Ann Thorac Surg 2008;86:1699-1700. doi:10.1016/j.athoracsur.2008.04.019
© 2008 The Society of Thoracic Surgeons
How To Do It
Posterior Leaflet Shortening to Correct Systolic Anterior Motion After Mitral Valve Repair
Kristopher M. George, MD,
A. Marc Gillinov, MD*
Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
Accepted for publication April 9, 2008.
* Address correspondence to Dr Gillinov, Cleveland Clinic, Department of Thoracic and Cardiovascular Surgery, 9500 Euclid Ave/Desk F24, Cleveland, OH 44195 (Email: gillinom{at}ccf.org).
| Dr. Gillinov discloses that he has a financial relationship with Edwards Lifesciences, Medtronic, and St. Jude.
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Abstract
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In patients with degenerative mitral valve disease and tall leaflets, systolic anterior motion after mitral valve repair is generally avoided by use of a sliding posterior leaflet repair technique with an annuloplasty of appropriate size. Occasionally, in spite of these maneuvers, systolic anterior motion occurs intraoperatively after discontinuing cardiopulmonary bypass. In such cases, posterior leaflet shortening is a simple option that effectively moves the coaptation point of the mitral leaflets posteriorly, and eliminates left ventricular outflow tract obstruction caused by systolic anterior motion.
Systolic anterior motion (SAM) created during a mitral valve repair (MVR) is often related to an anteriorly malpositioned leaflet coaptation point. Repairs that leave a relatively tall posterior leaflet or use a small annuloplasty ring can result in an anteriorly displaced leaflet coaptation point, and therefore SAM. A sliding posterior leaflet repair technique and upsized annuloplasty ring will often prevent this problem [1]. Occasionally, in spite of these maneuvers, SAM will occur intraoperatively after discontinuing cardiopulmonary bypass, which is unresponsive to medical manipulation. By reducing posterior leaflet height, posterior leaflet shortening is an option that effectively moves the coaptation point of the anterior and posterior mitral leaflets posteriorly and reduces the risk of future SAM.
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Technique
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Both MVR and posterior leaflet shortening can be performed through sternotomy, thoracotomy, or various minimally invasive approaches. When an MVR is completed, the valve is typically tested, and if it is found to be competent, then the atrium is closed, the cross clamp is removed, and the bypass is terminated to inspect the valve in a beating heart by tranesophageal echocardiography (TEE). If SAM exists with the heart fully recovered, in spite of medical management, the surgeon must decide whether the situation warrants a second attempt at repair. If a sliding posterior leaflet repair was performed, and the ring was of generous size, redoing these steps may be of little value. Posterior leaflet shortening is a quick and simple option that may eliminate the SAM while maintaining valve competence.
Cardiopulmonary bypass is reinitiated, the aorta is cross clamped, and the heart is arrested in the surgeon's usual fashion. The mitral valve is exposed through the reopened atriotomy, either directly through the left atrium or transseptally. Four 4-0 pledgeted Prolene (Ethicon, Somerville, NJ) interrupted horizontal mattress sutures are placed in the posterior leaflet to shorten it approximately 5 mm. Care is taken to space the sutures evenly and symmetrically on the posterior leaflet, thereby reducing the leaflet height the same amount at each point. Figure 1
illustrates the position of the pledgeted sutures on the posterior leaflet. The valve is again tested for competence, and if no regurgitation was created by the shortening, the atrium is once again closed, the cross clamp is removed, and the bypass is terminated when a stable rhythm is achieved. The TEE is used to re-evaluate the valve for presence of SAM and regurgitation. In most cases, the second arrest for the placement of four sutures should add only 10 to 15 minutes of cross-clamp time to the case.
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Fig 1. (A) Illustration represents a mitral valve after a quadrangular posterior leaflet resection and sliding repair with placement of a 34-mm annuloplasty ring. (B) Illustration shows placement of four pledgeted horizontal mattress sutures, and (C) demonstrates the posterior mitral leaflet shortening of approximately 5 mm.
