Mitral annulus calcification is a chronic degenerative process in the fibrous base of the mitral valve. Assessment and treatment of mitral valve disease in patients with severe mitral annulus calcification is challenging, and a multimodal approach is helpful to delineate its severity and anatomic features, and to guide the therapeutic strategy. This article reviews the current literature to provide a clinically relevant description of mitral annulus calcification, analyze the diagnostic pathway of a patient with mitral annulus calcification, and summarize the therapeutic options.
CarpentierAFPellerinMFuzellierJFRellandJY.Extensive calcification of the mitral valve anulus: pathology and surgical management.J Thorac Cardiovasc Surg1996;
111: 718–729.
2.
FertmanMHWolffL.Calcification of the mitral valve.Am Heart J1946;
31: 580–589.
3.
AllisonMACheungPCriquiMHLangerRDWrightCM.Mitral and aortic annular calcification are highly associated with systemic calcified atherosclerosis.Circulation2006;
113: 861–866.
4.
KohsakaSJinZRundekT, et al.
Impact of mitral annular calcification on cardiovascular events in a multiethnic community: the Northern Manhattan Study.JACC Cardiovasc Imaging2008;
1: 617–623.
5.
KanjanauthaiSNasirKKatzR, et al.
Relationships of mitral annular calcification to cardiovascular risk factors: the Multi-Ethnic Study of Atherosclerosis (MESA).Atherosclerosis2010;
213: 558–562.
6.
FoleyPWHamaadAEl-GendiHLeyvaF.Incidental cardiac findings on computed tomography imaging of the thorax.BMC Res Notes2010;
3: 326.
7.
FoxCSVasanRSPariseH, et al.
Mitral annular calcification predicts cardiovascular morbidity and mortality: the Framingham Heart Study.Circulation2003;
107: 1492–1496.
8.
FusiniLGhulam AliSTamboriniG, et al.
Prevalence of calcification of the mitral valve annulus in patients undergoing surgical repair of mitral valve prolapse.Am J Cardiol2014;
113: 1867–1873.
9.
UchimuroTFukuiTShimizuATakanashiS.Mitral valve surgery in patients with severe mitral annular calcification.Ann Thorac Surg2016;
101: 889–895.
10.
SellSScullyRE.Aging changes in the aortic and mitral valves. Histologic and histochemical studies, with observations on the pathogenesis of calcific aortic stenosis and calcification of the mitral annulus.Am J Pathol1965;
46: 345–365.
11.
FoxCSLarsonMGVasanRS, et al.
Cross-sectional association of kidney function with valvular and annular calcification: the Framingham heart study.J Am Soc Nephrol2006;
17: 521–527.
12.
UmanaEAhmedWAlpertMA.Valvular and perivalvular abnormalities in end-stage renal disease.Am J Med Sci2003;
325: 237–242.
13.
ElmariahSDelaneyJABluemkeDA, et al.
Associations of LV hypertrophy with prevalent and incident valve calcification: multi-ethnic study of atherosclerosis.JACC Cardiovasc Imaging2012;
5: 781–788.
14.
SilbigerJJ.Anatomy, mechanics, and pathophysiology of the mitral annulus.Am Heart J2012;
164: 163–176.
15.
BoonACheriexELodderJKesselsF.Cardiac valve calcification: characteristics of patients with calcification of the mitral annulus or aortic valve.Heart1997;
78: 472–474.
16.
AdlerYFinkNSpectorDWiserISagieA.Mitral annulus calcification—a window to diffuse atherosclerosis of the vascular system. Atherosclerosis2001;
155: 1–8.
17.
ElmariahSBudoffMJDelaneyJA, et al.
Risk factors associated with the incidence and progression of mitral annulus calcification: the multi-ethnic study of atherosclerosis.Am Heart J2013;
166: 904–912.
18.
FaganelloGFaggianoPCandidoR, et al.
The worrisome liaison between left ventricular systolic dysfunction and mitral annulus calcification in type 2 diabetes without coronary artery disease: data from the SHORTWAVE study.Nutr Metab Cardiovasc Dis2013;
23: 1188–1194.
19.
CorreiaJRodriguesDda SilvaAMSá e MeloAProvidenciaLA.Massive calcification of the mitral valve annulus in an adolescent with Marfan syndrome. A case report. Rev Port Cardiol2006;
25: 921–926.
