P M Shah1, A A Raney. 1. Hoag Heart Institute, Newport Beach, CA 92658-6100, USA.
Abstract
BACKGROUND AND AIM OF THE STUDY: Systolic anterior motion (SAM) of the mitral valve resulting in left ventricular outflow obstruction is a well-recognized complication of repair of the degenerative myxomatous mitral valve. A precise mechanism is unknown. A current approach consists of sliding annuloplasty of the posterior leaflet. It was postulated that excess tissue of the anterior mitral leaflet (AML) was as equally (or more) important as the excess posterior mitral leaflet (PML) tissue in the development of SAM subsequent to valve repair. METHODS: Thirty-two patients without post-repair SAM (No-SAM group) were compared with eight patients with SAM (SAM group). The AML and PML heights and the mitral annulus diameter were measured by TEE using mid-esophageal four-chamber and long-axis planes. RESULTS: Pre-repair TEE showed the AML height to be greater in the SAM group (p = 0.04), and that of the posterior leaflet tended to be greater (p = 0.08), whilst the annular dimensions were similar in both groups. In the post-repair status, the AML height was markedly greater (p = 0.005) and the annulus markedly smaller (p = 0.001) in the SAM group. Post-repair assessment showed the relative difference between AML height and annular dimension (AML - Ann) as well as the difference between combined leaflet heights and annular dimension (AML + PML - Ann) to be strikingly greater in the SAM group as compared with the No-SAM group (p = 0.001). CONCLUSION: A disparity between dimension of the annulus following mitral valve repair and combined heights of the two leaflets explains post-repair SAM. The AML height is a more important factor in the development of SAM. Thus, surgical techniques to reduce AML heights should be considered in patients with disproportionately large anterior leaflets in order to prevent SAM. Selection of size of the annuloplasty ring should take into consideration the height of the AML.
BACKGROUND AND AIM OF THE STUDY: Systolic anterior motion (SAM) of the mitral valve resulting in left ventricular outflow obstruction is a well-recognized complication of repair of the degenerative myxomatous mitral valve. A precise mechanism is unknown. A current approach consists of sliding annuloplasty of the posterior leaflet. It was postulated that excess tissue of the anterior mitral leaflet (AML) was as equally (or more) important as the excess posterior mitral leaflet (PML) tissue in the development of SAM subsequent to valve repair. METHODS: Thirty-two patients without post-repair SAM (No-SAM group) were compared with eight patients with SAM (SAM group). The AML and PML heights and the mitral annulus diameter were measured by TEE using mid-esophageal four-chamber and long-axis planes. RESULTS: Pre-repair TEE showed the AML height to be greater in the SAM group (p = 0.04), and that of the posterior leaflet tended to be greater (p = 0.08), whilst the annular dimensions were similar in both groups. In the post-repair status, the AML height was markedly greater (p = 0.005) and the annulus markedly smaller (p = 0.001) in the SAM group. Post-repair assessment showed the relative difference between AML height and annular dimension (AML - Ann) as well as the difference between combined leaflet heights and annular dimension (AML + PML - Ann) to be strikingly greater in the SAM group as compared with the No-SAM group (p = 0.001). CONCLUSION: A disparity between dimension of the annulus following mitral valve repair and combined heights of the two leaflets explains post-repair SAM. The AML height is a more important factor in the development of SAM. Thus, surgical techniques to reduce AML heights should be considered in patients with disproportionately large anterior leaflets in order to prevent SAM. Selection of size of the annuloplasty ring should take into consideration the height of the AML.