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BACKGROUND Mitral annular calcification (MAC) occurs represents a challenge to surgeons during mitral valve (MV) surgery with increased perioperative risk. CASE PRESENTATION We describe a challenging case of an elderly female patient with multiple comorbidities who presented with symptoms and signs of heart failure with a previous history of mechanical aortic valve replacement 15 years prior to presentation. Echocardiogram showed severe mitral stenosis and regurgitation with severe calcification of the mitral annulus. Given her high-ri