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Practice Guideline
. 2025 Aug;170(2):502-522.
doi: 10.1016/j.jtcvs.2025.04.003. Epub 2025 May 3.

The American Association for Thoracic Surgery (AATS) 2025 Expert Consensus Document: Surgical management of mitral annular calcification

Ahmed El-Eshmawi  1 , Monika Halas  2 , Brian T Bethea  3 , Tirone E David  4 , Eugene A Grossi  5 , Mayra Guerrero  6 , Samir R Kapadia  7 , Serguei Melnitchouk  8 , Stephanie L Mick  9 , Eduard Quintana  10 , Matthew A Romano  11 , Gilbert H L Tang  12 , Shinya Unai  13 , Ravi K Ghanta  14 ; AATS Volunteer Leadership
Collaborators, Affiliations
Practice Guideline

The American Association for Thoracic Surgery (AATS) 2025 Expert Consensus Document: Surgical management of mitral annular calcification

Ahmed El-Eshmawi et al. J Thorac Cardiovasc Surg. 2025 Aug.

Abstract

Objective: Surgery for mitral valve disease in patients with mitral annular calcification (MAC) remains challenging. There is no consensus on the ideal management strategy or patient selection, and perioperative and periprocedural morbidity and mortality rates remain high. The recent surge of patients presenting with MAC has been accompanied by increased interest in MAC surgery and interventions. This expert consensus document is meant to provide a simplified outline for managing MAC, including patient selection, imaging, and surgical and transcatheter therapeutic options, with a particular focus on conventional surgical techniques and hybrid approaches.

Methods: The American Association for Thoracic Surgery Clinical Practice Standards Committee assembled an international panel of cardiac surgeons and structural heart interventionalists with established expertise in the field of MAC. A comprehensive literature review was performed by the panel and a medical librarian. Clinical recommendations were developed utilizing a modified Delphi method.

Results: Expert consensus was reached on 33 recommendations, with class of recommendation and level of evidence, for each of 5 main topics: (1) preoperative evaluation for patients with MAC, patient selection, and indications for intervention; (2) standard surgical techniques in MAC; (3) hybrid procedures in MAC; (4) transcatheter MAC interventions; and (5) complications and bailout of MAC surgery and interventions.

Conclusions: Despite the complexity and heterogenicity of patients presenting with MAC, consensus on several key recommendations was reached by this American Association for Thoracic Surgery expert panel. These recommendations provide guidance for cardiac surgeons and structural heart interventionists in treating most patients who present with MAC.

Keywords: mitral annular calcification; mitral valve repair; mitral valve replacement.

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Conflict of interest statement

Conflict of Interest Statement Dr Bethea reported consulting fees from Abbott and Edwards Lifesciences. Dr Ghanta reported grants from the National Institutes of Health and American Heart Association (to institution); consulting fees: RBL, LLC (to self); stock options: Sentinel Bio (to self); and expert testimony for various attorneys (payment to institution) unrelated to current work. Dr Grossi reported royalties or licenses, consulting fees, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events, payment for expert testimony, and participation on a Data Safety Monitoring Board or Advisory Board: Medtronic, Edwards, and Baim. Dr Guerrero reported institutional research grant support from Edwards Lifesciences. Dr Kapadia reported Transcatheter Tricuspid Valve Replacement NDA writing committee. Dr Mick reported consulting fees from Johnson & Johnson, Artivion, AtriCure, and Medtronic. Dr Quintana reported speakers fees (<5K) from Medtronic and Edwards; support for attending and presenting in 1 conference from Cardiva SL; and European Association for Cardio-Thoracic Surgery (EACTS) Vascular Task Forces, EACTS Clinical Guidelines Committee, European Board of Cardiothoracic Surgery (EBCTS) board member, and EACTS Francis Fontan Board Member. Dr Romano reported consulting fees from Edwards Lifesciences. Dr Tang reported consulting fees and payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Medtronic, Abbott Structural Heart, Boston Scientific, Siemens Healthineers, Shockwave Medical, Peija Medical, Shenqi Medical Technologies, NeoChord, and JenaValve. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

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