Mitral valve replacement in patients with moderate-severe MAC: a 20-year single-center experience

Objectives: Severe mitral annular calcification (MAC) creates substantial challenges and can increase the risk of complications during mitral valve replacement (MVR). This retrospective study aims to summarize our 20-year experience with MVR in patients who present with moderate-severe MAC, focusing on perioperative mortality, early complications, and long-term outcomes.

Methods: Between March 2004 and July 2024, 1,907 MVR procedures were conducted at our center, of which 101 involved moderate-severe MAC. Patients were separated into three groups based on the surgical approach: 57 received a conservative method with no direct annular intervention, 12 underwent complete annular decalcification, and 32 underwent partial decalcification or no decalcification accompanied by a pericardial patch. Data were gathered on in-hospital mortality, complications such as reoperation for bleeding and stroke, incidence of acute kidney failure, and postoperative echocardiographic findings.

Results: The mean patient ages in the three groups were 72.1±11.9, 66.6±11.5, and 71.2±9.2 years, respectively, with corresponding logistic EuroSCOREs of 12.6±14.8, 10.8±8.2, and 16.4±14.1. In-hospital mortality was 7.1%, 25%, and 9.7%, respectively, while one-year survival reached 89.5%, 66.7%, and 90.3%. Five-year survival rates were 86.0%, 58.3%, and 67.7%. Two patients in the partial decalcification/pericardial patch group developed severe paravalvular leaks.

Conclusions: MVR in patients with moderate-severe MAC can be safely performed using conservative or partial decalcification strategies, which yielded better five-year survival compared to complete decalcification. However, the pericardial patch approach was linked to an increased risk of paravalvular leak. Further investigation is needed to confirm whether such leaks differ significantly across various surgical strategies.