Morphological analysis of systolic anterior motion after mitral valve repair.
ABSTRACT The systolic anterior motion (SAM) of mitral valves occurs at a certain rate despite the introduction of several preventive procedures. The purpose of this study was to investigate its mechanism by analysing the change in mitral valve morphology associated with operative procedures.
Components of mitral valves were measured before and after operative procedures by transoesophageal echocardiography in 179 patients who underwent mitral valve repair. Comparisons were made between 15 patients with SAM (SAM group) and 164 patients without SAM (non-SAM group).
Morphological analysis in all the studied patients revealed that operative procedures shifted the coaptation point towards the left ventricular outflow tract by 6.9 mm and increased the extra portion of anterior leaflet that extended beyond the coaptation point by 5.4 mm. These changes were enhanced in the SAM group. Intergroup comparison revealed that there were no differences in the preoperative mitral valve morphologies between the two groups. After operative procedures, however, the SAM group showed smaller annular diameter and smaller coapted anterior/posterior length ratio compared with the non-SAM group.
The results of this study show that operative procedures might modify the morphology of mitral valves susceptible to developing SAM. Postoperative smaller annular diameter and anterior shift of coaptation point were considered to contribute to the development of SAM.
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ABSTRACT: The natural history and management of patients with systolic anterior motion after mitral valve repair are uncertain. We performed a retrospective chart review and survey follow-up of all patients in whom systolic anterior motion developed intraoperatively after mitral valve repair. From January 1993 to December 2002, mitral valve repair was performed in 2076 patients, and in 174 cases (8.4%) systolic anterior motion was identified on intraoperative echocardiography. These patients form the study group. Initially, patients were managed with a combination of beta-blockade, vasoconstriction with phenylephrine, and/or intravascular volume expansion. Four patients had revision of repair because of persistent systolic anterior motion, and 3 additional patients had revision of repair because of mitral regurgitation from other causes. The median follow-up of the remaining 167 patients was 5.4 years (range 0-13.2 years). There were 2 late reoperations, but none were caused by systolic anterior motion or left ventricular outflow tract obstruction. Ninety percent of patients were in New York Heart Association class I, 7% were in class II, and 3% were in class III or IV. Echocardiograms were available for review in 93 patients at a median interval of 5.4 years (range 0.2-12.2 years); 13 patients had systolic anterior motion, and 4 patients had systolic anterior motion with left ventricular outflow tract obstruction. In this experience, most cases of systolic anterior motion resolved with conservative measures including beta-blockade, vasoconstriction, and fluid administration. Persistent systolic anterior motion with left ventricular outflow tract obstruction was documented in 2.3% of patients who had early systolic anterior motion, but late reoperation was not required. Furthermore, the clinical outcomes of patients with systolic anterior motion are comparable to the current norms for mitral valve repair. Ninety percent of patients were in New York Heart Association class I, 7% were in class II, and 3% were in class III or IV.The Journal of thoracic and cardiovascular surgery 02/2007; 133(1):136-43. · 3.41 Impact Factor
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ABSTRACT: The Carpentier-Edwards (CE) ring was developed to restore the normal 3:4 ratio between the anteroposterior and transverse diameters of the mitral valve orifice during systole. It is difficult to use in patients in whom the ratio is more than 3:4. To overcome this problem, we developed an adjustable obturator, the ratio of which may be changed by sliding apart its two components. Remodeling annuloplasty was performed using part of a flexible Duran ring or autologous pericardium and the adjustable obturator in 17 patients with severe MR, including two with high anterior leaflet. Physiologic remodeling annuloplasty was easily accomplished in all cases. Intraoperative echocardiography was performed in 14 patients, and it showed no regurgitant jet in 11 cases and only trivial jet in three. Physiologic remodeling annuloplasty to retain the natural shape of the anterior leaflet by using an adjustable obturator is a very useful technique that enables annuloplasty to be performed in all cases, irrespective of the shape of the anterior leaflet.The Journal of heart valve disease 12/1997; 6(6):604-7. · 1.07 Impact Factor
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ABSTRACT: To determine predictors of systolic anterior motion and left ventricular outflow tract obstruction (SAM/LVOTO) after mitral valve repair (MVRep) in patients with myxomatous mitral valve disease. Mechanisms for the development of SAM/LVOTO after MVRep have been described; however, predictors of this complication have not been explored. We hypothesize that pre-MVRep transesophageal echocardiography (TEE) can predict postrepair SAM/ LVOTO. Using TEE, the lengths of the coapted anterior (AL) and posterior (PL) leaflets and the distance from the coaptation point to the septum (C-Sept) were measured before and after MVRep in 33 patients, including 11 who developed SAM/LVOTO (Group 1) and 22 who did not (Group 2). Group 1 patients had smaller AL/PL ratios (0.99 vs. 1.95, p < 0.0001) and C-Sept distances (2.53 vs. 3.01 cm, p = 0.012) prior to MVRep than those in Group 2. Resolution of SAM/LVOTO was associated with increases in AL/PL ratio and C-Sept distance. This reflects a more anterior position of the coaptation point in those who developed SAM/ LVOTO. These data suggest that TEE analysis of the mitral apparatus can identify patients likely to develop SAM/LVOTO after MVRep for myxomatous valve disease. The findings are consistent with the concept that SAM of mitral leaflets is due to anterior malposition of slack mitral leaflet portions into the LVOT. The position of the coaptation point of the mitral leaflets is dynamic and a potential target and end point for surgical designs to prevent SAM/LVOTO post MVRep.Journal of the American College of Cardiology 01/2000; 34(7):2096-104. · 14.09 Impact Factor