Complexity and MV Repair Risk for SAM

Complexity of Repair

Simple More Complex Increased Complexity More Complex More Complex More Complex More Complex Complex Spectrum of Repair Difficulty Annular Ring

Repair Type

Annular Ring Quadrangular resection Annular Ring Quadrangular Resection Posterior leaflet height adjustment to Prevent SAM Annular Ring +/- Quad Resection Artificial Chords vs. Transfer ?Larger Ring Above Plus Anterior Leaflet - resection - shortening - artificial chords Closing Commissure Rings and Strings --Assessing mechanism of post Repair SAM How to fix it Do you want to fix it

Mitral Valve Pathology

Dilated Annulus Dilated Annulus Flail Posterior Scallop Dilated Annulus Flail Posterior Scallop Increased Posterior Scallop height Dilated Annulus Torn Chordae Risk for Sam Barlow’s Above plus anterior leaflet pathology Commissural Scallop Prolapse Ischemic MR

 In next slide note how ring annuloplasty moves the posterior wall to a more anterior position. In Mitral Valves with increased height of posterior scallops, the increased height can push the anterior leaflet into the LVOT (resulting in SAM) if not corrected by using either large ring, posterior leaflet slide, or folding-plasty. Patients with increased anterior leaflet height must also have this addressed by using larger ring, or reducing the anterior leaflet height.

4.3cm

3.2cm

SAM

 Systolic Anterior Motion of the anterior leaflet of the mitral valve  Produces left ventricular outflow track (LVOT) obstruction.

 May produce mitral regurgitation.

Post Repair SAM ME AV LAX

Maslow AD, Regan MM, Haering JM, Johnson RG, Levine RA J Am Coll Cardiol 1999;34:2096-2104

Risk Factors for SAM

Anatomic risks for systolic anterior motion (SAM) of the anterior leaflet of mitral valve post repair - Posterior leaflet height greater than 20mm - AL/PL ratio <1.2

- Anterior leaflet height greater than 35mm - C-sept <2.5cm

Measuring the AL/PL Ratio

 This ratio is defined as measured at AL/PL coaptation. The length of each from the annulus to point of coaptation. As such does not measure true leaflet length.

Sizing Ring

Determining mitral annular ring size has been done by two methods 1. According to height of the anterior leaflet  Used more in degenerative disease – Especially in patients at risk for SAM – Especially with large anterior leaflets/Barlow type valve  Under sizing ring based on anterior leaflet can increase risk of SAM in degenerative disease with Carpentier Type I and II pathology 2. According to the intertrigonal distance  Most commonly used in Type IIIb (restrictive leaflet motion in systole) of ischemic and non ischemic cardiomyopathy.

– Note in these states typically have dilated LV so risk of SAM is less – Size to normal intertrigonal distance or one size below

Calculating Normal Intertrigonal Distance

Intertrigonal Distance = Surgical Annulus Diameter (MELAX) 0.8

Duran et al: J Heart Valve Dis. 1998 Sep;7(5):593-7

Know how the manufacture defines the ring size - Commissure to Commissure (Carpentier classical ring) - Trigone to Trigone (Duran flexible ring)