20.
SchiekenRMKerberREIonasescuVVZellwegerH.Cardiac manifestations of the mucopolysaccharidoses.Circulation1975;
52: 700–705.
21.
JohnsonRCLeopoldJALoscalzoJ.Vascular calcification: pathobiological mechanisms and clinical implications.Circ Res2006;
99: 1044–1059.
22.
EleidMFFoleyTASaidSMPislaruSVRihalCS.Severe mitral annular calcification: multimodality imaging for therapeutic strategies and interventions. JACC Cardiovasc imaging2016;
9: 1318–1337.
23.
AbramowitzYJilaihawiHChakravartyTMackMJMakkarRR.Mitral annulus calcification.J Am Coll Cardiol2015;
66: 1934–1941.
24.
OktayAAGillilandYELavieCJ, et al.
Echocardiographic assessment of degenerative mitral stenosis: a diagnostic challenge of an emerging cardiac disease.Curr Prob Cardiol2017;
42: 71–100.
25.
NishimuraRAVahanianAEleidMFMackMJ.Mitral valve disease—current management and future challenges.Lancet2016;
387: 1324–1334.
26.
BaraschEGottdienerJSLarsenEKChavesPHNewmanABManolioTA.Clinical significance of calcification of the fibrous skeleton of the heart and aortosclerosis in community dwelling elderly. The Cardiovascular Health Study (CHS).Am Heart J2006;
151: 39–47.
27.
MovvaRMurthyKRomero-CorralASeetha RammohanHRFumoPPressmanGS.Calcification of the mitral valve and annulus: systematic evaluation of effects on valve anatomy and function.J Am Soc Echocardiogr2013;
26: 1135–1142.
28.
HigginsJMayoJSkarsgardP.Cardiac computed tomography facilitates operative planning in patients with mitral calcification.Ann Thorac Surg2013;
95: e9–e11.
29.
GroverROhanaMArepalliCD, et al.
Role of MDCT imaging in planning mitral valve intervention.Curr Cardiol Rep2018;
20: 16.
30.
BlankePNaoumCDvirD, et al.
Predicting LVOT obstruction in transcatheter mitral valve implantation: concept of the neo-LVOT.JACC Cardiovasc Imaging2017;
10: 482–485.
31.
WangDDEngMGreenbaumA, et al.
Predicting LVOT Obstruction After TMVR.JACC Cardiovasc Imaging2016;
9: 1349–1352.
32.
CammackPLEdieRNEdmundsLHJr.Bar calcification of the mitral anulus. A risk factor in mitral valve operations.J Thorac Cardiovasc Surg1987;
94: 399–404.
33.
el AsmarBAckerMCouetilJP, et al.
Mitral valve repair in the extensively calcified mitral valve annulus.Ann Thorac Surg1991;
52: 66–69.
34.
GrossiEAGallowayACSteinbergBM, et al.
Severe calcification does not affect long-term outcome of mitral valve repair.Ann Thorac Surg1994;
58: 685–687.
35.
DavidTEFeindelCMArmstrongSSunZ.Reconstruction of the mitral anulus. A ten-year experience.J Thorac Cardiovasc Surg1995;
110: 1323–1332.
36.
MihaljevicTKoprivanacMKelavaMSmediraNGLytleBWBlackstoneEH.Mitral valve replacement in patients with severely calcified mitral valve annulus: surgical technique.J Thorac Cardiovasc Surg2013;
146: 233–235.
37.
CasselmanFPGillinovAMMcDonaldMLCosgroveDM3rd.Use of the anterior mitral leaflet to reinforce the posterior mitral annulus after debridement of calcium.Ann Thorac Surg1999;
68: 261–262.
38.
ChanVRuelMHynesMChaudrySMesanaTG.Impact of mitral annular calcification on early and late outcomes following mitral valve repair of myxomatous degeneration.Interact Cardiovasc Thorac Surg2013;
17: 120–125.
39.
De OliveiraNCDavidTEArmstrongSIvanovJ.Aortic and mitral valve replacement with reconstruction of the intervalvular fibrous body: an analysis of clinical outcomes.J Thorac Cardiovasc Surg2005;
129: 286–290.
40.
NatafPPavieAJaultFBorsVCabrolCGandjbakhchI.Intraatrial insertion of a mitral prosthesis in a destroyed or calcified mitral annulus.Ann Thorac Surg1994;
58: 163–167.
