Skip to main content

Advertisement

SpringerLink
Log in

Mitral annular calcification: challenges and future perspectives

  • Review Article
  • Published:
Indian Journal of Thoracic and Cardiovascular Surgery Aims and scope Submit manuscript

Abstract

Mitral annular calcification (MAC) is a chronic degenerative process that implies calcification on the mitral support structure. It usually appears as a bystander to other cardiac pathologies hindering surgical treatment and increasing morbidity and mortality. When addressing the mitral valve, many surgical strategies have been suggested in the past with no clear consensus on what to choose. Moreover, and as transcatheter therapies have gained popularity over the last few decades, transcatheter mitral valve implantation has appeared as another alternative to conventional surgery. In this review, we aim at describing an overview of MAC, highlighting current challenges and treatment options as well as new potential alternatives.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8

Similar content being viewed by others

References

  1. Cammack PL, Edie RN, Edmunds LH Jr. Bar calcification of the mitral anulus. A risk factor in mitral valve operations. J Thorac Cardiovasc Surg. 1987;94:399–404.

    CAS  PubMed  Google Scholar 

  2. Abramowitz Y, Jilaihawi H, Chakravarty T, Mack MJ, Makkar RR. Mitral annulus calcification. J Am Coll Cardiol. 2015;66:1934–41.

    PubMed  Google Scholar 

  3. Savage DD, Garrison RJ, Castelli WP, et al. Prevalence of submitral (anular) calcium and its correlates in a general population-based sample (the Framingham study). Am J Cardiol. 1983;51:1375–78.

    CAS  PubMed  Google Scholar 

  4. Pomerance A. Pathological and clinical study of calcification of the mitral valve ring. J Clin Pathol. 1970;23:354–61.

    CAS  PubMed  PubMed Central  Google Scholar 

  5. Weissler-Snir A, Weisenberg D, Natanzon S, et al. Clinical and echocardiographic features of mitral annular calcium in patients aged < = 50 years. Am J Cardiol. 2015;116:1447–50.

  6. Elmariah S, Budoff MJ, Delaney JA, et al. Risk factors associated with the incidence and progression of mitral annulus calcification: the multi-ethnic study of atherosclerosis. Am Heart J. 2013;166:904–12.

    PubMed  PubMed Central  Google Scholar 

  7. D’Cruz IA, Cohen HC, Prabhu R, Bisla V, Glick G. Clinical manifestations of mitral annulus calcification, with emphasis on its echocardiographic features. Am Heart J. 1977;94:367–77.

    PubMed  Google Scholar 

  8. Fulkerson PK, Beaver BM, Auseon JC, Graber HL. Calcification of the mitral annulus. Am J Med. 1979;66:967–77.

    CAS  PubMed  Google Scholar 

  9. Rezaeian P, Miller PE, Haberlen SA, et al. Extra-coronary calcification (aortic valve calcification, mitral annular calcification, aortic valve ring calcification and thoracic aortic calcification) in HIV seropositive and seronegative men: Multicenter AIDS Cohort Study. J Cardiovasc Comput Tomogr. 2016;10:229–36.

    PubMed  PubMed Central  Google Scholar 

  10. Asselbergs FW, Mozaffarian D, Katz R, et al. Association of renal function with cardiac calcifications in older adults: the cardiovascular health study. Nephrol Dial Transplant. 2009;24:834–40.

    PubMed  Google Scholar 

  11. Schieken RM, Kerber RE, Ionasescu VV, Zellweger H. Cardiac manifestations of the mucopolysaccharidoses. Circulation. 1975;52:700–5.

    CAS  PubMed  Google Scholar 

  12. Radke RM, Baumgartner H. Diagnosis and treatment of Marfan syndrome: an update. Heart. 2014;100:1382–91.

    PubMed  Google Scholar 

  13. Robinson CR, Roberts WC. Outcome of combined mitral and aortic valve replacement in adults with mucopolysaccharidosis (the Hurler syndrome). Am J Cardiol. 2017;120:2113–8.

    PubMed  Google Scholar 

  14. Atar S, Jeon DS, Luo H, Siegel RJ. Mitral annular calcification: a marker of severe coronary artery disease in patients under 65 years old. Heart. 2003;89:161–4.

