0.769
LVEF (%)	0.026	0.647	0.132	0.019	−0.038	0.497

HCM is a genetic disorder affecting the myocardium and the mitral valve as well as its apparatus. and MAC is more prevalent in patients with HOCM [13]. Therefore, it is of great value to address the risk factors for MAC development in HOCM patients. This study focused on the risk factors for the development of MAC in patients with HOCM and the effects of MAC on prognosis.

As previously reported, MAC is correlated with an higher incidence of cardiovascular disorders, mitral valve disease, arrhythmias, and death [9]. Meanwhile, it is demonstrated that women have more extended MAC in comparison with men [14]. In patients with MAC, the septal-mitral valve distance is shorter and the mitral valve position ratio is greater versus those without MAC, which denotes greater anterior displacement, particularly in those with MAC and left ventricular outflow tract obstruction (LVOTO) [3]. In our paper, it was found that there were 24 patients with MAC (7.74%), and 286 patients without MAC (92.26%), and there was a higher percentage of female and older patients in the MAC group. Moreover, the MAC group also had a higher incidence of SAM sign, aortic annular calcification, aortic calcification, coronary artery calcification, mitral leaflet thickening, and moderate and severe tricuspid regurgitation. Increasing evidence has revealed that MAC is a risk factor for cardiac surgery, and HOCM patients with MAC have more recurrent mitral valve regurgitation and worse prognosis after septal myectomy. In addition, all-cause mortality and MACCE are more common in HOCM patients with MAC [12]. Furthermore, it is also reported that patients with MAC possess higher resting left ventricular outflow tract gradients, and are more likely to have worse mitral regurgitation after surgery and undergo a concomitant mitral valve replacement versus those without MAC. After surgery, patients with MAC have raised residual mitral regurgitation [7]. In our paper, we found that there was no significant difference in LV diameter between the two groups; patients in the MAC group possessed higher LVEDD, lower LVEF and heavier LVMM versus those in the no-MAC group and gender, age, aortic calcification, aortic annular calcification, SAM sign, and mitral leaflet thickening were independent risk factors for MAC development.

HOCM patients are at raised risk of sudden cardiac arrest owing to dynamic LVOTO, arrhythmias and myocardial ischaemia, and septal myectomy is considered as a gold standard therapy for HOCM patients [15]. In our study, all patients underwent modified enlarged septal myotomy. The two groups had similar duration of extracorporeal circulation and aortic block. Surgical information displayed a higher percentage of valve annuloplasty and longer ICU stay, hospitalization, and ventilation time in the MAC group. MAC is linked to adverse clinical results. Patients with MAC may frequently possess stenotic, regurgitant, or mixed valvular disorder, and the valvular dysfunction is recognized to have an independent association with worse prognosis [16]. In our study, at the follow-up endpoint, 3 patients without MAC (1.05%) and 2 patients with MAC (8.33%) died, indicating that MAC patients had a higher proportion of deaths and experienced heart failure as well as MACCE events more commonly.

B-type natriuretic peptide (BNP) is an important regulator of cardiovascular physiology [17]. Apelin, belonging to the most commonly studied member of apelinergic system, is reported to play a crucial role in the cardiovascular system [18]. Galectin-3 has been implicated in heart disease development [19]. Moreover, we examined the levels of BNP, Apelin, and Galectin-3 in the preoperative serum of patients with and without MAC, and found that Apelin levels were lower and Galectin-3 levels were higher in patients with MAC versus those in patients without MAC, and there was a negative correlation between Apelin levels and LVMM and was a positive correlation between Galectin-3 and LVMM.

In summary, this research demonstrates that the independent risk factors that affect MAC development in HOCM patients include gender, age, aortic calcification, aortic annular calcification, SAM sign, and mitral leaflet thickening. MAC development may lead to a poor prognosis in HOCM patients. This study lays a foundation to study the risk factors of MAC development in patients with HOCM and the effects of MAC on prognosis. Our study is based on limited clinical data, and further exploration is necessary to further convince our findings.

Funding

No funds, grants, or other support was received.

Conflict of interest

The authors have no conflicts of interest to declare that are relevant to the content of this article.

Availability of data and material

The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author.

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No competing interests reported.

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Mitral annular calcification in patients with hypertrophic obstructive cardiomyopathy: risk factors and prognosis

Status:

Version 1

Abstract

Objective

Methods

Results

Conclusion

Figures

Introduction

Materials and methods

Ethics statement

Study subjects

Observation indicators

Statistics

Results

Baseline data in patients with and without MAC

Cardiac function indicators in patients with and without MAC

Multivariate logistic regression analysis of MAC

Surgical information and perioperative information

Follow-up results

Differences in BNP, Apelin, and Galectin-3 levels between patients with MAC and those without MAC

Correlation of BNP, Apelin, and Galectin-3 with cardiac function indicators

Discussion

Declarations

References

Additional Declarations

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