Interpretation of the 2025 American Association for Thoracic Surgery expert consensus document: <i>Surgical Management of Mitral Annular Calcification</i>_West China Medical Journal

Authors：

LI Yijian ¹ ,  MENG Wei ²

1. Department of Cardiology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P. R. China;
2. Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P. R. China;

Corresponding author：

MENG Wei, Email: 929831722@qq.com

Keywords：

Mitral annular calcification; mitral valve repair; mitral valve replacement; transcatheter mitral valve intervention; expert consensus

DOI：

10.7507/1002-0179.202509110

Video：

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For mitral valve disease with mitral annular calcification (MAC), surgery remains challenging. Up to now, there is no ideal management strategy or patient selection standard, and perioperative and periprocedural morbidity and mortality rates remain high. The recent surge of patients presenting with MAC has been accompanied by increased interest in MAC surgery and interventions. The American Association for Thoracic Surgery Clinical Practice Standards Committee is meant to provide a simplified outline for managing MAC. Combined with progress of MAC therapy, a detailed interpretation of the 2025 expert consensus is provided which include patient selection, preoperative evaluation (especially imaging evaluation), indications of intervention, surgical and transcatheter therapeutic options, and postoperative complications and remedial measures.

1.	Fann JL, Ingels NB, Miller DC. Pathophysiology of mitral valve disease//Cohn LH, Adams DH. Cardiac surgery in the adult. 5th ed. New York: McGraw-Hill Education, 2017: 761-796.
2.	Abramowitz Y, Jilaihawi H, Chakravarty T, et al. Mitral annulus calcification. J Am Coll Cardiol, 2015, 66(17): 1934-1941.
3.	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(3): 422-437.
4.	Kanjanauthai S, Nasir K, Katz R, et al. Relationships of mitral annular calcification to cardiovascular risk factors: the Multi-Ethnic Study of Atherosclerosis (MESA). Atherosclerosis, 2010, 213(2): 558-562.
5.	Lerner RG, Aronow WS, Sekhri A, et al. Warfarin use and the risk of valvular calcification. J Thromb Haemost, 2009, 7(12): 2023-2027.
6.	Xu B, Kocyigit D, Wang TKM, et al. Mitral annular calcification and valvular dysfunction: multimodality imaging evaluation, grading, and management. Eur Heart J Cardiovasc Imaging, 2022, 23(3): e111-e122.
7.	el Asmar B, Acker M, Couetil JP, et al. Mitral valve repair in the extensively calcified mitral valve annulus. Ann Thorac Surg, 1991, 52(1): 66-69.
8.	Carpentier A, Adams DH, Filsoufi F. Carpentier’s reconstructive valve surgery. Philadelphia: Saunders, 2010.
9.	Ng CK, Punzengruber C, Pachinger O, et al. Valve repair in mitral regurgitation complicated by severe annulus calcification. Ann Thorac Surg, 2000, 70(1): 53-58.
10.	Feindel CM, Tufail Z, David TE, et al. Mitral valve surgery in patients with extensive calcification of the mitral annulus. J Thorac Cardiovasc Surg, 2003, 126(3): 777-782.
11.	d’Alessandro C, Vistarini N, Aubert S, et al. Mitral annulus calcification: determinants of repair feasibility, early and late surgical outcome. Eur J Cardiothorac Surg, 2007, 32(4): 596-603.
