Tips and tricks in addressing mitral annular calcification in mitral valve surgery

Mitral annular calcification (MAC) is a heterogeneous condition that can complicate mitral valve (MV) repair and replacement operations. Surgery in the context of MAC varies considerably. Relatively simple repairs or replacements can be performed in several patients without the need to remove the calcium bar. However, extensive annular debridement, reconstruction of the atrioventricular junction, reconstruction of the intervalvular fibrous body, and mitral and aortic valve replacement may be necessary in some instances. Outcomes of these patients are directly related to the avoidance of technical problems amid a variety of potential anatomic challenges and pitfalls. Careful preoperative assessment, patient selection, detailed preoperative planning, and intraoperative judgment are required to optimize the chance of a successful outcome. Here we describe our approach to the MV patients with MAC, including preoperative planning, intraoperative technical tips and tricks, as well as a discussion of outcomes and remaining questions in this challenging population. This review only includes patients with MAC and MV dysfunction. It excludes those with associated aortic valve disease. The article contains a lecture on MV surgery in patients with MAC. We also highlight emerging experimental approaches, including hybrid and percutaneous techniques.