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This technique was used on 4 consecutive patients who all originally underwent MVR by posterior leaflet resection with a generous sliding repair and placement of a 34-mm Cosgrove-Edwards annuloplasty ring (Edwards Lifesciences, Irvine, CA). One repair was done through a sternotomy, the other three through miniature right thoracotomy incisions. All patients exhibited SAM after discontinuing cardiopulmonary bypass, which did not resolve with immediate medical management. In each case, a second cross-clamp period, as described with posterior leaflet shortening, eliminated the SAM without compromising the competency of the valve on intraoperative TEE. Pre-discharge transthoracic echocardiograms maintained these results.
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Comment
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The SAM rates after MVR with modern techniques varied from 4% to 8.4% in the literature, depending in part on whether intraoperative or early postoperative echocardiography is used [2–5]. A recent Mayo Clinic review of 2,076 mitral valve repairs indicated that postoperative SAM was seen only in patients with degenerative disease who had an annuloplasty ring placed as part of their repair. Medical management including volume loading, vasoconstriction, and β-blockade often eliminated the problem at least temporarily, and most SAM resolved by the time follow-up echocardiography was performed [4]. It is unclear how serious this form of SAM will be long-term for those who are unresponsive to medical therapy. Reoperation for SAM created at an initial MVR surgery, however, is quite rare [4, 6–8].
Carpentier [1] has recommended three principles to prevent or treat SAM associated with MVR. First, reduce posterior leaflet height by using a sliding repair technique when posterior leaflet resection is performed. Second, choose annuloplasty ring size by comparing the height of the anterior leaflet with the height of the ring erring on the large size. Finally, perform anterior leaflet height reduction if excess anterior leaflet tissue is present [8].
During intraoperative TEE after MVR, if a generous sliding repair and placement of a large annuloplasty ring have already been done, and the patient has SAM that does not resolve with medical management and needs to be corrected, leaflet height reduction is one option. The choice of anterior height reduction or posterior shortening depends on the anatomy at hand. A competent mitral valve without SAM is clearly the goal and this technique provides the surgeon a quick and simple maneuver with good short-term results provided a second cross clamp is practical. Further follow-up is necessary to confirm the durability of this new technique.
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References
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- Carpentier A. The SAM issue Le Club Mitrale Newsletter 1989;1:72-75.
- Grossi EA, Galloway AC, Parish MA, et al. Experience with twenty-eight cases of systolic anterior motion after mitral valve reconstruction by the Carpentier technique J Thorac Cardiovasc Surg 1992;103:466-470.[Abstract]
- Jebara VA, Mihaileanu S, Acar C, et al. Left ventricular outflow tract obstruction after mitral valve repair. Results of the sliding leaflet technique. Circulation 1993;88:II30-II34.[Medline]
- Brown ML, Abel, MD, Click RL, et al. Systolic anterior motion after mitral valve repair: is surgical intervention necessary? J Thorac Cardiovasc Surg 2007;133:136-143.[Abstract/Free Full Text]
- Gazoni LM, Fedoruk LM, Kern JA, et al. A simplified approach to degenerative disease: triangular resections of the mitral valve Ann Thorac Surg 2007;83:1658-1665.[Abstract/Free Full Text]
- Doguet F, Zegdi R, Garcon P, et al. Systolic anterior motion (SAM): a rare cause of late failure in mitral valve repair Arch Mal Coeur Vaiss 2006;99:928-931.[Medline]
- Dumont E, Gillinov AM, Blackstone EH, et al. Reoperation after mitral valve repair for degenerative disease Ann Thorac Surg 2007;84:444-450.[Abstract/Free Full Text]
- Zegdi R, Carpentier A, Doguet F, et al. Systolic anterior motion after mitral valve repair: An exceptional cause of late failure J Thorac Cardiovasc Surg 2005;130:1453-1454.[Free Full Text]
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