41.
MihosCGSantanaOPegueroJLamelasJ.Intra-atrial placement of a mitral prosthesis in patients with severe mitral annular calcification. J Heart Valve Dis2012;
21: 702–706.
42.
Di StefanoSLopezJFlorezSReyJArevaloASan RomanA.Building a new annulus: a technique for mitral valve replacement in heavily calcified annulus.Ann Thorac Surg2009;
87: 1625–1627.
43.
KurazumiHMikamoASuzukiRHamanoK.Mitral-valve replacement for a severely calcified mitral annulus: a simple and novel technique.Eur J Cardiothorac Surg2011;
39: 407–409.
d’AlessandroCVistariniNAubertS, et al.
Mitral annulus calcification: determinants of repair feasibility, early and late surgical outcome.Eur J Cardiothorac Surg2007;
32: 596–603.
46.
SaidSMSchaffHV.An alternate approach to valve replacement in patients with mitral stenosis and severely calcified annulus.J Thorac Cardiovasc Surg2014;
147: e76–e78.
47.
HasanRMahadevanVSSchneiderHClarkeB.First in human transapical implantation of an inverted transcatheter aortic valve prosthesis to treat native mitral valve stenosis.Circulation2013;
128: e74–e76.
48.
SinningJMMellertFSchillerWWelzANickenigGHammerstinglC.Transcatheter mitral valve replacement using a balloon-expandable prosthesis in a patient with calcified native mitral valve stenosis.Eur Heart J2013;
34: 2609.
49.
WilbringMAlexiouKTugtekinSM, et al.
Pushing the limits—further evolutions of transcatheter valve procedures in the mitral position, including valve-in-valve, valve-in-ring, and valve-in-native-ring.J Thorac Cardiovasc Surg2014;
147: 210–219.
50.
GuerreroMGreenbaumAO’NeillW.First in human percutaneous implantation of a balloon expandable transcatheter heart valve in a severely stenosed native mitral valve.Catheter Cardiovasc Interv2014;
83: E287–E291.
51.
LimZYBoixRPrendergastB, et al.
First reported case of transcatheter mitral valve implantation in mitral annular calcification with a fully repositionable and self-expanding valve.Circ Cardiovasc Interv2015;
8: e003031.
52.
MellertFSinningJMWernerN, et al.
First-in-man transapical mitral valve replacement using the Direct Flow Medical(R) aortic valve prosthesis.Eur Heart J2015;
36: 2119.
53.
SorajjaPGosslMBaeR, et al.
Severe mitral annular calcification: first experience with transcatheter therapy using a dedicated mitral prosthesis.JACC Cardiovasc Interv2017;
10: 1178–1179.
54.
GuerreroMUrenaMHimbertD, et al.
1-year outcomes of transcatheter mitral valve replacement in patients with severe mitral annular calcification.J Am Coll Cardiol2018;
71: 1841–1853.
55.
El SabbaghAEleidMFFoleyTA, et al.
Direct transatrial implantation of balloon-expandable valve for mitral stenosis with severe annular calcifications: early experience and lessons learned.Eur J Cardiothorac Surg2018;
53: 162–169.
56.
HulmanMBenaMArtemiouP, et al.
Iterative learning of transcatheter mitral valve replacement in mitral valve annulus calcification: management and prevention of transcatheter mitral valve replacement dislocation.Ann Thorac Surg2016;
102: e287–e290.
57.
PoulinABernierMRodes-CabauJDoyleDParadisJM.Subacute mitral valve dysfunction after transcatheter aortic and mitral valve replacements.J Thorac Cardiovasc Surg2018;
155: e167–e172.
58.
GuerreroMWangDDHimbertD, 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 Intervent2017;
90: 1220–1226.
59.
BabaliarosVCGreenbaumABKhanJM, et al.
Intentional percutaneous laceration of the anterior mitral leaflet to prevent outflow obstruction during transcatheter mitral valve replacement: first-in-human experience.JACC Cardiovasc Intervent2017;
10: 798–809.
60.
PrazFKhaliqueOKLeeR, et al.
Transatrial implantation of a transcatheter heart valve for severe mitral annular calcification.J Thorac Cardiovasc Surg2018;
156: 132–42.
