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• W3096758061 abstract "Systolic anterior motion (SAM) of the mitral valve is a well-known complication in mitral valve repair. Because excessive leaflet tissue is an important mechanism, surgical correction is sometimes required to reduce leaflet height or mobility. However, a different approach may be necessary in cases of normal leaflet height. Herein, we describe papillary muscle reorientation for treating SAM after isolated anterior leaflet repair. The papillary muscle heads were approximated and fixed to the posterior ventricular wall, relocating them away from the ventricular septum. This technique is useful for treating postrepair SAM, without addressing the leaflet, in patients with degenerative mitral disease. Systolic anterior motion (SAM) of the mitral valve is a well-known complication in mitral valve repair. Because excessive leaflet tissue is an important mechanism, surgical correction is sometimes required to reduce leaflet height or mobility. However, a different approach may be necessary in cases of normal leaflet height. Herein, we describe papillary muscle reorientation for treating SAM after isolated anterior leaflet repair. The papillary muscle heads were approximated and fixed to the posterior ventricular wall, relocating them away from the ventricular septum. This technique is useful for treating postrepair SAM, without addressing the leaflet, in patients with degenerative mitral disease. The Video can be viewed in the online version of this article [https://doi.org/10.1016/j.athoracsur.2020.08.065] on http://www.annalsthoracicsurgery.org. The Video can be viewed in the online version of this article [https://doi.org/10.1016/j.athoracsur.2020.08.065] on http://www.annalsthoracicsurgery.org. Systolic anterior motion (SAM) of the mitral valve occasionally occurs after mitral valve repair for degenerative mitral disease, particularly in patients with an elongated posterior mitral leaflet (PML). In most cases, SAM is transient and resolves intraoperatively with aggressive medical management. However, if SAM persists, surgical revision is required, which includes resection or plication of the elongated leaflet, annuloplasty ring replacement with a larger-sized ring, or prosthetic valve replacement. We herein describe a case of postrepair SAM successfully treated using papillary muscle reorientation. Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A 57-year-old man with severe organic mitral regurgitation (MR) was referred to us for minimally invasive mitral valve repair. Preoperative echocardiography showed A2 prolapse, with torn chordae. Left ventricular function was normal, with an ejection fraction of 0.65 and diastolic and systolic dimensions of 48 mm and 31 mm, respectively. The thickness of the interventricular septum was 10 mm. Intraoperatively, leaflet prolapse with moderate myxomatous degeneration was noted in the A2 and A3 segments. The other segments appeared intact, with normal leaflet size. The anterolateral and posteromedial papillary muscles had multiple independent heads, with the posterior heads directly arising from the posterior left ventricular wall (Figure 1A ). Five artificial chordae were implanted into the anterior mitral leaflet (AML) using the tourniquet technique,1Kasegawa H. Kamata S. Hirata S. et al.Simple method for determining proper length of artificial chordae in mitral valve repair.Ann Thorac Surg. 1994; 57: 237-238Abstract Full Text PDF PubMed Scopus (44) Google Scholar,2Tabata M. Kasegawa H. Fukui T. Shimizu A. Sato Y. Takanashi S. Long-term outcomes of artificial chordal replacement with tourniquet technique in mitral valve repair: a single-center experience of 700 cases.J Thorac Cardiovasc Surg. 2014; 148: 2033-2038Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar and a true-sized (32 mm) partial semirigid annuloplasty band (CG Future Band; Medtronic, Minneapolis, MN) was placed. A saline injection test revealed good apposition of both leaflets, with the zone of coaptation slightly displaced anteriorly (Figure 1B). After termination of cardiopulmonary bypass, transesophageal echocardiography revealed severe SAM, which was not resolved by aggressive medical management (Figure 2A ). Thus, the heart was rearrested, and the mitral valve was inspected. Because the PML was normal, with a leaflet height of less than 1.5 cm, a height reduction procedure to the PML was not considered appropriate. We therefore performed papillary muscle reorientation, which was previously reported for the management of SAM in patients with hypertrophic cardiomyopathy.3Bryant 3rd, R. Smedira N.G. Papillary muscle realignment for symptomatic left ventricular outflow tract obstruction.J Thorac Cardiovasc Surg. 2008; 135: 223-224Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 4Kwon D.H. Smedira N.G. Thamilarasan M. Lytle B.W. Lever H. Desai M.Y. Characteristics and surgical outcomes of symptomatic patients with hypertrophic cardiomyopathy with abnormal papillary muscle morphology undergoing papillary muscle reorientation.J Thorac Cardiovasc Surg. 2010; 140: 317-324Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar, 5Hodges K. Rivas C.G. Aguilera J. et al.Surgical management of left ventricular outflow tract obstruction in a specialized hypertrophic obstructive cardiomyopathy center.J Thorac Cardiovasc Surg. 2019; 157: 2289-2299Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar, 6Sakaguchi T. Totsugawa T. Tamura K. Hiraoka A. Chikazawa G. Yoshitaka H. Minimally invasive trans-mitral septal myectomy for diffuse-type hypertrophic cardiomyopathy.Gen Thorac Cardiovasc Surg. 2018; 66: 321-326Crossref PubMed Scopus (3) Google Scholar Specifically, a pledgeted mattress suture was placed on the posterior ventricular wall. It was then passed through both posterior and anterior papillary heads and tied (Figure 