Systolic anterior motion after mitral valve repair: Is surgical intervention necessary?

Brown, Morgan L.; Abel, Martin; Click, Roger L.; Morford, Ronald G.; Dearani, Joseph A.; Sundt, Thoralf M.; Orszulak, Thomas A.; Schaff, Hartzell V.

doi:10.1016/j.jtcvs.2006.09.024

Cited by 124 publications

(93 citation statements)

References 21 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…An intra-aortic balloon pump could induce or worsen LVOTO by reducing afterload. 9 Phenylephrine may selectively improve vascular tone and reduce LVOTO. 10 Use of ␤-blockers would benefit LVOTO gradients by reducing basal hypercontractility, increasing LV filling and size, and reducing heart rate.…”

Section: Management Of Lvotomentioning

confidence: 99%

Dynamic Left Ventricular Outflow Tract Obstruction in Acute Myocardial Infarction With Shock

et al. 2007

View full text Add to dashboard Cite

Case presentation: A 70-yearold white woman with a prior history of tobacco abuse, emphysema, and recent pneumonia presented to an outside emergency room with brief episodes of dull chest pressure recurring over 5 days. Because the current episode was not relieved after 4 hours, and because her ECG showed ST elevation up to 3 mm in V 2 through V 6 , she was given heparin and nitroglycerin infusions and was transferred to the University of Missouri. On admission to our hospital, she was painfree with stable vital signs. Her examination was remarkable for a grade 2/6 systolic ejection murmur in the left third intercostal space. An ECG showed Q waves in V 1 through V 3 . Echocardiography revealed significant left ventricular (LV) dysfunction, ejection fraction of 35% with systolic anterior motion (SAM) of the anterior mitral leaflet, and moderate mitral regurgitation (MR; Figure 1). LV outflow tract (LVOT) gradients were not quantified owing to MR Doppler contamination. Her maximum troponin was 5 ng/mL, and brain natriuretic peptide was 190 pg/mL. Catheterization showed normal coronaries with anteroapical akinesia and LV dysfunction with an ejection fraction of 30%.The patient became hypotensive after catheterization, with systolic pressures between 70 and 85 mm Hg. Dopamine infusion did not improve blood pressure, and the murmur increased to grade 3/6 intensity. Atrial fibrillation developed with a ventricular rate of 150 bpm. Dopamine was discontinued, and intravenous amiodarone converted the atrial fibrillation to sinus tachycardia at 115 bpm, but the hypotension and murmur persisted. Under close supervision, intravenous metoprolol was initiated. With reduction of heart rate to below 70 bpm, the murmur disappeared, and her blood pressure improved. Several hours later, a repeat echocardiogram showed no SAM or LVOT obstruction (LVOTO) and only mild MR.Numerous reports have highlighted the occurrence of dynamic LVOTO as a complication of ST-elevation myocardial infarction (STEMI). 1,2 LVOTO has also been detected in Ϸ20% of transient LV apical ballooning syndrome, also called Takatsubo cardiomyopathy. 3 The actual incidence of dynamic LVOTO is unclear, but it may be significantly underdiagnosed and can indeed mimic cardiogenic shock in an acute-care setting. 4 Mechanism of LVOTOStructural and functional factors contribute to the midsystolic development of gradients referred to as dynamic LVOTO. The asymmetrically hypertrophied septum, progressive narrowing of the LVOT during systole, and direction of the bloodstream cause drag forces and a Venturi effect on the anterior mitral leaflet, which results in SAM of the anterior mitral leaflet. This movement results in the anterior mitral leaflet contacting the septum for a period of systole, effectively obstructing the path of ventricular outflow. Failure of the anterior mitral leaflet to coapt with the posterior leaflet in systole results in MR. The degree and duration of mitral SAM determine the severity of the dynamic LVOTO gradients and MR. Although classically descr...

show abstract

Section: Management Of Lvotomentioning

confidence: 99%

Dynamic Left Ventricular Outflow Tract Obstruction in Acute Myocardial Infarction With Shock

et al. 2007

View full text Add to dashboard Cite

show abstract

“…Furthermore, in this study, SAM insisted in the long-term follow-up of 17 patients, the best option is medical treatment in mild SAM and surgery can be considered in a case of severe LVOTO related to SAM [6]. In our case, while postoperative 3th hour hemodynamics deteriorated with entering into pulmonary edema plane, when we faced with about 140 mm Hg gradient of LVOTO related to SAM, we initiated the fluid replacement therapy with dobutamine termination and we started thinking about surgical options.…”

