Complexity and MV RepairComplexity and MV RepairRisk for SAMRisk for SAM

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 AnnulusTorn ChordaeRisk for Sam

More Complex Above PlusAnterior Leaflet - resection - shortening - artificial chords

Barlow’sAbove plus anteriorleaflet pathology

More Complex Closing Commissure Commissural ScallopProlapse

More Complex Rings and Strings Ischemic MR

Complex --Assessing mechanism of post Repair SAM How to fix it Do you want to fix it

INC

RE

AS

ED

CO

MPL

EX

ITY

Spectrum of Repair Difficulty

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

4.3cm

3.2cm

SAMSAM

Systolic Anterior Motion of the anterior Systolic Anterior Motion of the anterior leaflet of the mitral valveleaflet of the mitral valve

Produces left ventricular outflow track Produces left ventricular outflow track (LVOT) obstruction.(LVOT) obstruction.

May produce mitral regurgitation.May produce mitral regurgitation.

Post Repair SAMME AV LAX

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

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

Risk Factors for SAM

Measuring the AL/PL RatioMeasuring the AL/PL Ratio

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

Sizing RingSizing Ring

Determining mitral annular ring size has been done by Determining mitral annular ring size has been done by two methodstwo methods1.1. According to height of the anterior leafletAccording to height of the anterior leaflet

Used more in degenerative disease Used more in degenerative disease – Especially in patients at risk for SAMEspecially in patients at risk for SAM– Especially with large anterior leaflets/Barlow type valveEspecially with large anterior leaflets/Barlow type valve

Under sizing ring based on anterior leaflet can increase risk of SAM Under sizing ring based on anterior leaflet can increase risk of SAM in degenerative disease with Carpentier Type I and II pathologyin degenerative disease with Carpentier Type I and II pathology

2.2. According to the intertrigonal distanceAccording to the intertrigonal distance Most commonly used in Type IIIb (restrictive leaflet motion in systole) Most commonly used in Type IIIb (restrictive leaflet motion in systole)

of ischemic and non ischemic cardiomyopathy.of ischemic and non ischemic cardiomyopathy.– Note in these states typically have dilated LV so risk of SAM is lessNote in these states typically have dilated LV so risk of SAM is less– Size to normal intertrigonal distance or one size belowSize to normal intertrigonal distance or one size below

Calculating Normal Intertrigonal DistanceCalculating Normal Intertrigonal Distance

Intertrigonal Distance = Intertrigonal Distance = Surgical Annulus Diameter (MELAX)Surgical Annulus Diameter (MELAX)

0.80.8

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

Know how the manufacture defines the ring Know how the manufacture defines the ring sizesize

- Commissure to Commissure- Commissure to Commissure(Carpentier classical ring)(Carpentier classical ring)

- Trigone to Trigone- Trigone to Trigone(Duran flexible ring)(Duran flexible ring)