What is the Mitral Annulus?
The mitral annulus is a ring like structure that separates the top and bottom chambers of the left side of the heart. The left side of the heart is the main pumping side. The upper chamber is the left atrium that collects blood returning from the lungs. The lower chamber of the left side of the heart is called the left ventricle, and is the main pumping chamber that pumps blood to the body. The mitral annulus sits in between the top and bottom chamber and houses the mitral valve. It can be thought of as a support ring for the mitral valve. The mitral valve is the valve that stops blood flowing backward from the left ventricle to the left atrium, and therefore allows blood to go forward in to the body where it is needed.
What is Mitral Annular Calcification?
Mitral annular calcification is a chronic process in which there is deposition of calcium in the mitral valve annulus. The mitral annulus is typically flexible. In mitral annular calcification it becomes less flexible and thicker. The posterior annulus is most commonly affected. In the majority of people the amount of calcification is mild and therefore usually of no significance. Calcification of the mitral annulus is increased in situations where there is increased stress on the annulus and valve.
Diagnosis
Mitral Annular Calcification may be associated with a murmur that is picked up on physical examination although often there will be no murmur. The diagnosis of mitral annular calcification is most commonly by echocardiography. As in the pictures above, there is increased calcium deposition seen in the mitral annulus. Mitral annular calcification when severe can be seen on chest x-ray. It can also be picked up on CT scan and MRI scan.
Commonality
Mitral annular calcification is more common in women. 9% of woman and 3% of men over the age of 60 are found to have it on echocardiography. It is also more common in those with mitral valve prolapse. Mitral annular calcification is very common in those with chronic kidney disease, and is found in 40% of those undergoing echocardiography.
Risk Factors
Factors that increase stress on the mitral valve and its surrounding structures increase the chance of mitral valve calcification. The following conditions are associated with development of mitral annular calcification.
- Female sex
- Older Age
- Hypertension
- Mitral Valve Prolapse
- Aortic Stenosis
- Hypertrophic Cardiomyopathy
- Chronic Kidney Disease
- Atherosclerosis
Complications
Several studies have looked at the association of mitral annular calcification and the development of cardiac and other events. There is increased risk of heart attacks, stroke and death from cardiovascular causes. There is also an increased risk of development of atrial fibrillation with RVR, an irregular heart rhythm. The risk is probably explained by the fact that patients with mitral annular calcification have risk factors for cardiovascular disease. The presence of the calcium itself is unlikely dangerous.
The presence of mitral annular calcium makes it harder for surgeons to repair the mitral valve, as surgery is technically more challenging. The calcium in the annulus can make the flexible valve more rigid and predispose to a leaky valve, however that is usually not significant. Mitral annular calcification is rarely associated with obstruction to blood flow and therefore typically will not have symptoms.
Caseous Calcification of the Mitral Annulus
Caseous calcification of the mitral annulus is a rare type of mitral annular calcification where there is extensive calcification and infiltration of the annulus accompanied by a liquid center, a process known as liquefactive necrosis. As can be seen in the picture, this has a remarkable appearance. It is usually benign, however it is important it is recognized, as it can be mistaken for tumor or other more dangerous complications that can lead to unnecessary interventions such as operations. Sometimes it resolves spontaneously.
Treatment of Mitral Annular Calcification
Mitral annular calcification is usually of no clinical significance and no specific treatment such as MitraClip is required. Those with mitral annular calcification are at increased risk of cardiac events, although this is still relatively small, likely due to the presence of traditional cardiac risk factors. Therefore it is reasonable to advise those with mitral annular calcification to pay attention to blood pressure, cholesterol, lifestyle, smoking, diabetes and other common risk factors. This will serve to reduce overall cardiac risk.
Very helpful.
Thank You
I read the report of a cat scan and mentioned I had this. I am Diabetic under control. my last A1C was 6. I guess my one concern is As I sit quietly I can feel a click. It is not constant only as I am still and not really often. Have been on warfarin for several years due to a pulmonary embolus no reason found. I see my PCP every 4-6 mths. I know I will be discussing this with him son. For now I am waiting to see if there is Ca in my lungs. Recently diagnosed nodules found.
for now any noncommittal advice would be appreciated.
I wouldn’t worry about the mitral annular calcification for now. At some point an echocardiogram would be advised.
Thank you for responding. The cancer was ruled out. Thank God! Do you recommend anything further for now?
My brother in law passed away 5 months ago at the age of 31 from mitral valve prolapse with severe calcification of the annular ring. It was a shock to everyone because he always had a good BP and HR and never have chest pains. The only medical problem he had was severe stomach pains on and off for the past few years. The doctors could never figure it out and passed it off as pancreatitis. The last time he went to the ED, 2 years ago, a doctor said he had dangerously low vitamin D (although the drank milk all the time and was outside most of the day), but everything else seemed to be within normal limits. He did smoke cigarettes for about 12 years but had recently stopped. I was wondering if you had any insight on this? We were told his condition was hereditary and that’s why it was so advanced at such a young age.