12.	Dietrich M, Doss M, Aybek T, et al. Decalcification of the mitral annulus: surgical experience in 81 patients. Thorac Cardiovasc Surg, 2006, 54(7): 464-467.
13.	El-Eshmawi A, Tang GHL, Sun E, et al. Contemporary surgical techniques for mitral valve replacement in extensive mitral annular calcification. JTCVS Tech, 2023, 22: 1-12.
14.	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(3): 685-687.
15.	Naito N, Loulmet DF, Dorsey M, et al. Short-term outcomes of robotic left ventricular patch ventriculoplasty for significant mitral annular calcification. JTCVS Tech, 2024, 27: 81-90.
16.	Papadopoulos N, Dietrich M, Christodoulou T, et al. Midterm survival after decalcification of the mitral annulus. Ann Thorac Surg, 2009, 87(4): 1143-1147.
17.	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(2): 444-452.
18.	Tomšič A, Hiemstra YL, van Brakel TJ, et al. Outcomes of valve repair for degenerative disease in patients with mitral annular calcification. Ann Thorac Surg, 2019, 107(4): 1195-1201.
19.	Uchimuro T, Fukui T, Shimizu A, et al. Mitral valve surgery in patients with severe mitral annular calcification. Ann Thorac Surg, 2016, 101(3): 889-895.
20.	Alexis SL, Malik AH, El-Eshmawi A, et al. Surgical and transcatheter mitral valve replacement in mitral annular calcification: a systematic review. J Am Heart Assoc, 2021, 10(7): e018514.
21.	Di Stefano S, López J, Flórez S, et al. Building a new annulus: a technique for mitral valve replacement in heavily calcified annulus. Ann Thorac Surg, 2009, 87(5): 1625-1627.
22.	Baumgartner FJ, Pandya A, Omari BO, et al. Ultrasonic debridement of mitral calcification. J Card Surg, 1997, 12(4): 240-242.
23.	McEnany MT. Mitral valve replacement in the presence of severe valvular and annular calcification. J Card Surg, 1993, 8(2): 117-124.
24.	Yoshikai M, Ohnishi H, Fumoto H, et al. Mitral valve replacement for a severely calcified mitral annulus. J Card Surg, 2007, 22(6): 502-504.
25.	Guerrero ME, Eleid MF, Wang DD, et al. 5-year prospective evaluation of mitral valve-in-valve, valve-in-ring, and valve-in-mac outcomes: MITRAL trial final results. JACC Cardiovasc Interv, 2023, 16(18): 2211-2227.
26.	Coisne A, Ludwig S, Scotti A, et al. Outcomes following transcatheter mitral valve replacement using dedicated devices in patients with mitral annular calcification. JACC Cardiovasc Interv, 2024, 17(18): 2141-2153.
27.	Hatab T, Bou Chaaya RG, Zaid S, et al. Feasibility and outcomes of mitral transcatheter edge-to-edge repair in patients with variable degrees of mitral annular calcification. J Am Heart Assoc, 2023, 12(19): e031118.
28.	Mustafa A, Basman C, Cinelli MP, et al. Contemporary experience of mitral transcatheter edge-to-edge repair technology in patients with mitral annular calcification. Catheter Cardiovasc Interv, 2024, 103(4): 618-625.
29.	Parikh P, Kassab J, Cohen J, et al. Novel leaflet modification of the native anterior mitral valve leaflet for transcatheter mitral valve replacement. JACC Case Rep, 2024, 29(18): 102558.
30.	Greenbaum AB, Ueyama HA, Gleason PT, et al. Transcatheter myotomy to reduce left ventricular outflow obstruction. J Am Coll Cardiol, 2024, 83(14): 1257-1272.
31.	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(7): 1220-1226.
32.	Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2021, 143(5): e72-e227.

