Mitral annular calcification (MAC) is a fibrous, degenerative calcification of the mitral valve supporting ring and is common in elderly patients. Patients with MAC are older, more likely to be female, and more likely to have higher systolic blood pressure and clinical heart valve disease. MAC is also common among dialysis patients. The calcified annular bar poses demanding technical problems for the surgeon attempting mitral valve surgery in these high risk patients. In operation, MAC is a contributing factor in cardiac rupture at the atrial ventricular junction and rupture of the left ventricular free wall. Since we do not have simple and reproducible technical resolutions of mitral valve surgery in patients with MAC, mitral valve surgery in this condition is always challenging to prevent left ventricular rupture and periprosthetic leakage. This article reviews the history, details of relevant surgical techniques, and results of mitral valve surgery associated with MAC.