Degenerative Mitral Stenosis with Mitral Annular Calcification in Elderly Patients: What to Do When Medical Therapy Has Not Controlled Symptoms
Clinical scenario
This protocol concerns elderly patients with degenerative mitral stenosis (MS) caused by mitral annular calcification (MAC). This is a distinct, age-dependent pathology — not rheumatic MS — and requires a different treatment strategy. Patients with MAC are typically elderly and carry significant comorbidities, often including disease of other valves.
Prior medical therapy — insufficient response
This protocol applies when a prior regimen — diuretics, beta-blockers, digoxin, non-dihydropyridine calcium channel blockers, and ivabradine — has failed to achieve adequate improvement of symptoms through control of volume overload and heart rate. Intervention is recommended in symptomatic patients who are not responsive to medical therapy.
Next-step management (partial overview)
When medical therapy proves insufficient, the pathway moves to structural intervention — surgical or transcatheter options exist for selected patients, chosen according to individual anatomy, operative risk, and the expertise of the treating centre.
References
DOI: 10.1093/eurheartj/ehaf194
- Degenerative MS related to MAC is a distinct age-dependent pathology requiring different treatment strategies.
- Patients presenting with MAC are elderly and have significant comorbidities, including disease of other valves.
- Intervention is recommended in symptomatic patients who are not responsive to medical therapy, weighing the potential benefits of the procedure against its associated risks.
- However, surgical MV repair or replacement with extensive decalcification and patch reconstruction of the annulus can be performed in selected patients at experienced centres (e.g. young patients post-chest radiation), where mortality rates of <5% have been reported.
- TMVI may be considered in symptomatic patients with extensive MAC and severe MV dysfunction at experienced Heart Valve Centres with expertise in complex MV surgery and transcatheter interventions.
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