LAUSR

SEE PAGE 1437 S urgeons and cardiologists have long recognized the technical challenges posed by mitral valve dysfunction in the setting of mitral annular calcification (MAC). More than 2 decades ago, Prof. Alain Carpentier, the father of mitral valve repair, characterized patterns of MAC in patients with mitral regurgitation and described a complex operation to remove the calcium and achieve valve repair (1). Although his results were outstanding, other surgical teams found the operation daunting and sought simpler techniques to repair and replace mitral valves affected by severe MAC (2,3). In general, limited MAC—localized to the posterior annulus and involving no more than one-third of the mitral annular circumference—presents a manageable surgical challenge. In patients with mitral valve dysfunction and this pattern of calcium, a variety of well-described surgical techniques facilitate valve repair and valve replacement. More extensive calcification, particularly in the elderly patient with comorbidities, dramatically increases surgical morbidity and mortality, and often precludes surgery. This is the group of patients most in need of innovative therapies to enhance procedural safety and effectiveness (4). The development of transcatheter valves has spurred renewed interest in the development of innovative techniques for valve replacement in such patients. In this issue of the Journal, Russell et al. (5) provide a detailed, step-by-step guide to surgical mitral valve