Transcript Complexity and MV Repair and Risk for SAM

Complexity and MV Repair
Risk for SAM
Spectrum of Repair Difficulty
INCREASED COMPLEXITY
Complexity of Repair
Repair Type
Mitral Valve Pathology
Simple
Annular Ring
Dilated Annulus
More Complex
Annular Ring Quadrangular resection
Dilated Annulus Flail Posterior
Scallop
Increased Complexity
Annular Ring
Quadrangular Resection
Posterior leaflet height adjustment
to Prevent SAM
Dilated Annulus
Flail Posterior Scallop
Increased Posterior
Scallop height
More Complex
Annular Ring
+/- Quad Resection
Artificial Chords vs. Transfer
?Larger Ring
Dilated Annulus
Torn Chordae
Risk for Sam
More Complex
Above Plus
Anterior Leaflet
- resection
- shortening
- artificial chords
Barlow’s
Above plus anterior
leaflet pathology
More Complex
Closing Commissure
Commissural Scallop
Prolapse
More Complex
Rings and Strings
Ischemic MR
Complex
--Assessing mechanism of post
Repair SAM
How to fix it
Do you want to fix it
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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)