a 79-year - old woman with a history of hypertension was transferred in a near - shock state from a regional hospital where she had presented 10 days previously , complaining of one week of nausea , diarrhea , and nocturnal fever . despite various conservative treatments including antibiotics , dyspnea with palpitations she denied any history of trauma , recent invasive procedures such as dental care , infections , or tuberculosis . one year previously , she refused to undergo recommended surgical treatment for symptomatic severe aortic stenosis at st . her vital signs at arrival were a blood pressure of 70/30 mmhg , an irregular heart rate of 127 beats / min , a respiratory rate of 26 cycles / min , and a body temperature of 36.9c . laboratory testing revealed a white blood cell count of 3,730/mm , a hemoglobin level of 9.0 g / dl , an aspartate transaminase / alanine transaminase ratio of 168/89 iu / l , and a c - reactive protein level of 23.7 mg / dl , while other parameters were within their normal limits . severe cardiomegaly and bilateral pulmonary edema were apparent in chest radiography , and electrocardiography showed atrial fibrillation with rapid ventricular response . portable transthoracic echocardiography ( tte ) revealed a massive pericardial effusion , which prompted emergency pericardiocentesis with the drainage of large amounts of serous pericardial fluid . the findings of tte and trans - esophageal echocardiography ( tee ) after pericardiocentesis were suspicious for a 1.2-cm hypermobile vegetation on the anterior mitral valve leaflet with calcification through the posterior mitral annulus and severe aortic valve stenosis . brain magnetic resonance imaging revealed focal acute embolic infarction of the left basal ganglia , without focal neurological signs . chest computed tomography showed extensive mitral valve calcification ( mac ) through the posterior mitral annulus , pulmonary edema , and pleural effusion around both lungs ( fig . emergency surgery was performed with a diagnosis of mitral infective endocarditis with extensive posterior mac and aortic valve stenosis . after aortic cross - clamping , exposure of the mitral valve was achieved through a longitudinal left atriotomy via the interatrial groove , revealing multiple friable vegetations attached to the anterolateral commissure and leaflets , as well as extensive mac through the posterior annulus . the anterior mitral valve leaflet was nearly completely necrotized with inflammation , but the annulus and subvalvular apparatus were preserved with only degenerative changes . an abscess pocket containing dirty yellowish pus was found on the posterior annulus between p2 and p3 , extending into the endocardium of the left ventricular posterior wall , without an intracavitary connection to the left ventricle ( fig . after complete debridement and resection of the infected tissue leaving the mac intact , multiple 2 - 0 polyester pledgeted mattress sutures were placed on the left atrial wall and the remaining posterior leaflet for plication . we passed the valve sutures from the atrial wall to the posterior leaflets , while avoiding passing through the mac and obliterating the abscess pocket site . the sutures were sequentially passed through bovine pericardium , and then through the sewing ring of a prosthetic valve ( 27-mm carpentier - edwards perimount magna valve ; edwards lifesciences inc . , irvine , ca , usa ) ( fig . the bovine pericardium was sutured to the left atrial wall with 4 - 0 polypropylene running stitches to cover the abscess pocket site and mac . after repairing the left atriotomy , the aortic valve was also replaced with a prosthetic valve ( 21-mm carpentier - edwards perimount magna valve ; edwards lifesciences inc . ) . preoperative blood culture and tissue culture were negative due to the use of preoperative antibiotics , and the patient was treated with broad - spectrum antibiotics ( ampicillin - sulbactam , 8 g / day ; gentamicin , 3 mg / kg / day ) for six weeks . follow - up tte on postoperative day 19 showed well positioned and functioning prosthetic valves without paravalvular leakage or dehiscence ( fig . although mitral valve repair is the preferred surgical approach if circumstances allow , the complete debridement of infectious necrotic lesions on the mitral valve may often hinder valve repair , inevitably requiring replacement . in particular , the existence of extensive mac renders mitral valve replacement a risky procedure because aggressive annular de - calcification is associated with an increased risk of fatal complications , including intractable hemorrhage from atrioventricular disruption or ventricular rupture , as well as acute myocardial infarction secondary to circumflex artery injury . partial annular decalcification can lead to a postoperative paravalvular leak and/or dehiscence and fracture of the remaining calcified annulus . several surgical techniques have been reported for addressing the presence of an unsuitable mitral annulus during mitral valve replacement , and can be divided into two categories : those for mac and those for the management of conditions involving destruction of the annulus , such as infective endocarditis or redo valve replacement . one approach involves leaving the mac intact and building a new annulus , securing the prosthesis to the leaflet tissue   with intra - atrial implantation of a mitral prosthesis . some surgeons have also used the cavitron ultrasonic surgical aspirator ( cavitron surgical systems inc . , stanford , ct , usa ) to decalcify mac . despite their variety , the proposed surgical techniques must be modified in practice for cases combining an extensive endocarditis lesion and mac , as in the case presented here . in this case , we planned to avoid decalcification of the mac and to reconstruct a stronger annulus with the hope of minimizing the risk of grave postoperative complications . we used bovine pericardium to reinforce the new anchoring site after plicating both the mitral posterior leaflet and the left atrial wall to secure the mitral prosthesis without decalcifying the mac . the bovine pericardium not only reinforced the suture on the new annulus , but also acted as a barrier to prevent perivalvular leakage , and may have strengthened the vulnerable left atrial wall by covering the fragile site after debridement of the abscess pocket . in conclusion , the presence of an unsuitable mitral annulus remains a challenge for current surgical techniques . we report a surgical modification used to successfully treat a patient with extensive endocarditis complicated by subendocardial abscess and posterior mac by reconstructing the new annulus with plication between the left atrial wall and posterior mitral leaflet , reinforcing the bovine pericardium without decalcifying the mac . further evaluation and extended follow - up are warranted to assess the effectiveness of this surgical technique .