Mitral annular calcification predicts immediate results of percutaneous transvenous mitral commissurotomy.

Abstract

Many previous studies have evaluated the impact of mitral valve (MV) deformity scores on the percutaneous transvenous mitral commissurotomy (PTMC) outcome in patients with mitral stenosis; however, the relationship between mitral annulus calcification (MAC) and the PTMC result has not yet been established. The current study aimed to investigate whether MAC could independently influence the immediate result of PTMC.
Of all patients undergoing PTMC in our institution between April 2005 and November 2009, we included 87 patients (28.7%male, mean ± SD age = 42.8 ± 12.6 years) with rheumatic mitral stenosis who had additional data on the echocardiographic evaluation of MAC along with MV leaflets morphology. Echocardiographic assessments were repeated up to six weeks after PTMC to evaluate the immediate PTMC outcome. The frequency of the optimal PTMC result (secondary MV area > = 1.5 cm(2) with > = 25% increase and without final mitral regurgitation grade > 2) was compared between two groups of patients with MAC (n = 17) and those without MAC (n = 70).
The optimal result was obtained in 55 (63.2%) patients, whereas the result was suboptimal in 32 (36.8%) patients due to insufficient MV area increase in 31(96.9%) subjects and post-procedure mitral regurgitation grade > 2 in 1(3.1%). The rate of optimal PTMC results was less in patients with MAC in comparison to those without MAC (29.4% vs.71.4%). After adjustments for possible confounders such as age and leaflets morphological subcomponents (thickening, mobility, calcification, and subvalvular thickening), MAC remained a significant negative predictor of a suboptimal PTMC result (odds ratio = 0.154; 95%CI = 0.038-0.626, p value = 0.009) together with leaflet thickening (odds ratio = 0.214; 95%CI = 0.060-0.770, p value = 0.018).
MAC appeared to independently influence the immediate result of PTMC; therefore, mitral annulus evaluation may be considered in the echocardiographic assessment of the mitral apparatus prior to PTMC.

Full text

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RESEARCHOpen Access
Mitral annular calcification predicts immediate
results of percutaneous transvenous mitral
commissurotomy
Mojtaba Salarifar1, Mehrnaz Rezvanfard2, Hakimeh Sadeghian3*, Azam Safir-mardanloo3and Nahid Shafii2
Abstract
Background: Many previous studies have evaluated the impact of mitral valve (MV) deformity scores on the
percutaneous transvenous mitral commissurotomy (PTMC) outcome in patients with mitral stenosis; however, the
relationship between mitral annulus calcification (MAC) and the PTMC result has not yet been established. The
current study aimed to investigate whether MAC could independently influence the immediate result of PTMC.
Methods: Of all patients undergoing PTMC in our institution between April 2005 and November 2009, we
included 87 patients (28.7%male, mean ± SD age = 42.8 ± 12.6 years) with rheumatic mitral stenosis who had
additional data on the echocardiographic evaluation of MAC along with MV leaflets morphology.
Echocardiographic assessments were repeated up to six weeks after PTMC to evaluate the immediate PTMC
outcome. The frequency of the optimal PTMC result (secondary MV area > = 1.5 cm2with > = 25% increase and
without final mitral regurgitation grade > 2) was compared between two groups of patients with MAC (n = 17)
and those without MAC (n = 70).
Results: The optimal result was obtained in 55 (63.2%) patients, whereas the result was suboptimal in 32 (36.8%)
patients due to insufficient MV area increase in 31(96.9%) subjects and post-procedure mitral regurgitation grade >
2 in 1(3.1%). The rate of optimal PTMC results was less in patients with MAC in comparison to those without MAC
(29.4% vs.71.4%). After adjustments for possible confounders such as age and leaflets morphological
subcomponents (thickening, mobility, calcification, and subvalvular thickening), MAC remained a significant
negative predictor of a suboptimal PTMC result (odds ratio = 0.154; 95%CI = 0.038-0.626, p value = 0.009) together
with leaflet thickening (odds ratio = 0.214; 95%CI = 0.060-0.770, p value = 0.018).
