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Ann Thorac Surg 2005;79:471-473
© 2005 The Society of Thoracic Surgeons

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Original article: Cardiovascular

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

^a Department of Cardiac Surgery and Cardiology, Villa Maria Cecilia Hospital, Cotignola (RA), Italy
^b Department of Cardiac Surgery of the Centre Cardiologique du Nord, Saint DenisVilla Maria Cecilia Hospital
^c Department of Anesthesia and Critical Care Medicine, Lariboisiere Hospital, Paris, France

Accepted for publication August 3, 2004.

^* Address reprint requests to Dr Lessana, Centre Cardiologique du Nord, Département de Chirurgie Cardiaque, 32–36 rue des Moulins Gémeaux, St. Denis 93200, France (E-mail: a.lessana{at}wanadoo.fr).

	Abstract

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
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.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
The mechanism of systolic anterior motion (SAM) after mitral valve repair is complex and somehow controversial [1]. It is generally accepted that a redundant anterior leaflet is often associated with postmitral repair SAM, although the precise relationship is not clear [2]. Moreover, some authors claim that a large posterior leaflet may contribute to the mechanism of the SAM by forcing the coaptation zone anteriorly [3, 4]. Two different techniques have been adopted in an attempt to prevent postmitral repair SAM; namely, triangular resection of the anterior leaflet [2] and sliding plasty of the posterior leaflet [3]. Nevertheless, postmitral repair SAM with left ventricular outflow tract obstruction (LVOTO) and mitral regurgitation (MR) are still a concern and continue to occur in 1% to 16% of patients [2, 3–5].

It is our opinion that post-repair SAM is due to a sequence of events including anterior motion of the body of the anterior leaflet toward the septum, reinforced by the Venturi effect, all of which are responsible for the LVOTO and consequently for the loss of the coaptation point inducing MR.

We hypothesized that by assuring a large coaptation zone with an edge-to-edge suture [6, 7] the mobility of the anterior leaflet could be reduced. Therefore this may prevent the anterior movement of the leaflets and the cascade of events that lead to LVOTO and MR. According to this concept, we prospectively evaluated the technique of an edge-to-edge suture on post-mitral repair SAM, which persisted despite conservative treatment (ei, left ventricular volume loading, ß blockers).

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
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 prolapse but without chordal rupture. Echocardiographic and operative data are summarized in Table 1.

	Results

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
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 ß blockers (esmolol), failed to resolve the SAM and LVOTO.

View larger version (52K): [in this window] [in a new window]   Fig 1. Intraoperative transesophageal echocardiography after mitral repair. Relief of systolic anterior motion (SAM) and left ventricular outflow tract obstruction (LVOTO). (LA = left atrium; LV = left ventricle.)

View larger version (77K): [in this window] [in a new window]   Fig 2. Intraoperative transesophageal echocardiography after edge-to-edge suture. Disappearance of systolic anterior motion and resolution of the left ventricular outflow tract obstruction (LVOT). (LA = left atrium; LV = left ventricle.)

	Comment

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
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 ß-blocker therapy. Although valve replacement is the ultimate option, various surgical techniques have been proposed to treat SAM [8–10].

We describe here the first clinical experience of the edge-to-edge technique as a curative treatment after failure of medical management. These 4 patients had degenerative mitral valve pathology and analysis of the valve lesions demonstrate a number of comparable elements. The posterior leaflet was repaired for significant prolapse with chordal rupture and flail aspect. The anterior leaflet showed tissue excess, billowing, elongated chordae and a tendency to mild prolapse. As advocated by others [11], our initial approach was to refrain from treating the mild prolapse of the anterior leaflet. Since then, we have been more active in treating mild anterior leaflet prolapse. Jebara and colleagues [3] reported that the incidence of post-repair SAM and LVOTO is reduced by combining posterior leaflet resection with a sliding plasty; however, 2 patients in our series developed SAM despite sliding repair. Likewise, other authors performing sliding plasty have had patients who had SAM develop [8]. Triangular resection of the anterior leaflet as advocated by the New York University group [2] significantly diminished the incidence of SAM from 9.1% to 3.4%. None of our 4 patients had a triangular resection.

Accordingly, SAM remains an important issue that may appear despite sliding of the posterior leaflet or plication of the annulus, and equally whether a complete or open semi-rigid ring was used in the annuloplasty [5]. Our study strongly suggests that uniting the two leaflets over a short length could prevent their displacement into the outflow tract, thus blocking the cascade of events leading to SAM, LVOTO, and MR.

In conclusion, with the edge-to-edge repair, the early and 2-year results were satisfactory in patients with redundant anterior leaflet with total disappearance of the SAM, of the LVOTO, and of the recurrent MR. However, further clinical experience is necessary to determine the impact of this technique and its use as part of the surgeon armamentarium.

	Acknowledgments

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
We thank Claude Scheuble for reviewing our article.

	References

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 

1. Lee KS, Stewart WJ, Lever HM, Underwood PL, Cosgrove DM. Mechanism of outflow tract obstruction causing failed mitral valve repairAnterior displacement of leaflet coaptation. Circulation 1993;88:II24-9.
2. Grossi EA, Steinberg BM, LeBoutillier 3rd M. Decreasing incidence of systolic anterior motion after mitral valve reconstruction Circulation 1994;90:II195-7.
3. Jebara VA, Mihaileanu S, Acar C, et al. Left ventricular outflow tract obstruction after mitral valve repairResults of the sliding leaflet technique. Circulation 1993;88:II30-4.
4. Maslow AD, Regan MM, Haering JM, Johnson RG, Levine RA. Echocardiographic predictors of left ventricular outflow tract obstruction and systolic anterior motion of the mitral valve after mitral valve reconstruction for myxomatous valve disease J Am Coll Cardiol 1999;34:2096-2104.[Abstract/Free Full Text]
5. Rey MJ, Mercier LA, Castonguay Y. Echocardiographic diagnosis of left ventricular outflow tract obstruction after mitral valvuloplasty with a flexible Duran ring J Am Soc Echocardiogr 1992;5:89-92.[Medline]
6. Maisano F, Torracca L, Oppizzi M, et al. The edge-to-edge technique: a simplified method to correct mitral insufficiency Eur J Cardiothorac Surg 1998;13:240-245.[Abstract/Free Full Text]
7. Alfieri O, Maisano F, De Bonis M. The double-orifice technique in mitral valve repair: a simple solution for complex problems J Thorac Cardiovasc Surg 2001;122:674-681.[Abstract/Free Full Text]
8. Lee KS, Stewart WJ, Savage RM, Loop FD, Cosgrove 3rd DM. Systolic anterior motion of mitral valve after the posterior leaflet sliding advancement procedure Ann Thorac Surg 1994;57:1338-1340.[Abstract]
9. Raney AA, Shah PM, Joyo CI. The "Pomeroy procedure" — a new method to correct post-mitral valve repair systolic anterior motion J Heart Valve Dis 2001;10:307-311.[Medline]
10. Reed MK, Iverson LI. Simplified correction of outflow obstruction after mitral valve replacement Ann Thorac Surg 1992;54:985-986.[Abstract]
11. Gillinov AM, Cosgrove 3rd DM, Wahi S, et al. Is anterior leaflet repair always necessary in repair of bileaflet mitral valve prolapse? Ann Thorac Surg 1999;68:820-823.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) 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): Nawwar Al Attar Alberto Tripodi Arrigo Lessana Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Mascagni, R. Articles by Lessana, A. Search for Related Content PubMed PubMed Citation Articles by Mascagni, R. Articles by Lessana, A. Related Collections Valve disease