This video submission is from the 2025 CTSNet Instructional Video Competition. Watch all entries from the competition, including the winning videos.  [3] 

Mitral annular calcification (MAC) is a chronic degenerative process in the fibrous skeleton of the mitral valve annulus, which adds technical complexity to the mitral valve replacement procedure. Careful assessment of MAC severity using multimodality imaging is critical for optimal surgical planning (1). This approach involves debriding the bulky MAC while preserving the posterior capsule, with the goal of ensuring proper seating of an adequately sized prosthesis (2). The method for annular support after MAC debridement can be tailored to the severity of the MAC and may include mitral valve leaflets, a felt strip, or a pericardial patch (3).  

This video presents a case of severe MAC in which a pericardial patch was used to support the annulus posteriorly after MAC debridement. A trans-septal approach was utilized to expose the mitral valve. The procedure began with separation of the posterior leaflet, followed by debridement of the posterior MAC. The ascending aorta was opened to debride the anterior MAC and the fibrous trigones. The anterior leaflet was separated from the annulus and divided in the middle, then used to support the lateral sides of the annulus toward the fibrous trigones. A bovine pericardial patch was used to support the posterior annulus after MAC debridement. A running suture anchored the pericardial patch to the lower edge of the debrided annulus. The valve noneverting sutures were then passed through the patch and into the posterior capsule of the MAC. The valve was tied down, and the patient was separated from cardiopulmonary bypass. A postoperative echocardiogram showed a well-seated mitral valve prosthesis with a low gradient across the valve.  

This case highlights the high-risk features that can be associated with MAC, including long-standing mitral stenosis, a small left ventricular cavity with hypertrophied walls, and calcium extension into the left ventricular wall. These features increase the risk for postoperative pulmonary complications and atrioventricular groove laceration and should be carefully assessed before surgery. 

References

1. Bo Xu, Duygu Kocyigit , Tom Kai Ming Wang , Carmela D Tan , E Rene Rodriguez , Gösta B Pettersson , Shinya Unai , Brian P Griffin. Mitral annular calcification and valvular dysfunction: multimodality imaging evaluation, grading, and management. European Heart Journal - Cardiovascular Imaging, Volume 23, Issue 3, March 2022, Pages e111–e122, https://doi.org/10.1093/ehjci/jeab185
2. Gabriele M Iacona, Syed O Ali, Shinya Unai, Serge C Harb, Gosta B Pettersson. Mitral valve replacement in patients with severe mitral calcification. JTCVS Tech. 2021 Nov 9;11:7–9. doi: 10.1016/j.xjtc.2021.11.001.
3. Nicholas G. Smedira, MD. Mitral valve replacement with a calcified annulus. Operative Techniques in Thoracic and Cardiovascular Surgery, Vol 8, No 1 (February), 2003: pp 2-13

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