Conclusions: MAC appeared to independently influence the immediate result of PTMC; therefore, mitral annulus
evaluation may be considered in the echocardiographic assessment of the mitral apparatus prior to PTMC.
Keywords: Percutaneous transvenous mitral commissurotomy (PTMC), Mitral annular calcification (MAC), PTMC
result, Mitral valve morphology
Introduction
percutaneous transvenous mitral commissurotomy
(PTMC) has become established as a procedure of
choice for the treatment of mitral stenosis (MS) [1-3]
and it confers equivalent results to open and closed sur-
gical valvotomy in patients whose valves are anatomi-
cally suitable [4-6]. Appropriate patient selection,
however, is of paramount importance for a successful
PTMC.
In the selection of patients for PTMC, the echocardio-
graphic assessment of the mitral valve morphology plays
a crucial role [7-10] and it is now performed routinely
in most centers. The Wilkins score is one of the most
widelyused echocardiographic
[7,9,11,12] in that it provides a semi-quantitative assess-
ment of mitral leaflets thickening, mobility, calcification,
and the extent of the subvalvular apparatus disease. A
favorable Wilkins score (< 8 points) is highly predictive
scoring systems
* Correspondence: sadeghianhakimeh@yahoo.com
3Echocardiography Department, Tehran Heart Center, Tehran University of
Medical Sciences, Tehran, Iran
Full list of author information is available at the end of the article
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CARDIOVASCULAR
ULTRASOUND
© 2011 Salarifar et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.

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of an optimal outcome after PTMC [3,7,9]. Nevertheless,
there are studies which have questioned the precision of
this score as a predictor of the outcome and have sug-
gested the need for more refined and comprehensive
echocardiographic assessments [1,11,13,14]. Likewise,
the Wilkins scoring system does not examine mitral
annular calcification (MAC), which is characterized by
calcium and lipid deposition within the annular fibrosa
of the mitral valve [15,16] and might independently
influence the PTMC result as it appears to be a different
feature from leaflets or commissural calcification in
terms of the incidence rate, underlying predisposing fac-
tors, pathophysiology, and associative cardiovascular dis-
orders or systemic comorbidities [15-21].
To our knowledge, there is not enough studies evalu-
ating the impact of MAC on the PTMC immediate
result. The current study aimed to investigate if pre-pro-
cedure echocardiographic evaluation of MAC could help
the clinician to predict the immediate result of PTMC.
Methods
Study Population
From April 2005 to November 2009, PTMC was
attempted in 153 consecutive patients with the diagnosis
of rheumatic MS at Tehran heart center according to
previously established criteria [22]. Patients population
were those referred from inside cardiology clinics or
directly from outside physicians. Pre-procedure conven-
tional echocardiography conducted in all patients to
investigate the MV morphology in our echocardio-
graphic units; however, we just included 89 consecutive
patients who underwent echocardiographic evaluation in
one of our units equipped by Vivid-7 (Vingmed GE)
echocardiography apparatus and had additional data on
the echocardiographic evaluation of the mitral annulus.
After excluding two cases (because of the previous his-
tory of open or closed mitral commissurotomy) retro-
spective analysis conducted on the data of the final 87
patients [mean ± SD age = 42.8 ± 12.6 years and 25
(28.7%) male]. PTMC was contraindicated in the pre-
sence of left atrial thrombus, significant coexistent valve
lesions, bilateral commissural calcification, and mitral
regurgitation (MR) greater than grade 2+ and unfavor-
able MV morphology with Wilkins total score > 12 as
estimated by echocardiography. The relation between
the echocardiographic score of the valve morphology
and PTMC immediate result was assessed by defining
the optimal result as mitral valve area (MVA) ≥ 1.5 cm2
or more and increase in the MVA of at least 25% with-
out post-procedure MR grade > 2. This definition was
employed on account of the fact that it is one of the
most commonly employed criteria in the existing litera-
ture [3,23]. The study protocol was approved by the
Ethics Committee Review Board of the hospital.
