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Systolic Anterior Motion after Mitral Repair Predictors, Prevention, Solutions

Vinay Badhwar, MD Associate Professor of Surgery Department of Cardiothoracic Surgery Director, Center for Mitral Valve Disease Chief of Cardiac Surgery, UPMC Presbyterian University of Pittsburgh

UPMC


Disclosures •

Nothing to disclose

10th Gulf Heart Association, 24th Saudi Heart Association February 14, 2013


Objectives •

What to do during Mitral Repair •

How to Identify and Avoid Pitfalls •

Intraoperative signs

Anatomic signs increasing risk

How to treat SAM •

Medical and Surgical Therapy 10th Gulf Heart Association, 24th Saudi Heart Association February 13, 2013


Principles: Preoperative • Good preoperative evaluation (TEE) • Preoperative planning of the repair • Understand your mechanism of MR as this invariably dictates the repair and enables avoidance of systolic anterior motion • Objective for Anatomic Restoration 10th Gulf Heart Association, 24th Saudi Heart Association February 13, 2013


Principles: Preoperative • Stay ahead of potential trouble: • Anterior leaflet excess • Posterior leaflet excess • Posterior annular calcification MAC • Septal “Bulge” (Asymmetric Thickening) • Small ventricle, Small annulus • Acute aorto-mitral angle

Anatomic findings may occur together 10th Gulf Heart Association, 24th Saudi Heart Association February 13, 2013


Principles: Operative Principles of reconstructive restoration of coaptation can be performed with simplified methods:

• Triangular Valvuloplasty • Simplified and preferred method for all patients with small isolated prolapse

• Folding Valvuloplasty/Gortex Neochords • May be applied to variety of posterior leaflet prolapse, when chords and annulus intact

• Sliding Valvuloplasty • Severe prolapse, bileaflet disease. Goal to decrease posterior leaflet height 10th Gulf Heart Association, 24th Saudi Heart Association February 13, 2013


Triangular Valvuloplasty


Triangular Valvuloplasty


Folding Valvuloplasty


Sliding Valvuloplasty


…or Gortex AML Neochords


Anatomic Predictors C-SEPT < 2.5 cm

AL:PL < 1.3 C-ANN Increased LVID Decreased

EF Increased Aorto-Mitral Angle Acute > 20째


64 yo male, Acute Flail P2-3, Severe MR

High Risk for SAM: Acute A-M Angle, Small C-Sept, Long PML, Normal LV

UPMC


64 yo male, Acute Flail P2-3, Severe MR

Triangular Repair with Upsized Ring

UPMC


ALGORITHM FOR MANAGEMENT OF SAM LVOT gradient <50 and trace to mild MR, attempt Medical Management

LVOT gradient >50 or more than mild MR, attempt medical management but if does not completely resolve = Surgical Correction

Eur J Cardiothoracic Surg 2012;41:1260-70


Medical Management of SAM Stop all inotropic medications Volume expansion

Acute Afterload Increase (digital aortic compression) Beta blockade (Esmolol 1mg/kg)

J Thorac Cardiovasc Surg 2009;137:320-325


Summary • SAM is PREDICTABLE and PREVENTABLE – Excess PML, C-Sept < 2.5, Acute A-M Angle

• When anatomic predictors identified: – Reduced PML height, up-sized annuloplasty

• If SAM does occur post repair: – Mild MR, LVOT grad < 50: Medical Management* – Mod MR, LVOT grad > 50: Surgical Management * Must re-evaluate postoperatively 10th Gulf Heart Association, 24th Saudi Heart Association February 13, 2013


Summary • Know your mechanism of MR preoperatively

• Carefully evaluate TEE for leaflet pathology AND potential pitfalls to plan your repair • Upon mitral inspection, re-confirm your mechanism and plan of repair • Focus on tension-free alignment and durable restoration of the zone of coaptation 10th Gulf Heart Association, 24th Saudi Heart Association February 13, 2013


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SHA24/008002