How frequently do we do surveillance imaging for mild mitral stenosis 2* to calcific disease?
I started with the AHA/ACC 2020 valve guidelines, which are endorsed by ASE. They have this helpful general guide:
Table 5. Frequency of Echocardiograms in Asymptomatic Patients With VHD and Normal LV Function
But, I was curious to know if time intervals differed between calcific MS and rheumatic MS, so I kept reading.
I learned that rheumatic MS tends to progress slowly here, losing about 0.1 cm2 valve area annually, though this can vary. It's also important to remember that we can see an RV getting sicker even if the mitral valve area is not declining, so we need to evaluate both of these things on surveillance echos.
Calcific MS, on the other hand, is more variable in its progression, with gradients increasing somewhere between 0 and 9 mm Hg/year. Overall this group of patients tends to be sicker - older, more comorbidities, with a 5 year prognosis of less than 50%. There's not a clear rec for how often to image, but this variable gradient makes me think shorter interval at first, then space out.
I did check PubMed and found this fantastic JASE article, attached, that goes through the natural history of calcific MS. Interestingly, calcific MS is more common in women than men, and in people with progressive disease, they found the gradient gets worse by about 3 points annually, though there is splay here. I think what's key is identifying whether our patient is a progressor or non-progressor. The authors share that risk factors for progressing from MAC to true calcific MS include being a woman, starting with moderate or severe MAC, being of older age, having a higher EF, and comorbid moderate or severe AS. Only 4% of patients with mild MAC went on to develop calcific MS, whereas this number was 24% in moderate MAC and 60% in severe MAC. This picture summarizes the findings nicely:
Figure 3. Progression rate at 10 years to CMVD.
And here is the final rec from the study authors:
"In the absence of change in the medical condition or occurrence of new symptoms, we suggest that TTE might be repeated after 5 years in patients presenting with mild MAC, after 2 to 3 years for those with moderate MAC, and after 1 to 2 years for those with severe MAC."
Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2020;143(5). doi:https://doi.org/10.1161/cir.0000000000000923
Willner N, Burwash IG, Beauchesne L, et al. Natural History of Mitral Annular Calcification and Calcific Mitral Valve Disease. Journal of the American Society of Echocardiography. 2022;35(9):925-932. doi:https://doi.org/10.1016/j.echo.2022.05.007
