Mitral annular calcification (MAC) remains a challenging pathology in the context of mitral valve disease. It is associated with known cardiovascular risk factors, as well as a variety of chronic inflammatory, infective, or connective tissue diseases. Surgically, patients are at specific operative risk for atrioventricular dehiscence or rupture and/or injury to the circumflex artery. To mitigate these risks, a broad portfolio of surgical options exists to safely anchor annular sutures. This can be performed after the calcium bar has been removed and the posterior annulus reconstructed with a patch, or even when the calcium bar is left in place. Knowledge of these techniques will help surgeons manage MAC and implant a properly sized valve. Even in the presence of severe MAC with additional involvement of the mitral valve leaflets, transatrial transcatheter heart valve (THV) implantation may be a viable option. An individualized decision-making process to determine the applicable technique should be used for patients with MAC, leading to adequate treatment for this high-risk patient group.