    CAS  PubMed  PubMed Central  Google Scholar 

  15. Allison MA, Cheung P, Criqui MH, Langer RD, Wright CM. Mitral and aortic annular calcification are highly associated with systemic calcified atherosclerosis. Circulation. 2006;113:861–6.

    PubMed  Google Scholar 

  16. Takamoto T, Popp RL. Conduction disturbances related to the site and severity of mitral anular calcification: a 2-dimensional echocardiographic and electrocardiographs correlative study. Am J Cardiol. 1983;51:1644–9.

    CAS  PubMed  Google Scholar 

  17. Abudiab MM, Chebrolu LH, Schutt RC, Nagueh SF, Zoghbi WA. Doppler echocardiography for the estimation of LV filling pressure in patients with mitral annular calcification. JACC Cardiovasc Imaging. 2017;10:1411–20.

    PubMed  Google Scholar 

  18. Carpentier AF, Pellerin M, Fuzellier JF, Relland JY. Extensive calcification of the mitral valve anulus: pathology and surgical management. J Thorac Cardiovasc Surg. 1996;111:718–29.

    CAS  PubMed  Google Scholar 

  19. David TE, Feindel CM, Armstrong S, Sun Z. Reconstruction of the mitral anulus. A ten-year experience. J Thorac Cardiovasc Surg. 1995;110:1323–32.

    CAS  PubMed  Google Scholar 

  20. Johnson RC, Leopold JA, Loscalzo J. Vascular calcification: pathobiological mechanisms and clinical implications. Circ Res. 2006;99:1044–59.

    CAS  PubMed  Google Scholar 

  21. Movva R, Murthy K, Romero-Corral A, Seetha Rammohan HR, Fumo P, Pressman GS. Calcification of the mitral valve and annulus: systematic evaluation of effects on valve anatomy and function. J Am Soc Echocardiogr. 2013;26:1135–42.

    PubMed  Google Scholar 

  22. Jassal DS, Tam JW, Bhagirath KM, et al. Association of mitral annular calcification and aortic valve morphology: a substudy of the aortic stenosis progression observation measuring effects of rosuvastatin (ASTRONOMER) study. Eur Heart J. 2008;29:1542–7.

    PubMed  Google Scholar 

  23. Kohsaka S, Jin Z, Rundek T, et al. Impact of mitral annular calcification on cardiovascular events in a multiethnic community: the Northern Manhattan Study. JACC Cardiovasc Imaging. 2008;1:617–23.

    PubMed  PubMed Central  Google Scholar 

  24. Saran N, Greason KL, Schaff HV, et al. Does mitral valve calcium in patients undergoing mitral valve replacement portend worse survival? Ann Thorac Surg. 2019;107:444–52.

    PubMed  Google Scholar 

  25. Lad VS, Newcomb AE, Davis PJ, Leng CY. Surgical techniques for the management of the ‘hostile mitral annulus’. Heart Lung Circ. 2014;23:217–23.

    PubMed  Google Scholar 

  26. Feindel CM, Tufail Z, David TE, Ivanov J, Armstrong S. Mitral valve surgery in patients with extensive calcification of the mitral annulus. J Thorac Cardiovasc Surg. 2003;126:777–82.

    PubMed  Google Scholar 

  27. Hosseini S, Samiei N, Mestres CA. The mitral annular stone: a surgical challenge. Eur J Cardiothorac Surg. 2015;48:805.

    PubMed  Google Scholar 

  28. Ng CK, Punzengruber C, Pachinger O, et al. Valve repair in mitral regurgitation complicated by severe annulus calcification. Ann Thorac Surg. 2000;70:53–8.

    CAS  PubMed  Google Scholar 

  29. Uchimuro T, Fukui T, Shimizu A, Takanashi S. Mitral valve surgery in patients with severe mitral annular calcification. Ann Thorac Surg. 2016;101:889–95.

    PubMed  Google Scholar 

  30. Mihaljevic T, Koprivanac M, Kelava M, Smedira NG, Lytle BW, Blackstone EH. Mitral valve replacement in patients with severely calcified mitral valve annulus: surgical technique. J Thorac Cardiovasc Surg. 2013;146:233–5.

