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Management of valve dysfunction in patients with mitral annular calcification
  1. Till Joscha Demal,
  2. Lenard Conradi
  1. Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
  1. Correspondence to Professor Lenard Conradi, Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg D-20246, Germany; l.conradi{at}

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Learning objectives

  • Know typical comorbidities that associate with mitral annular calcification (MAC).

  • Understand optimal diagnostic pathways in the preprocedural evaluation of patients with MAC and mitral valvular dysfunction.

  • Know typical advantages, pitfalls and complications of surgical and transcatheter therapeutic strategies for patients with MAC and mitral valvular dysfunction.

  • Understand possible treatment allocation algorithms for patients with MAC and mitral valvular dysfunction.


Mitral annular calcification (MAC) is a degenerative process of the fibrous base of the mitral valve. Most patients with MAC present with mild or moderate severity of the calcification pattern, whereas severe MAC is rather rare.1 It increases the risk for mitral valve dysfunction (regurgitation and/or stenosis).2 Predisposing factors for MAC include advanced age, female gender or chronic kidney disease (especially if dialysis dependent), and it is frequently associated with atrial fibrillation, stroke, infective endocarditis or coronary artery disease. Furthermore, MAC has been shown to be independently associated with the severity of arteriosclerotic comorbidities (ie, carotid artery plaques).3 Due to their comorbidities and anatomical characteristics, patients with MAC typically present with high surgical risk. Furthermore, surgical treatment is technically demanding and accompanied by a high risk of paravalvular leakage (PVL), circumflex artery injury or atrioventricular groove disruption. Therefore, to minimise procedural risk, several transcatheter-based techniques have been proposed as alternative treatment options in patients with MAC. This article reviews both surgical and transcatheter-based treatment strategies and proposes a risk-based and anatomy-based therapy allocation algorithm.

Definition, diagnosis and grading

MAC is a chronic, degenerative process resulting in the deposition of calcium in and around the fibrous base of the mitral valve.4 5 MAC, especially in early stages, more commonly affects the posterior annulus than the anterior annulus, but the complete circumference can be involved.5 6

Diagnosis is made by chest X-ray, echocardiography or CT scan of the chest. X-ray images give …

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  • Contributors Both authors contributed equally in writing the manuscript. TJD created the figures and tables.

  • Funding TJD is supported by the Clinician Scientist programme of the German Center for Cardiovascular Research (DZHK; FKZ 81X3710109).

  • Competing interests LC is an advisory board member for Medtronic, Abbott, JenaValve and Neovasc and has received personal fees from Edwards Lifesciences, Boston Scientific, MicroInterventions and PiCardia.

  • Provenance and peer review Commissioned; internally peer reviewed.