Echocardiographic Evaluation
Echocardiographic assessments were conducted in all
the patients during the week leading up to the proce-
dure using a combination of transthoracic two-dimen-
sional (2D), pulsed and continuous-wave Doppler with
color-flow imaging (Vingmed GE, Horten, Norway, 3.5-
MHz transducer), and transesophageal echocardiography
(Vivid-7, Vingmed GE, Horten, Norway, 7-MHz trans-
ducer). From the echocardiographic study, the MVA
was calculated via planimetry [See additional file 1 and
additional file 2] and MR severity was scored 0 as no or
trivial, 1 as mild, 2 as moderate, 3 as moderate to
severe, and 4 as severe [24]. The morphological features
of the mitral valve (MV) were scored individually in
terms of (a) leaflet thickening, (b) leaflet mobility, (c)
leaflet calcification, and (d) subvalvular thickening
according to the Wilkins scoring system [7]. Each sub-
component had a possible score of 0 to 4 corresponding
to zero to severe abnormality. The presence of calcifica-
tion of the mitral annulus and commissures determined
the use of 2D-echocardiograms in the parasternal short-
axis view. MAC was defined as a dense, highly reflected
area at the base of the posterior mitral leaflet [15] (Fig-
ure 1), while anterolateral and/or posteromedial com-
missure calcification was identified by bright and
confluent echo which was brighter than the adjacent
aortic root [25]. A secondary transthoracic echocardio-
graphy evaluation was performed for all the patients
between twenty-four hours and six weeks after the pro-
cedure in order to evaluate the hemodynamic change
and immediate PTMC outcome [See additional file 3
and additional file 4]. Figure 2 and 3 show the MVA
change in a patients without MAC prior and following
the PTMC while Figure 4 and 5 show the MVA change
in a patient with MAC.
Figure 1 Parasternal short-axis view of mitral annulus
calcification (MAC) by transthoracic echocardiography.
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Cardiac Catheterization and Percutaneous Transvenous
Mitral Commissurotomy
A self-positioning single balloon (Inoue balloon) was
applied for commissurotomy in all the patients. The
upper limit of the balloon diameter was chosen accord-
ing to the patient’s height. Inflation was commenced at
less than the predetermined upper-limit diameter. If the
hemodynamic results were suboptimal, the procedure
was repeated by gradually increasing the balloon dia-
meter until the reduction in the transmitral gradient
was satisfactory. If optimal hemodynamic results were
not achieved at the maximum diameter of the balloon,
additional inflation was not attempted as a general rule.
Statistical Methods
The data are presented as mean ± SD (standard devia-
tion) for the numerical variables and are summarized by
absolute frequencies and percentages for the categorical
variables. A univariate analysis of the baseline demo-
graphic data and echocardiographic measurements was
performed within the individual groups applying the
Student t-test, Mann-Whitney U test, and Fisher exact
test, as appropriate.
Multiple logistic regression analysis was employed to
appraise the association between MAC and the immedi-
ate PTMC result (binary variables were defined as opti-
mal and suboptimal) when simultaneously controlled for
the known parameters which might affect the PTMC
result. Indeed, the presence or absence of MAC along
with age (years) and MV morphological subcomponents
(thickening, calcification, mobility, and subvalvular
thickening) were all entered into the multivariable
model. Finally, the associations between the independent
predictors of the optimal result were expressed as odds
ratios (OR) with 95% CIs. Model discrimination was
measured using the statistic, which is equal to the area
Figure 2 Calculation of mitral valve area(MVA) via planimetry
method from parasternal short-axis view in one patient
without mitral annulus calcification(MAC) prior PTMC.
Figure 3 Calculation of mitral valve area(MVA) via planimetry
method from parasternal short-axis view in one patient
without mitral annulus calcification(MAC) after PTMC.
