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Mitral annular calcification

Rosario V Freeman, MD, MS
Section Editor
Catherine M Otto, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC


Mitral annular calcification (MAC) is a common degenerative process involving the fibrous annulus of the mitral valve. It is generally an incidental finding associated with aging, although it occasionally is prominent enough to cause significant left ventricular inflow obstruction and symptomatic mitral stenosis. In addition, MAC is associated with atrial fibrillation, conduction system disease, atherosclerotic disease and adverse cardiovascular events, including stroke and increased mortality.

The diagnosis, clinical significance, and associated cardiovascular risk of MAC and management of MAC-related disorders are discussed here.

Echocardiography of the mitral valve, mitral valve disease, and conduction system disease are discussed separately. (See "Echocardiographic evaluation of the mitral valve" and "Clinical manifestations and diagnosis of chronic mitral regurgitation" and "Medical management and indications for intervention for mitral stenosis" and "Etiology of atrioventricular block".)


Normal anatomy — The mitral valve annulus is the C-shaped segment of the fibrous skeleton at the base of the left ventricle at its junction with the left atrium. The leaflets of the mitral valve are attached to and are suspended from the mitral annulus, which provides structural support to the valve apparatus along the medial, posterior, and lateral aspects of the valve. Anteriorly, the mid-section of the anterior mitral leaflet is in fibrous continuity (via the intervalvular fibrosa) with the posterior aortic root without intervening annular tissue.

Mitral annular calcification — Mitral annular calcification (MAC) is caused by progressive calcium deposition along and beneath the mitral valve annulus [1]. MAC generally follows the C-shape of the mitral annulus, so the base of the anterior mitral leaflet is generally (but not always [2]) spared. MAC is most commonly visualized by echocardiography as an echodense, irregular shelf-like structure involving the mitral valve annulus with associated acoustic shadowing (image 1A-B). Although mitral valve leaflets and chordae tendineae are generally not involved, calcification may progressively accumulate in the subvalvular region beneath the posterior leaflet with encroachment on the leaflet. Relative sparing of the leaflet commissures and anterior leaflet distinguishes MAC from rheumatic mitral disease.

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Literature review current through: Nov 2017. | This topic last updated: Mar 01, 2017.
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