1C), such that both papillary heads were tacked to the posterior wall. The anterolateral and posteromedial papillary muscles were both realigned. The final saline injection test revealed that the zone of coaptation moved posteriorly (Figure 1D), and postbypass transesophageal echocardiography showed the absence of SAM and no evidence of mitral valve stenosis (Figure 2B; Video). SAM occurs after mitral valve repair in 6% to 10% of patients with organic MR.7Brown M.L. Abel M.D. Click R.L. et al.Systolic anterior motion after mitral valve repair: is surgical intervention necessary?.J Thorac Cardiovasc Surg. 2007; 133: 136-143Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar,8Varghese R. Anyanwu A.C. Itagaki S. Milla F. Castillo J. Adams D.H. Management of systolic anterior motion after mitral valve repair: an algorithm.J Thorac Cardiovasc Surg. 2012; 143: S2-S7Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar The primary mechanism comprises a mismatch between the anterior-posterior dimension of the mitral annulus and the amount of leaflet tissue. The risk factors of SAM include a narrow aortomitral angle, ventricular septal hypertrophy, a hyperdynamic small left ventricle, excessive PML tissue, and a relatively small annuloplasty ring. Although most cases of postrepair SAM can be managed medically (eg, with intravenous volume loading, β-blockade, increased cardiac afterload, or discontinuation of inotropic agents), in some cases, SAM persists and surgical correction is required. Various surgical techniques for the management of postrepair SAM have been reported, most of which address excessive leaflet tissue. When the PML height exceeds 1.5 cm and the leaflet closure line is anteriorly displaced, additional leaflet resection or implantation of an artificial chord should be considered. However, if excessive leaflet tissue is not observed, as in the present case, addressing the leaflet may not be appropriate, and thus, alternative procedures are necessary. Papillary muscle reorientation has been reported as a useful technique in the treatment of left ventricular outflow tract obstruction caused by SAM in patients with hypertrophic cardiomyopathy, which is frequently accompanied by abnormal papillary muscle morphology. 3Bryant 3rd, R. Smedira N.G. Papillary muscle realignment for symptomatic left ventricular outflow tract obstruction.J Thorac Cardiovasc Surg. 2008; 135: 223-224Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 4Kwon D.H. Smedira N.G. Thamilarasan M. Lytle B.W. Lever H. Desai M.Y. Characteristics and surgical outcomes of symptomatic patients with hypertrophic cardiomyopathy with abnormal papillary muscle morphology undergoing papillary muscle reorientation.J Thorac Cardiovasc Surg. 2010; 140: 317-324Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar, 5Hodges K. Rivas C.G. Aguilera J. et al.Surgical management of left ventricular outflow tract obstruction in a specialized hypertrophic obstructive cardiomyopathy center.J Thorac Cardiovasc Surg. 2019; 157: 2289-2299Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar, 6Sakaguchi T. Totsugawa T. Tamura K. Hiraoka A. Chikazawa G. Yoshitaka H. Minimally invasive trans-mitral septal myectomy for diffuse-type hypertrophic cardiomyopathy.Gen Thorac Cardiovasc Surg. 2018; 66: 321-326Crossref PubMed Scopus (3) Google Scholar Specifically, excessively mobile or anteriorly displaced papillary muscles pull the AML toward the ventricular septum, potentiating SAM. By tacking the anterior papillary heads to the posterior heads, the papillary muscles and the zone of coaptation are moved away from the ventricular septum, thus eliminating SAM. Although abnormal papillary muscle morphology is unusual in patients with degenerative mitral valve disease, we considered this technique as potentially useful in the treatment of SAM after the repair of organic MR. In the present case, we modified the technique by tacking the approximated papillary muscle heads onto the posterior ventricular wall to potentiate relocation (Figure 3). The suture was passed through the ventricular trabeculae to avoid tearing the ventricular free wall, not passing through the free wall itself. If there is any concern, the suture may be anchored to the most posterior papillary head, which is usually not very mobile. We have performed this reorientation procedure in 3 patients, including those with hypertrophic cardiomyopathy.6Sakaguchi T. Totsugawa T. Tamura K. Hiraoka A. Chikazawa G. Yoshitaka H. Minimally invasive trans-mitral septal myectomy for diffuse-type hypertrophic cardiomyopathy.Gen Thorac Cardiovasc Surg. 2018; 66: 321-326Crossref PubMed Scopus (3) Google Scholar Neither restriction of the leaflet motion nor functional mitral stenosis was noted after this procedure. Although the occurrence of SAM after isolated AML repair is rare,7Brown M.L. Abel M.D. Click R.L. et al.Systolic anterior motion after mitral valve repair: is surgical intervention necessary?.J Thorac Cardiovasc Surg. 2007; 133: 136-143Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar,8Varghese R. Anyanwu A.C. Itagaki S. Milla F. Castillo J. Adams D.H. Management of systolic anterior motion after mitral valve repair: an algorithm.J Thorac Cardiovasc Surg. 2012; 143: S2-S7Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar surgical management can be challenging when excessive leaflet tissue is not found. Papillary muscle reorientation is a useful alternative technique for treating postrepair SAM in organic MR. https://www.annalsthoracicsurgery.org/cms/asset/56c5f4ab-f9e9-4ebe-8171-fd8cad19af41/mmc1.mp4Loading ... Download .mp4 (20.81 MB) Help with .mp4 files Video" @default.
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• W3096758061 title "Papillary Muscle Reorientation for Systolic Anterior Motion After Mitral Valve Repair" @default.
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