    PubMed  Google Scholar 

  31. Smedira NG. Mitral valve replacement with a calcified annulus. Op Tech Thorac Cardiovasc Surg. 2003;8:2–13.

    Google Scholar 

  32. Grossi EA, Galloway AC, Steinberg BM, et al. Severe calcification does not affect long-term outcome of mitral valve repair. Ann Thorac Surg. 1994;58:685–87.

    CAS  PubMed  Google Scholar 

  33. Van der Salm TJV. Mitral annular calcification: a new technique for valve replacement. Ann Thorac Surg. 1989;48:437–9.

    Google Scholar 

  34. Vander Salm TJ. Mitral annular calcification: a new technique for valve replacement. Ann Thorac Surg.1997; 63:1819–1820.

  35. Casselman FP, Gillinov AM, McDonald ML, Cosgrove DM. Use of the anterior mitral leaflet to reinforce the posterior mitral annulus after debridement of calcium. Ann Thorac Surg. 1999;68:261–2.

    CAS  PubMed  Google Scholar 

  36. Di Stefano S, Lopez J, Florez S, Rey J, Arevalo A, San Roman A. Building a new annulus: a technique for mitral valve replacement in heavily calcified annulus. Ann Thorac Surg. 2009;87:1625–7.

    PubMed  Google Scholar 

  37. Nataf P, Pavie A, Jault F, Bors V, Cabrol C, Gandjbakhch I. Intraatrial insertion of a mitral prosthesis in a destroyed or calcified mitral annulus. Ann Thorac Surg. 1994;58:163–7.

    CAS  PubMed  Google Scholar 

  38. Gandjbakhch I, Lascar M, Pavie A, Cabrol C. Intra-atrial insertion of a prosthetic mitral valve. J Cardiovasc Surg. 1988;29:113–4.

    CAS  Google Scholar 

  39. Salhiyyah K, Kattach H, Ashoub A, et al. Mitral valve replacement in severely calcified mitral valve annulus: a 10-year experience. Eur J Cardiothorac Surg. 2017;52:440–4.

    PubMed  Google Scholar 

  40. Smith CR, Stamou SC, Boeve TJ, Patzelt LH. Folding mitral valvuloplasty without posterior leaflet resection for calcified mitral annulus. Interact Cardiovasc Thorac Surg. 2012;14:143–5.

    PubMed  Google Scholar 

  41. Roberts WC, Morrow AG. Causes of early postoperative death following cardiac valve replacement - clinico-pathologic correlations in 64 patients studied at necropsy. J Thorac Cardiovasc Surg. 1967;54:422–37.

    CAS  PubMed  Google Scholar 

  42. Spencer FC, Galloway AC, Colvin SB. A clinical-evaluation of the hypothesis that rupture of the left-ventricle following mitral-valve replacement can be prevented by preservation of the chordae of the mural leaflet. Ann Surg. 1985;202:673–80.

    CAS  PubMed  PubMed Central  Google Scholar 

  43. Eleid MF, Foley TA, Said SM, Pislaru SV, Rihal CS. Severe mitral annular calcification: multimodality imaging for therapeutic strategies and interventions. JACC Cardiovasc Imaging. 2016;9:1318–37.

    PubMed  Google Scholar 

  44. Wright JS, Thomson DS, Warner G. Mitral valve bypass by valved conduit. Ann Thorac Surg. 1981;32:294–6.

    CAS  PubMed  Google Scholar 

  45. Said SM, Schaff HV. An alternate approach to valve replacement in patients with mitral stenosis and severely calcified annulus. J Thorac Cardiovasc Surg. 2014;147:e76–8.

    PubMed  Google Scholar 

  46. Lopez-Rodriguez FJ, Arnaiz-Garcia ME, Barreiro-Perez M, Gonzalez-Santos JM. Left atrial to left ventricular valved conduit for a calcified mitral annulus and ascending aorta. J Thorac Cardiovasc Surg. 2019;157:e143–5.

    PubMed  Google Scholar 

  47. Hasan R, Mahadevan VS, Schneider H, Clarke B. First in human transapical implantation of an inverted transcatheter aortic valve prosthesis to treat native mitral valve stenosis. Circulation. 2013;128:e74–6.