1. Fann JL, Ingels NB, Miller DC. Pathophysiology of mitral valve disease//Cohn LH, Adams DH. Cardiac surgery in the adult. 5th ed. New York: McGraw-Hill Education, 2017: 761-796.
2. Abramowitz Y, Jilaihawi H, Chakravarty T, et al. Mitral annulus calcification. J Am Coll Cardiol, 2015, 66(17): 1934-1941.
3. 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(3): 422-437.
4. Kanjanauthai S, Nasir K, Katz R, et al. Relationships of mitral annular calcification to cardiovascular risk factors: the Multi-Ethnic Study of Atherosclerosis (MESA). Atherosclerosis, 2010, 213(2): 558-562.
5. Lerner RG, Aronow WS, Sekhri A, et al. Warfarin use and the risk of valvular calcification. J Thromb Haemost, 2009, 7(12): 2023-2027.
6. Xu B, Kocyigit D, Wang TKM, et al. Mitral annular calcification and valvular dysfunction: multimodality imaging evaluation, grading, and management. Eur Heart J Cardiovasc Imaging, 2022, 23(3): e111-e122.
7. el Asmar B, Acker M, Couetil JP, et al. Mitral valve repair in the extensively calcified mitral valve annulus. Ann Thorac Surg, 1991, 52(1): 66-69.
8. Carpentier A, Adams DH, Filsoufi F. Carpentier’s reconstructive valve surgery. Philadelphia: Saunders, 2010.
9. Ng CK, Punzengruber C, Pachinger O, et al. Valve repair in mitral regurgitation complicated by severe annulus calcification. Ann Thorac Surg, 2000, 70(1): 53-58.
10. Feindel CM, Tufail Z, David TE, et al. Mitral valve surgery in patients with extensive calcification of the mitral annulus. J Thorac Cardiovasc Surg, 2003, 126(3): 777-782.
11. d’Alessandro C, Vistarini N, Aubert S, et al. Mitral annulus calcification: determinants of repair feasibility, early and late surgical outcome. Eur J Cardiothorac Surg, 2007, 32(4): 596-603.
12. Dietrich M, Doss M, Aybek T, et al. Decalcification of the mitral annulus: surgical experience in 81 patients. Thorac Cardiovasc Surg, 2006, 54(7): 464-467.
13. El-Eshmawi A, Tang GHL, Sun E, et al. Contemporary surgical techniques for mitral valve replacement in extensive mitral annular calcification. JTCVS Tech, 2023, 22: 1-12.
14. 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(3): 685-687.
15. Naito N, Loulmet DF, Dorsey M, et al. Short-term outcomes of robotic left ventricular patch ventriculoplasty for significant mitral annular calcification. JTCVS Tech, 2024, 27: 81-90.
16. Papadopoulos N, Dietrich M, Christodoulou T, et al. Midterm survival after decalcification of the mitral annulus. Ann Thorac Surg, 2009, 87(4): 1143-1147.
17. 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(2): 444-452.
18. Tomšič A, Hiemstra YL, van Brakel TJ, et al. Outcomes of valve repair for degenerative disease in patients with mitral annular calcification. Ann Thorac Surg, 2019, 107(4): 1195-1201.
19. Uchimuro T, Fukui T, Shimizu A, et al. Mitral valve surgery in patients with severe mitral annular calcification. Ann Thorac Surg, 2016, 101(3): 889-895.
20. Alexis SL, Malik AH, El-Eshmawi A, et al. Surgical and transcatheter mitral valve replacement in mitral annular calcification: a systematic review. J Am Heart Assoc, 2021, 10(7): e018514.
21. Di Stefano S, López J, Flórez S, et al. Building a new annulus: a technique for mitral valve replacement in heavily calcified annulus. Ann Thorac Surg, 2009, 87(5): 1625-1627.
22. Baumgartner FJ, Pandya A, Omari BO, et al. Ultrasonic debridement of mitral calcification. J Card Surg, 1997, 12(4): 240-242.
23. McEnany MT. Mitral valve replacement in the presence of severe valvular and annular calcification. J Card Surg, 1993, 8(2): 117-124.
24. Yoshikai M, Ohnishi H, Fumoto H, et al. Mitral valve replacement for a severely calcified mitral annulus. J Card Surg, 2007, 22(6): 502-504.
25. Guerrero ME, Eleid MF, Wang DD, et al. 5-year prospective evaluation of mitral valve-in-valve, valve-in-ring, and valve-in-mac outcomes: MITRAL trial final results. JACC Cardiovasc Interv, 2023, 16(18): 2211-2227.
26. Coisne A, Ludwig S, Scotti A, et al. Outcomes following transcatheter mitral valve replacement using dedicated devices in patients with mitral annular calcification. JACC Cardiovasc Interv, 2024, 17(18): 2141-2153.
27. Hatab T, Bou Chaaya RG, Zaid S, et al. Feasibility and outcomes of mitral transcatheter edge-to-edge repair in patients with variable degrees of mitral annular calcification. J Am Heart Assoc, 2023, 12(19): e031118.
28. Mustafa A, Basman C, Cinelli MP, et al. Contemporary experience of mitral transcatheter edge-to-edge repair technology in patients with mitral annular calcification. Catheter Cardiovasc Interv, 2024, 103(4): 618-625.
29. Parikh P, Kassab J, Cohen J, et al. Novel leaflet modification of the native anterior mitral valve leaflet for transcatheter mitral valve replacement. JACC Case Rep, 2024, 29(18): 102558.
30. Greenbaum AB, Ueyama HA, Gleason PT, et al. Transcatheter myotomy to reduce left ventricular outflow obstruction. J Am Coll Cardiol, 2024, 83(14): 1257-1272.
31. 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(7): 1220-1226.
32. Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2021, 143(5): e72-e227.

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