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Transcatheter mitral valve replacement (TMVR) is an emerging treatment for mitral valve (MV) disease, avoiding the need for open cardiac surgery. TMVR can be performed in a native annulus, although the anatomy can be markedly altered with dystrophic calcification (mitral annular calcification or MAC). Additionally, TMVR can be performed in an existing prosthetic valve (valve-in-valve) or within an annuloplasty ring (valve-in-ring). Several ongoing trials are studying native valves, valve-in-valve and valve-in-MAC [1, 2].

MAC is an increasingly common cause of MV disease [3]. It is a silent degenerative process of the MV fibrous annulus with pathophysiology resembling that of atherosclerosis [4]. Microtears from MV annular stress (as in hypertension) result in calcium deposition and disrupted endothelium, both leading to structural remodeling, a process that becomes more prominent with increasing age [5]. Due to …