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Ann Thorac Surg 1997;64:1805-1806
© 1997 The Society of Thoracic Surgeons

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Case Report

Left Ventricular Outflow Tract Obstruction After Mitral Valve Replacement

Department of Cardiac Surgery, Erasme University Hospital, Brussels, Belgium

Accepted for publication August 1, 1997.

	Abstract

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We describe a patient with left ventricular outflow tract obstruction after mitral valve replacement preserving the anterior subvalvular apparatus. Postoperative transesophageal echocardiography demonstrated systolic narrowing of the left ventricular outflow tract by a bulging septum and systolic anterior motion of the preserved anterior mitral leaflet. Septal myectomy and transaortic mitral apparatus resection enabled us to relieve the left ventricular outflow tract obstruction. This suggests that septal hypertrophy might be a relative contraindication to the preservation of the anterior mitral subvalvular apparatus in mitral replacement.

	Introduction

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See also page 1806.

A 73-year-old man with a history of recurrent episodes of cardiac failure and severe chronic obstructive pulmonary disease was admitted for increasing dyspnea. Electrocardiogram showed 2/1 atrioventricular block. Transesophageal echocardiography demonstrated 4+ mitral and trivial tricuspid regurgitation. Severe annular calcification and posterior leaflet retraction contraindicated valvular repair. Severe left ventricular hypertrophy was reported without further comment. The left ventricular ejection fraction was 0.60.

At cardiac catheterization pulmonary artery pressure and pulmonary artery occlusion pressure were 78/35 and 33 mm Hg, respectively, and cardiac index was 2.6 L • min^-1 • m^-2. The mitral valve was replaced by a porcine Carpentier-Edwards 29-mm SAV bioprosthesis (Baxter Xenomedica, Horw, Switzerland) with preservation of the anterior and posterior subvalvular mitral apparatus after the anterior leaflet had been split to the annulus as described by Miki and associates [1]. The procedure was uneventful, and the patient was weaned from bypass with slight inotropic support (2 µg • kg^-1 • min^-1 dobutamine). The operation was ended by the placement of a VDD pacemaker through the left subclavian vein. Temporary pacing wires on the right atrium provided electrostimulation of the atria, and the ventricular contraction was synchronized on this event by the endocardiac VDD system.

During the first hour the hemodynamic situation deteriorated rapidly in the intensive care unit; a progressive decrease in cardiac index and systemic pressure occurred leading to an increase in inotropic support. Transesophageal echocardiography was performed. Systolic narrowing of the left ventricular outflow tract was observed between a bulging septum (18 mm) and the remainders of the anterior mitral leaflet (Fig 1). The decrease in inotropic support and the insertion of an intraaortic balloon pump somewhat ameliorated the situation.

View larger version (78K): [in this window] [in a new window]   Fig 1. . Systolic narrowing of the left ventricular outflow tract.

	Comment

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Systolic anterior motion of the mitral valve, leading to left ventricular outflow tract obstruction, is a classic complication after mitral valve repair [3]. Two risk factors are associated with the occurence of systolic anterior motion: the excess of valvular tissue and the presence of a bulging septum [4, 5]. Recent data from the literature highlight the functional importance of preserving the subvalvar mitral apparatus during mitral valve replacement [6].

We report the case of a patient with mitral valve disease and septal hypertrophy in whom systolic anterior motion and left ventricular outflow tract obstruction developed after mitral valve replacement with preservation of the mitral subvalvar apparatus. This condition was successfully treated by transaortic septal myectomy and resection of the anterior subvalvar apparatus. The present case suggests that preservation of the anterior leaflet during mitral valve replacement might be deleterious if marked septal hypertrophy is present. If preservation is mandatory, a solution of partial resection of the anterior leaflet as described by David [7] or Rose and Oz [8] might be preferred. Careful preoperative transthoracic echocardiography detection of septal hypertrophy and perioperative transesophageal echocardiography should enable the surgeon to anticipate this complication and thus select the appropriate surgical approach.

	Footnotes

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Address reprint requests to Dr De Canniere, Department of Cardiac Surgery, Erasme University Hospital, Route de Lennik, 808, 1070 Brussels, Belgium (e-mail: ddc{at}skynet.be).

	References

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1. Miki S, Ueda Y, Tahata T, Okita Y. Mitral valve replacement with preservation of chordae tendineae and papillary muscles. Ann Thorac Surg 1995;60:225–6.[Abstract/Free Full Text]
2. Morrow AG. Hypertrophic subaortic stenosis: operative methods utilized to relieve left ventricular outflow obstruction. J Thorac Cardiovasc Surg 1978;76:423–30.[Abstract]
3. Perier P, Hagen T, Stümpf Y. Septal myectomy for left ventricular outflow obstruction after mitral valve repair. Ann Thorac Surg 1994;57:1328–30.[Abstract/Free Full Text]
4. Jiang L, Levine RA, King ME, Weyman AE. An integrated mechanism for systolic anterior motion of the mitral valve in HCMO based on echocardiographic observations. Am Heart J 1987;113:633–44.[Medline]
5. Lee KS, Stewart WJ, Lever HM, Underwood PL, Cosgrove DM. Mechanism of outflow tract obstruction causing failed mitral valve repair. Circulation 1993;88:24–9.
6. DeAndra A Jr, Komeda M, Nikolic SD, Daughters GT, Ingels NB, Miller DC. Left ventricular function, twist, and recoil after mitral valve replacement. Circulation 1995;92:458–66.[Abstract/Free Full Text]
7. David TE. Mitral valve replacement with preservation of chordae tendineae: rationale and technical considerations. Ann Thorac Surg 1986;41:680–2.[Abstract/Free Full Text]
8. Rose EA, Oz MC. Preservation of anterior leaflet chordae tendineae during mitral valve replacement. Ann Thorac Surg 1994;57:768–9.[Abstract/Free Full Text]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Jean-Louis Le Clerc Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by De Canniere, D. Articles by Le Clerc, J.-L. Search for Related Content PubMed PubMed Citation Articles by De Canniere, D. Articles by Le Clerc, J.-L. Related Collections Related Article