Figure 4 Calculation of mitral valve area(MVA) via planimetry
method from parasternal short-axis view in one patient with
mitral annulus calcification(MAC) prior PTMC.
Figure 5 Calculation of mitral valve area(MVA) via planimetry
method from parasternal short-axis view in one patient with
mitral annulus calcification(MAC) after PTMC.
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under the ROC (Receiver Operating Characteristic)
curve. Model calibration was estimated using the Hos-
mer-Lemeshow goodness-of-fit statistic (higher p values
imply that the model fits the observed data better). The
Pearson coefficient was utilized to investigate the asso-
ciation between the various subcomponents of the Wilk-
ins scoring system. For the statistical analysis, the
statistical package SAS version 9.1 for Windows (SAS
Institute Inc., Cary, NC, USA) was used. All the p values
were two-tailed, with statistical significance defined by a
p value ≤ 0.05. Intra- and inter-observer variability was
analyzed in 10 randomly selected subjects and expressed
as the mean percentage error (difference/mean) for the
numerical variables and the Cohen Kappa coefficient for
the categorical variables.
Results
The PTMC procedure was successfully completed in all
the patients, and there were no deaths or complications
associated with the procedure. The optimal result was
obtained in 55 (63.2%) patients, whereas the result was
suboptimal in 32 (36.8%) patients [due to insufficient
MV area increase in 31(96.9%) subjects and post-proce-
dure MR grade > 2 in 1 (3.1%0 case)]. The mean MVA
increased significantly from 1.0 ± 0.2 cm2(range = 0.6-
1.4) to 1.8 ± 0.2 cm2(range = 1.5-2.6) (p value < 0.001)
in patients with the optimal result. After the procedure,
echocardiographic development in MR grade developed
in one patient to moderate to severe level. As the
patient was hemodynamically stable, she was followed
up on pharmacological treatment with diuretic, ACE
inhibitors and digoxin without any need to urgent surgi-
cal mitral valve replacement therapy. Hemodynamic eva-
luation showed a significant decline in the mean of the
MV mean gradient (MVMG) (from 11.8 ± 5.7 to 5.0 ±
2.0 mmHg, p value < 0.001), MV peak gradient (MVPG)
(from 19.9 ± 8.0 to 9.3 ± 3.2 mmHg, p value < 0.001),
and pulmonary artery systolic pressure (PAPs) (from
44.7 ± 11.5 to 35.0 ± 9.3 mmHg, p value < 0.001) in
patients with the optimal result.
According to Table 1, 17 (19.5%) patients exhibited
echocardiographic evidence of MAC, while the mitral
annulus was normal in 70 (80.5%) patients. The total
Wilkins score ranged from 7 to 12 in patients who had
evidence of calcification in the mitral annulus. The rate
of the optimal PTMC result was significantly lower in
patients with MAC than in those with a normal mitral
annulus [5(29.4%) vs. 50(71.4%), p value < 001]. The
baseline demographic and hemodynamic data were not
different between these two groups; however, the MV
morphological evaluation indicated a higher frequency
of leaflets abnormalities in patients with MAC. In parti-
cular, the Wilkins total score and two of its subcompo-
nents (calcification and subvalvular thickness) were
significantly and the thickness score tended to be signifi-
cantly higher in patients with MAC than the corre-
sponding scores in patients without MAC. After
adjustments for age and the MV deformities subcompo-
nents (thickness, calcification, mobility, and subvalvular
thickness), which constitute the previously known para-
meters that might influence the PTMC outcome,
patients with MAC were still at an increased risk of a
suboptimal PTMC result (OR = 0.154, 95%CI = 0.038-
0.626, p value < 0.01). MV leaflet thickness was also
identified as an independent negative predictor of the
PTMC result (OR = 0.214, 95%CI = 0.060-0.770, p value
< 0.05). The good fit of the model was shown by the
absence of a significant difference between the predicted
(using the model) and observed results (Hosmer-Leme-
show goodness-of-fit test, p value = 0.33). The area
under the ROC curve reached 0.74343 (Figure 6).
