Abstract
BACKGROUND: Mitral annular calcification (MAC) poses unique challenges in infective endocarditis (IE). This study aimed to characterize echocardiographic features of IE involving MAC and assess its management and outcomes. METHODS: We reviewed cases discussed during our IE multidisciplinary meetings, 2021-2024. Clinical data, imaging findings, and outcomes were collected through chart review. RESULTS: Among 741 patients evaluated, 51 patients (7%; aged 73 ± 11 years; 45% female) had possible or definite IE and moderate-severe MAC. IE involved the mitral valve in 24 patients (47%). Mitral IE was more frequent in women (63% vs 30%, P = 0.02) and was less commonly associated with prior aortic valve replacement (17% vs 59%, P < 0.01). Staphylococcus aureus was the most common pathogen, with no difference between groups (38% vs 30% in the mitral vs nonmitral IE groups, respectively, P = 0.55). Patients with mitral IE often presented with large vegetations (median 13 mm), frequent valvular or perivalvular complications (moderate or greater mitral regurgitation in 54%, perforation in 33%, and perivalvular abscess in 13%). A succulent aspect of the vegetation mass with abnormal MAC mobility, described as "rocking," was observed in 7 patients (29%). Surgical indications were found in 63% of patients, but only 40% underwent surgery due to high perceived risk. The in-hospital mortality incidence was not different between the mitral and nonmitral IE groups (29% vs 15%, P = 0.32). CONCLUSIONS: In patients with IE and MAC, the mitral valve was often primarily affected, showing large, mobile vegetations with a "rocking" motion. Despite frequent surgical indications, few underwent surgery, highlighting the need for improved management in this high-risk group.