Section: Discussionmentioning

confidence: 97%

Left Ventricular Outflow Tract Obstruction after Ross-Konno Operation

Zeybek¹,

Avsar²,

Yildirim³

et al. 2017

OALib

View full text Add to dashboard Cite

INTRODUCTION: SAM (systolic anterior motion) is defined as the dynamic motion of the anterior mitral valve leaflet to the left ventricular outflow tract (LVOT) during systole. In this study, we present a case which we encountered with significant left ventricular outflow tract obstruction (LVOTO) related to SAM and developed after Ross-Konno operation. METHOD: A 4-month, 6.2 kg girl underwent balloon valvuloplasty due to bicuspid aortic stenosis when she was one-month. Ross-Konno operation was performed on the patient due to residual aortic stenosis (peak gradient of 140 mm Hg) and severe aortic regurgitation. Intraoperative echocardiography (ECHO) showed a peak gradient of 25 mmHg between the LV-Aorta. RESULTS: In the ICU at postoperative 3. hour, when tachycardia began with the patient's hemodynamic deterioration, SAM in ECHO and concomitant LVOTO (Peak grad: 140 mmHg) and 2nd degree MY was identified. Pulmonary edema was observed along with a decrease in oxygen saturation. The treatment initiated for removing the patient from hyperdynamic state and reducing the volume deficit. Sedation and analgesia were increased. The low-dose dobutamine was stopped. Tachycardia was attempted to take control with beta-blockers. The same treatment was continued on day 2, but the frequency of patient's tachycardia has not been reduced despite high doses of beta blockers. Heart rate was controlled by Amiodarone. On day 4, mitral regurgitation was slightly decreased while the LV-Aorta gradient was measured between 50 -60 mmHg. On day 5, SAM has diminished greatly (20 mmHg). The patient was extubated 6th day and was discharged on the 12th day without any problem. One year after, LVOT gradient was not detected in the ECHO. DISCUSSION: In adult patients, although a variety of surgical procedures for the removal of SAM had been reported, no experience in infants exists in the literature on these techniques. Despite intensive medical treatment, it may take longer than expected. We

show abstract

“…SAM is a well-known complication that follows MVP, and its incidence has been reported at 2%-14% [2][3][4]. As SAM increases the likelihood of MR and LVOTO, and these complications often occur together in MVP, there is a high risk of severe circulatory collapse during surgery.…”

Section: Discussionmentioning

confidence: 99%

A short-acting beta-blocker, landiolol, attenuates systolic anterior motion of the mitral valve after mitral valve annuloplasty

et al. 2008

View full text Add to dashboard Cite

Here, we describe three patients with severe hemodynamic instability after mitral valve annuloplasty (MVP) who were treated successfully using a new ultra-short-acting beta-blocker, landiolol hydrochloride. When systolic anterior motion (SAM) of the mitral valve occurs after MVP, left ventricular outflow tract obstruction (LVOTO) and mitral regurgitation (MR) often lead to hemodynamic collapse. Treatment of SAM is very difficult, and transfusion, or the reduction/discontinuation of catecholamine or vasopressor administration, is often ineffective. In our three patients, landiolol hydrochloride decreased the heart rate, markedly attenuated SAM, and improved the hemodynamics. We recommend that landiolol be administered before further surgical manipulation is considered in patients with SAM after MVP.

show abstract

Systolic anterior motion after mitral valve repair: Is surgical intervention necessary?

Cited by 124 publications

References 21 publications

Dynamic Left Ventricular Outflow Tract Obstruction in Acute Myocardial Infarction With Shock

Dynamic Left Ventricular Outflow Tract Obstruction in Acute Myocardial Infarction With Shock

Left Ventricular Outflow Tract Obstruction after Ross-Konno Operation

A short-acting beta-blocker, landiolol, attenuates systolic anterior motion of the mitral valve after mitral valve annuloplasty

Contact Info

Product

Resources

About