The impact of each MV morphological sub-score on
the total score of Wilkins was weighed by evaluating the
Pearson association between these scores and the total
score. As it can be seen from Table 2, leaflet calcifica-
tion contributes the most to the total score (r = 0.713, p
value < 0.01).
Inter- and intraobserver variability
The echocardiographic parameters measured by the
same observer were replicable for the MV morphologi-
cal components (Kappa ranging from 0.58 to 0.68,
approximate significance < 0.01) and MR severity
(Kappa = 0.72, approximate significance < 0.01).
Intraobserver variability was 7.5% for the Wilkins total
score, 11.9% for MV area. The measurements taken by
two echocardiographers were reproducible for the MV
morphological subcomponent scores (Kappa ranging
from 0.48 to 0.62, approximate significance < 0.01) and
MR severity (Kappa = 0.67, approximate significance <
0.01). The interobserver variability was 11.1% for mea-
suring the Wilkins total score, 6.4% for MV area.
Discussion
The current study identified MAC and MV leaflet thick-
ness as two negative predictors of the immediate PTMC
result and thus suggests that a pre-procedure echocar-
diographic evaluation of the morphology of the MV leaf-
lets along with mitral annulus could help have a better
prediction of the PTMC outcome.
Valvular and coronary artery calcification share many
similar risk factors and pathophysiological characteris-
tics [26,27]. Aortic valve calcification(AVC) and MAC
are also proposed as independent predictive factors of
cardiovascular disease(CVD) events and all-cause mor-
tality [28,29]. Calcification of the annulus fibrosus of
the MV is a frequent finding particularly in older
patients [16,30], but the pathophysiology of MAC is still
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a subject of controversy [15,18,19]. The most common
hypothesis is the progressive degeneration of the annu-
lus through life [16]; however, MAC can be also seen in
patients without any primary valve tissue disorders. Bio-
chemical factors (hypertension and metabolic disease)
also play a role [16,17] in a great majority of cases and
there are several studies comprising a large Multi-Ethnic
Study of Atherosclerosis (MESA) conducted on 6814
patients which indicated the higher rates of AVC and
MAC in patients with end-stage renal disease [28,31,32].
Rheumatic infection is a common cause of annulus cal-
cification, which usually could affect commissures and
leaflets coincidentally. Extension of calcium to the
annulus usually occurs over the years in these patients
[33].
MAC per se may accelerate an extensive degenerative
process through a vicious cycle; it may reduce leaflet
mobility, leading to secondary MV insufficiency and
triggering the degenerative process through increasing
tensions on the valvular structures. Likewise, our find-
ings showed that patients with MAC significantly scored
more than those with a normal mitral annulus in terms
of MV deformity sub-scores and in particular, leaflet
mobility, leaflet calcification, and leaflet thickness. How-
ever; explanation of the mechanism of the impact of
MAC on PTMC results requires further studies evaluat-
ing the role of the underlying etiology of MAC, its
severity, and its extension level to the adjacent parts
In regard to the predictive role of the Wilkins echo-
cardiographic measurements in the immediate outcome