I forgot to mention it was sudden cardiac death.
What was the stated cause of death, the valve disease in this setting is very unlikely to have contributed.
The stated cause of death said “mitral valve prolapse with severe calcification of the annular ring”, which caused him to go into sudden cardiac arrest. All of his other organs looked good according to the doctor who did his autopsy and she said she couldn’t even tell he was a smoker because his lungs looked good.
Hello sir I have rheumatic heart decease from last 20 yes I am 37 year old right now without operation I have AR grade II MR grade I & This week when I did 2D echo first time for tricuspid valve showing trivial TR . I have concered about it. Pulmonary valve is normal For last 20 years I have done 16 2D echoes but except this for every checking there was nil regurgitation for tricuspid. Positive thing is the all dimensions are same as before LVEF is 62% I don’t have any problems for doing daily activities. Dr only concerned about my heart beat & found sound .very high gradients due to tachycardia. No pulmonary hypertension. He prescribed me 1 tablet Ivabrid 5 half half daily. I am fine but I am concerned. I took nuril 2.5 2 tab daily & penicillin 12 lakhs monthly for last 20 years please give me suggestion
The valvular heart disease appears to be relatively mild in this case and if you have no symptoms then no specific therapy would be advised.
I missed one thing that mitral valve is thincked & heavily calcific & difficult to doctor to assess the severity of the stenosis due to merging of theAR & MS jets & due heavy calcification. Please reply sir. Is it time of surgery
I’ve had 2 stents, D.C.’s with A-fib, and now a CT this week shows calcification of the mitral annulus. I’m diabetic also with many health issues. My PCP has increased my beta blocker to help with the afib. How concerned should I be?
With regard to the mitral annular calcification i would suggest obtaining an echocardiogram to evaluate the structure and function of the mitral valve. If it is an isolated finding that does not affect the function of the valve you don’t have much cause for concern.
Hi. Is dense MAC with mild to moderate mitral regurgitation something to be worried about?
The valve is of course not normal but the MAC and moderate MR in isolation can often be well tolerated and not a large cause for concern. Surveillance would typically be recommended. If symptoms were to develop then further testing may be required. I would have to see the images to comment accurately.
I missed one thing that mitral valve is thincked & heavily calcific & difficult to doctor to assess the severity of the stenosis due to merging of theAR & MS jets & due heavy calcification. Please reply sir. Is it time of surgery
If i were seeing a similar case, i would do a TEE as the next step with 3D to characterize the valve more accurately.
I appreciate this article very much. I had a mitral valve repair (open heart) that couldn’t be completely done in August 2015 due to “giant bar of calcium posteriorly that precluded placing the valve sutures including the ring sutures.” I had MVP for decades, and severe regurgitation caused me to see the surgeon. After doing the partial repair, the post-op echo showed minor regurgitation. I had none of the palpitations that had plagued me for years for 14 glorious months but they started again. Heart rate goes to 160-170 for 90 minutes and finally settles down to 85 or so. Echo 17 months post-op shows SEVERE REGURGITATION again. Back to square one. Pre- and post-op diagnoses from operative report: “Mitral Annular Calcification, Severe Mitral Annular Calcification, Posterior Leaflet Prolapse; Paroxysmal Atrial Fibrillation.” Seeing surgeon in May for stress echo and consultation. He said maybe not surgery. I’m thin, eat super healthy, good BP, never smoked, no diabetes, 1 drink a month, a few cups of coffee a month. Why do I have these calcifications? Anything I should do? Are the palpitations related to the regurgitation? I get an “attack” about once a month.
Given the severe calcification it is likely that the next operation you have would be a mitral valve replacement and not a repair, particularly if a repair fails. Mitral valve repair is an art form and a lot depends on the ability of the surgeon. If you have truly severe regurgitation and are symptomatic or show other signs of strain, surgery may be advised. The palpitations are likely related to the leaky valve. https://myheart.net/articles/mitral-valve-repair-surgery-what-you-need-to-know/ https://myheart.net/articles/mitral-valve-replacement-surgery/ https://myheart.net/articles/mitral-regurgitation/
respected doctor, my 47 years old mother’s echocardiography result came and it said mitral valve is calcified, but other three valves are normal. she is obese too. should i consider valve replacement surgery? a suggestion will be appreciated.
Respected doctor, my 47 years old mother is diagnosed with rheumatic heart disease with severe mitral stenosis and mild mitral recurgitation. The mitral valve is calcified. Also there is mild recurgitation in tricuspid valve. What would be the advised steps to treat this? She is obese and does have hyperthyroid. Also she has been asthamatic for about 16 years. A suggestion would be appreciated. Thank you.
She has severe mitral stenosis and will likely require treatment. If the disease is symptomatic the question is, whether she is a candidate for balloon mitral valvuloplasty, or if the calcification means that she will require surgery instead.
Respected doctor, How will i know if she needs valvuloplasty or valve replacement surgery? thanks for replying.