The mitral annulus can be rendered hostile by several uncommon clinical situations such as infective endocarditis, calcification, or previous valve surgery. These can all lead to difficulties seating a prosthesis or annuloplasty ring. The posterior mitral annulus or anteriorly the intervalvar fibrous body can be affected. These situations continue to pose a formidable technical challenge to the cardiac surgeon in the operating room. We review the evidence around solutions for these problems with the intent of giving surgeons an overview of techniques to address these issues.
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