Table 1 Echocardiographic assessment of mitral valve apparatus morphology in patients undergoing percutaneous
transvenous mitral commissurotomy (PTMC)
Total
(n = 87)
Annulus calcification
Yes
(n = 17)
No
(n = 70)
P value
Age
Male gender
AF rhythm
Optimal PTMC result
Unilateral commissure calcification
Mitral leaflets morphological score
Total
Thickness
Calcification
Subvalvular thickening
Mobility
Pre-PTMC echocardiographic measurements
Pre-PTMC MVA
Mitral regurgitation (MR) grade
Left ventricle ejection fraction (%)
Mitral valve peak gradient (MVPG)(mmHg)
Mitral valve peak gradient (MVMG)(mmHg)
Systolic left ventricle dimension (sLVD)(mm)
Diastolic left ventricle dimension (dLVD)(mm)
Left atrium size (LAs) (mm)
Pulmonary artery systolic pressure (PAPs) (mmHg)
Post-PTMC echocardiographic measurements
Post-PTMC MVA (cm2)
Mitral regurgitation (MR) grade
Left ventricle ejection fraction (%)
Mitral valve peak gradient (MVPG)(mmHg)
Mitral valve peak gradient (MVPG)(mmHg)
Systolic left ventricle dimension (sLVD)(mm)
Diastolic left ventricle dimension (dLVD)(mm)
Left atrium size (LAs) (mm)
Pulmonary artery systolic pressure (PAPs) (mmHg)
43.3 ± 12.3
25(28.7)
23(27.7)
55(63.2)
13(14.9)
46.4 ± 12.1
7(41.2)
5(31.3)
5(29.4)
6(10.9)
42.5 ± 12.4
18(25.7)
18(26.9)
50(71.4)
7(21.9)
0.246
0.206
0.725
0.002
0.167
8.1 ± 1.2
2.1 ± 0.4
1.5 ± 0.6
2.4 ± 0.6
2.1 ± 0.3
8.8 ± 1.2
2.3 ± 0.5
1.8 ± 0.7
2.4 ± 0.5
2.2 ± 0.3
8.0 ± 1.1
2.1 ± 0.4
1.4 ± 0.6
2.4 ± 0.6
2.1 ± 0.3
0.013
0.089
0.049
0.685
0.024
1.0 ± 0.2
0.8 ± 0.6
54.5 ± 4.5
19.9 ± 7.7
12.3 ± 6.0
31.9 ± 6.5
45.2 ± 6.1
45.4 ± 7.3
46.0 ± 12.5
0.9 ± 0.2
0.8 ± 0.5
54.8 ± 6.7
22.2 ± 7.9
13.8 ± 5.8
31.8 ± 6.9
47.4 ± 1.1
43.5 ± 7.6
49.8 ± 9.3
1.0 ± 0.2
0.8 ± 0.6
54.5 ± 3.9
19.4 ± 7.6
11.9 ± 6.0
31.9 ± 6.4
45.8 ± 4.6
45.8 ± 7.3
45.0 ± 13.1
0.533
0.803
0.787
0.169
0.253
0.962
0.121
0.256
0.174
1.6 ± 0.4***
1.0 ± 0.7
54.8 ± 7.6
11.0 ± 5.2***
6.0 ± 3.1***
30.0 ± 6.4
45.6 ± 5.7
45.1 ± 9.2
38.9 ± 13.0**
1.4 ± 0.4
0.8 ± 0.5
55.6 ± 6.8
10.9 ± 4.6
6.2 ± 2.2
31.5 ± 6.9
46.5 ± 5.3
45.5 ± 13.8
34.9 ± 9.2
1.6 ± 0.4
1.0 ± 0.7
54.6 ± 7.8
11.1 ± 5.4
6.0 ± 3.3
29.6 ± 6.3
45.4 ± 5.8
45.0 ± 7.9
40.1 ± 13.8
0.038
0.350
0.635
0.903
0.805
0.292
0.509
0.846
0.228
MVA: mitral valve area,**: p value < 0.01 and ***: p value < 0.001 in comparison with corresponding variable assessed prior to the PTMC
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of PTMC, the existing literature abounds with contro-
versies. Whereas some investigators have identified the
echocardiographic characteristics of the MV as a signifi-
cant predictor of MV area increase [7,8,23,34], others
have rejected any correlation between the MV morphol-
ogy as assessed by echocardiography and MV area
change [35,36]. With respect to the MV morphological
subcomponents, there are studies that indicate a signifi-
cant association between MV area increase and valvular
thickening [9], subvalvular disease [37], and leaflet calci-
fication [11,38], while there are reports that question the
predictive role of leaflet thickness [39,40], subvalvular
pathology [40], valvular calcification [2] and leaflet
mobility [40] on the immediate result of PTMC. Consid-
erable mismatch between the inclusion criteria, adoption
of various definitions for a successful outcome of
PTMC, and variability in balloon types have all rendered
comparisons difficult or even impossible.
