Systolic anterior motion of the mitral valve after aortic valve replacement

Abstract

We present a case of severe systolic anterior motion developing intraoperatively after aortic valve replacement for aortic valve stenosis.KEYWORDS aortic valve replacement; cardiopulmonary bypass; mitral valve; systolic anterior motion; transthoracic echocardiogram S ystolic anterior motion (SAM) of the mitral valve is a paradoxical motion of the anterior, and occasionally posterior, mitral valve leaflet toward the ventricular septum during ventricular systole. Although SAM is well reported in cases of hypertrophic cardiomyopathy, there are relatively fewer cases that describe severe SAM in association with aortic valve replacement (AVR) for aortic valve stenosis.

Severe mitral regurgitation due to geometric changes in the mitral valve after surgical aortic valve replacement

“…Since mild functional MR can improve spontaneously after isolated surgical AVR for aortic valve stenosis [8], a concomitant mitral procedure would not be performed in most cases. However, severe exacerbation of MR following surgical AVR due to the mechanisms mentioned above have been reported in some cases [2][3][4][5][6][7]. In the present case, the observed geometric distortion of the anterior mitral leaflet was atypical for SAM [6,7], and myocardial ischemia-induced leaflet tethering was considered to be unlikely because of a lack of evidence of myocardial hypokinesis and ventricular dilation [5].…”

“…However, severe exacerbation of MR following surgical AVR due to the mechanisms mentioned above have been reported in some cases [2][3][4][5][6][7]. In the present case, the observed geometric distortion of the anterior mitral leaflet was atypical for SAM [6,7], and myocardial ischemia-induced leaflet tethering was considered to be unlikely because of a lack of evidence of myocardial hypokinesis and ventricular dilation [5]. In addition, there were no obvious injuries of the mitral valve as seen in previous cases [2][3][4].…”

“…Acute-onset severe mitral regurgitation (MR) can induce hemodynamic instability and worsen the mortality and morbidity of patients [1]. Reported mechanisms of massive increment of MR after surgical aortic valve replacement (AVR) include iatrogenic perforation or destruction of the mitral leaflets [2][3][4], papillary muscle dysfunction induced by myocardial ischemia [5], and systolic anterior motion (SAM) of the mitral valve [6,7]. Therefore, determination of the etiologies of MR by intraoperative transesophageal echocardiography (TEE) and appropriate decision-making are important.…”

New or Worsened Mitral Regurgitation After Surgical Aortic Valve Replacement: A Systematic Review

“…Across all studies, a total of patients underwent SAVR. The type of prosthesis used differed between the included studies, with 13 3,20,21,[23][24][25][26]30,33,39,41,44,47 implanting a bioprosthesis, 8 15,16,19,29,34,35,40,42 implanting a mechanical prosthesis, and 3 1,36,37 implanting mechanical and biological protheses; 12 studies 22,27,28,31,32,38,43,45,46,[48][49][50] did not specify prosthesis type. The size of the implanted prosthesis ranged from 17 mm 45 to 27 mm 20,24 ; however, 14 studies 1,[27][28][29]31,32,36,37,43,[46][47]…”

“…Of the 207 reported cases of new or worsened MR, 138 patients presented with a worsened severity of MR 1,3,20,[25][26][27]30,32,33,[36][37][38]48 after SAVR, for a reported prevalence of 66.7%. Additionally, 16 patients who received SAVR developed new MR, 15,16,19,21,23,24,34,38,39,44,46,49,50 for a reported prevalence of 7.7%. The remaining 53 cases 22,28,29,31,35,42,45 of reported new or worsened MR could not be specifically categorized due to lack of detail regarding the patients' preoperative status.…”