Original article
Cardiovascular
Edge-to-Edge Technique to Treat Post-Mitral Valve Repair Systolic Anterior Motion and Left Ventricular Outflow Tract Obstruction

https://doi.org/10.1016/j.athoracsur.2004.08.008Get rights and content

Background

Systolic anterior motion of the mitral valve causing left ventricular outflow tract obstruction is an uncommon complication of mitral valve repair that may necessitate immediate additional surgical action. We prospectively evaluated the technique of the edge-to-edge suture on post-mitral repair systolic anterior motion, which persisted despite conservative treatment.

Methods

From March 2002 to March 2004, 4 of 112 patients requiring mitral valve repair surgery for chronic degenerative mitral regurgitation had systolic anterior motion with severe left ventricular outflow tract obstruction and mitral regurgitation. All 4 patients (mean age, 50 years) had posterior leaflet prolapse with chordal rupture with a billowing anterior leaflet, but without chordal rupture. Repair was achieved through a quadrangular resection of the posterior leaflet, completed by plication of the annulus in 2 patients and leaflet sliding in the other 2. All patients had mitral annuloplasty; two patients had a complete CE Physio ring (Edwards Lifesciences, Irvine, CA) inserted, whereas the other 2 patients had an open CG Future band (Medtronic, Minneapolis, MN). Routine perioperative transesophageal echocardiography showed systolic anterior motion, severe left ventricular outflow tract obstruction (> 50 mm Hg), and mitral regurgitation. After resuming cardiopulmonary bypass, all patients had an edge-to-edge suture at the middle part of the free edge of the anterior and posterior leaflets.

Results

The control transesophageal echocardiography showed in all cases disappearance of the systolic anterior motion, of the left ventricular outflow tract obstruction and of mitral regurgitation. Mean follow-up was 14 months (range, 6 to 28 months). All patients were in New York Heart Association's functional class I.

Conclusions

With the edge-to-edge repair, the early and 2-year results were satisfactory with total disappearance of the systolic anterior motion, of the left ventricular outflow tract obstruction and of the recurrent mitral regurgitation.

Section snippets

Patients and Methods

Between March 2002 and March 2004, a series of 112 patients had mitral valve repair surgery for chronic degenerative mitral regurgitation at Villa Maria Cecilia Hospital. Routine perioperative transesophageal echocardiography showed SAM, severe LVOTO (> 50 mm Hg), and MR in 4 patients (mean age, 50 years).

Preoperative mitral regurgitation was mainly due to posterior leaflet prolapse with chordal rupture and flail aspect. All 4 patients had a large anterior leaflet with billowing and mild

Results

In the 4 patients with SAM and LVOTO, routine post-repair transesophageal echocardiography (Fig 1) demonstrated gradients ranging from 50 mmHg to 70 mmHg with significant MR (3 to 4+/4) that appeared 2 to 10 minutes after de-clamping the aorta. Furthermore, there was a persistent aspect of redundancy of the anterior leaflet. None of the patients were under catecholamine therapy. Initial conservative management, namely increasing pre-load and administration of β blockers (esmolol), failed to

Comment

Despite being an unusual consequence of mitral valve repair, SAM and consequent LVOTO are serious complications often defying medical treatment, which includes discontinuation of any catecholamines and volume loading followed by β-blocker therapy. Although valve replacement is the ultimate option, various surgical techniques have been proposed to treat SAM 8, 9, 10.

We describe here the first clinical experience of the edge-to-edge technique as a curative treatment after failure of medical

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