Posterior neo-annular reconstruction: An alternative approach to mitral valve replacement for caseous mitral annular calcification

Video clip is available online.Caseous mitral annular calcification (CMAC) is rare, accounting for 0.5 to 1% patients with mitral annular calcification. 1 Although the mechanism remains unknown, CMAC results from liquefaction and caseation within the calcified annulus, characterized by an annular mass filled with amorphous toothpaste-like material (Figure 1).1,2 Although often clinically indolent, surgical intervention is required in cases of severe mitral valve dysfunction, embolic phenomena, or progressive mass enlargement.Current literature offers limited guidance regarding optimal surgical management, particularly when evacuation of the caseous mass results in a large cavity with thin walls.We present our approach to mitral valve replacement in a 72-year-old woman presenting with progressive heart failure due to mitral regurgitation and CMAC measuring 3.5 3 2.2 cm (Figure 1, Video 1).Caseous material was completely evacuated, some denser mitral annular calcification was debrided, and the resulting cavity was obliterated with autologous pericardium.Valve sutures were placed through the robust reconstructed annulus, maximizing the use of residual leaflet tissue to buttress the posterior annulus and the thinned ventricular wall.Institutional Review Board or equivalent ethics committee of Cleveland Clinic did not approve this study, and the need for patient written consent was waived for this FIGURE 1. Incision of the mass along the posterior annulus revealed a large amount of caseous material.