Mitral Annular Calcification and Calcific Mitral Stenosis: Therapeutic Challenges and Considerations

Recommended Standards for the Performance of Transesophageal Echocardiographic Screening for Structural Heart Intervention: From the American Society of Echocardiography

“…47 Calcification can variably extend onto the leaflets, resulting in both MS and/or MR (Figures 18A-18D). 48 Because of the intrinsic limitations of echocardiography in the setting of calcified tissue (acoustic shadowing, blooming artifacts, and limited tissue characterization), preprocedural planning requires CT performed at experienced sites that are able to determine the extent and location of calcification, size the annulus 49 (Figure 18E), and predict the area of the neo-LVOT using ''virtual valve'' imaging algorithms. 50 A central coaptation gap can also be appreciated (yellow dot).…”

Mitral valve stenosis in the current era: a changing landscape

“…The mechanism of MAC-related mitral stenosis is likely because of calcification protruding from the mitral annulus into the base of the valve leaflets, leading to impairment of physiological diastolic annular dilatation during the cardiac cycle and reduction of leaflet motion. 27 MAC producing a potentially important mitral valve gradient is not rare in the general population. Indeed, this mechanism has been demonstrated in approximately 0.5% of unselected outpatient echocardiograms and seemed to be linked to restriction of anterior mitral leaflet motion, such that the leaflet's hinge becomes displaced toward its free margin.…”

“…Although MAC is most commonly an asymptomatic and incidental finding, it may also be associated with mitral valve stenosis. The mechanism of MAC-related mitral stenosis is likely because of calcification protruding from the mitral annulus into the base of the valve leaflets, leading to impairment of physiological diastolic annular dilatation during the cardiac cycle and reduction of leaflet motion 27 . MAC producing a potentially important mitral valve gradient is not rare in the general population.…”

Caseous calcification of the mitral annulus presenting with symptomatic complete heart block

“…Since calcification within the mitral anulus frequently progresses to massive proportions, it seems unlikely that image intensification fluoroscopy wouldn't detect patients with this condition. The likelihood that occult "precalcific" mitral annular calcium accounts for the fluoroscopically negative cases remains unexplored [18,19].…”