To sum up, pre-PTMC echocardiographic evaluation
of the mitral annulus in tandem with the assessment of
the MV leaflets by Wilkins scoring system appear to be
helpful for clinicians to make more accurate predictions
Figure 6 The ROC curve derived from factors affecting the optimal result following PTMC.
Table 2 The Pearson correlation coefficients between various morphological sub-scores of mitral leaflets, as assessed
by echocardiography
Total score Thickness CalcificationMobilitySubvalvular thickening
Total score
Thickness
Calcification
Mobility
Subvalvular thickness
1.0
.608**
.713**
.315**
.615**
1.0
.267*
-.028
.205
1.0
.145
.067
1.0
-.021
1.0
* P value ≤ 0.05, **P value ≤ 0.01
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about the PTMC immediate result prior to the proce-
dure. The presence of MAC might be regarded as a
parameter which could adversely influence the PTMC
immediate. Designing prospective studies with the aim
of quantifying the impact of MAC severity and exten-
sion on both PTMC immediate and long-term results
would help the future clinicians to better select patients
for PTMC.
Limitations
Morphological abnormalities may have been underesti-
mated through the use of transthoracic echocardiogra-
phy since we evaluated three-dimensional structures in
two-dimensions. Designing prospective studies for a pre-
cise assessment of individual anterior and posterior parts
of the mitral apparatus using 3-D or 4-D echocardio-
graphic images in large population samples may provide
a more accurate formula for a more accurate prediction
of the PTMC result based on morphological abnormal-
ities. Finally, it should be noted that these findings on
the role of MAC in the PTMC outcome could not be
generalized to the late PTMC result. Future studies
based on long-term echocardiographic follow-up data
would be helpful to determine whether the effect of
MAC is only temporary or lasts long.
Additional material
Additional file 1: Pre-PTMC echocardiographic assessments in a
patient without MAC. The file contains a short clip and three
echocardiographic images which show MVA measurement by planimetry
and PHT methods in a patient without MAC prior the PTMC.
Additional file 2: Pre-PTMC echocardiographic assessments in a
patient with MAC. The file contains a short clip and four
echocardiographic images which show MVA measurement by planimetry
and PHT methods in a patient with MAC prior the PTMC.
Additional file 3: Post-PTMC echocardiographic assessments in a
patient without MAC. The file contains a short clip and three
echocardiographic images which show MVA measurement by planimetry
and PHT methods in a patient without MAC after the PTMC
Additional file 4: Post-PTMC echocardiographic assessments in a
patient with MAC. The file contains a short clip and four
echocardiographic images which show MVA measurement by planimetry
and PHT methods in a patient with MAC after the PTMC.
Author details
1Interventional Department, Tehran Heart Center, Tehran University of
Medical Sciences, Tehran, Iran.2Research Department, Tehran Heart Center,
Tehran University of Medical Sciences, Tehran, Iran.3Echocardiography
Department, Tehran Heart Center, Tehran University of Medical Sciences,
Tehran, Iran.
Authors’ contributions
HS conceived of the study and designed the study. MS participated in its
design and coordination. AS participated in echocardiographic assessment
of the patients. NS participated in preparing patients’ data sheets and MR
performed the statistical analysis and drafted the manuscript. All authors
read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 4 July 2011 Accepted: 28 October 2011
Published: 28 October 2011
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doi:10.1186/1476-7120-9-29
Cite this article as: Salarifar et al.: Mitral annular calcification predicts
immediate results of percutaneous transvenous mitral
commissurotomy. Cardiovascular Ultrasound 2011 9:29.
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