    PubMed  Google Scholar 

  48. Russell HM, Guerrero ME, Salinger MH, et al. Open atrial transcatheter mitral valve replacement in patients with mitral annular calcification. J Thorac Cardiovasc Surg. 2019;157:907–16.

    Google Scholar 

  49. Ferrari E, Niclauss L, Locca D, Marcucci C. On-pump fibrillating heart mitral valve replacement with the SAPIEN XT transcatheter heart valve. Eur J Cardiothorac Surg. 2014;45:749–51.

    PubMed  Google Scholar 

  50. El Sabbagh A, Eleid MF, Foley TA, et al. Direct transatrial implantation of balloon-expandable valve for mitral stenosis with severe annular calcifications: early experience and lessons learned. Eur J Cardiothorac Surg. 2018;53:162–9.

  51. Praz F, Khalique OK, Lee R, et al. Transatrial implantation of a transcatheter heart valve for severe mitral annular calcification. J Thorac Cardiovasc Surg. 2018;156:132–142.

    PubMed  Google Scholar 

  52. Lim ZY, Boix R, Prendergast B, et al. First reported case of transcatheter mitral valve implantation in mitral annular calcification with a fully repositionable and self-expanding valve. Circ Cardiovasc Interv. 2015;8:e003031.

    PubMed  Google Scholar 

  53. Guerrero M, Urena M, Himbert D, et al. 1-year outcomes of transcatheter mitral valve replacement in patients with severe mitral annular calcification. J Am Coll Cardiol. 2018;71:1841–53.

    PubMed  Google Scholar 

  54. Guerrero M, Wang DD, Himbert D, et al. Short-term results of alcohol septal ablation as a bail-out strategy to treat severe left ventricular outflow tract obstruction after transcatheter mitral valve replacement in patients with severe mitral annular calcification. Catheter Cardiovasc Interv. 2017;90:1220–6.

    PubMed  Google Scholar 

  55. Deharo P, Urena M, Himbert D, et al. Bail-out alcohol septal ablation for left ventricular outflow tract obstruction after transcatheter mitral valve replacement. JACC Cardiovasc Interv. 2016;9:e73–6.

    PubMed  Google Scholar 

  56. Yoon SH, Bleiziffer S, Latib A, et al. Predictors of left ventricular outflow tract obstruction after transcatheter mitral valve replacement. JACC Cardiovasc Interv. 2019;12:182–193.

    PubMed  Google Scholar 

  57. Khan JM, Babaliaros VC, Greenbaum AB, et al. Anterior leaflet laceration to prevent ventricular outflow tract obstruction during transcatheter mitral valve replacement. J Am Coll Cardiol. 2019;73:2521–34.

    PubMed  PubMed Central  Google Scholar 

  58. Sorajja P, Gössl M, Bae R, et al. Severe mitral annular calcification; first experience with transcatheter therapy using a dedicated mitral prosthesis. JACC Cardiovasc Interv. 2017; 10:1178–79.

  59. Maisano F, Taramasso M. Mitral valve-in-valve, valve-in-ring, and valve-in-MAC: the good, the bad, and the ugly. Eur Heart J. 2019;40:452–5.

    PubMed  Google Scholar 

  60. Yoon SH, Whisenant BK, Bleiziffer S, et al. Outcomes of transcatheter mitral valve replacement for degenerated bioprostheses, failed annuloplasty rings, and mitral annular calcification. Eur Heart J. 2019;40:441–51.

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Cardiac Surgery, University Hospital Zürich, Rämistrasse 100, CH-8091, Zürich, Switzerland

    Mathias Van Hemelrijck, Maurizio Taramasso, Gökhan Gülmez, Francesco Maisano & Carlos-A. Mestres

Authors
  1. Mathias Van Hemelrijck
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Maurizio Taramasso
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Gökhan Gülmez
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Francesco Maisano
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Carlos-A. Mestres
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Carlos-A. Mestres.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

Not required being a review article.

Informed consent

Not Applicable.

Funding

Nil.

Human and animal rights

Not Applicable.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Van Hemelrijck, M., Taramasso, M., Gülmez, G. et al. Mitral annular calcification: challenges and future perspectives. Indian J Thorac Cardiovasc Surg 36, 397–403 (2020). https://doi.org/10.1007/s12055-019-00910-2

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12055-019-00910-2

Keywords

Search

Navigation