Surgical Management for Systolic Anterior Motion (SAM) of the Mitral Valve in Obstructive Hypertrophic Myopathy

Figures

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  Fig. 1. Schema of the surgical technique of plication of the AML. (A) Vertical plication. The AML is plicated along its long axis to reduce the billowing of the AML. (B) RPR (resection-plication-release) strategy. If the AML is excessively long, a horizontal plication can be performed, or if a residual leaflet portion is present, it can be resected. (C) Partial anterior leaflet valvuloplasty. A redundant lateral segment of the AML is plicated by folding its elongated portion underneath the body of the AML. AML: anterior mitral leaflet

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  Fig. 2. Schema of the surgical technique of extension of the AML. (A) AMLE (anterior mitral leaflet extension). It involves the vertical incision of the AML, followed by the suture of an oval autologous pericardial patch pretreated with glutaraldehyde. (B) Transverse incision of the AML. Transverse incision of the AML is made along the anterior annulus and is covered with an oval autologous pericardial patch pretreated with glutaraldehyde. AML: anterior mitral leaflet

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  Fig. 3. Schema of the surgical technique of sutures of the AML. (A) Edge-to-edge repair. The free edges of the AML and the posterior mitral leaflet are approximated at the site of regurgitation with a running 4-0 polypropylene monofilament suture or pledgeted polypropylene monofilament mattress sutures. (B) Asymmetric Alfieri’s stitch. The edge-to-edge suture is placed between the A1 and P1 segments and not in the midline. (C) ALRP (anterior leaflet retention plasty). The segments of the AML closest to the trigones are sutured to the corresponding posterior annulus with pledgeted polypropylene monofilament mattress sutures. AML: anterior mitral leaflet

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  Fig. 4. Schema of the surgical technique of a floating stitch. (A) Surgeons’ view. A double-arm Gore-Tex suture is applied to just the middle of the tip of the AML (A2) in a figure-eight fashion, and both arms of the suture are fixed to the annuloplasty ring at the middle of the posterior annulus (P2). (B) Long axis view. The length of the suture is then usually determined as A2–P2 length plus 2–3 mm of extra length on a water test. The AML is prevented from touching the IVS and SAM can theoretically be solved. AML: anterior mitral leaflet; IVS: interventricular septum; SAM: systolic anterior motion

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  Fig. 5. Schema of the surgical technique of traction of the AML. (A) Papillary muscle-to-anterior annulus stitches. Two double-armed 4-0 Gore-Tex sutures are placed on the tip of the head of the posterior papillary muscle, passed through at about the mid-AML, and are tightly tied onto the annuloplasty ring on the anterior annulus. (B) Paradoxical stitches. Two artificial chords are diagonally implanted at 5 and 7 o’clock locations between the posterior annulus and the AML. The paradoxical stitches avoid the contact between the tip of the elongated AML and the intraventricular septum. (C) Transposition of a directed chorda tendinea to the AML. The redundant AML is tethered posteriorly by transposition of a posteriorly directed chorda tendinea to an intermediate position on the ventricular side of the AML between the primary and secondary chordae tendineae of the A2 segment. AML: anterior mitral leaflet

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  Fig. 6. Schema of the surgical technique for the PML or papillary muscle. (A) Reduction height of the PML. The height of the PML is reduced by using pledgeted interrupted horizontal mattress sutures. (B) Sliding plasty of the PML. Sliding plasty of the PML reduces the PML height if this procedure was not carried out at the initial repair. (C) Papillary muscle reorientation. One or more pledgeted mattress sutures are placed to the posterior papillary muscle head and are passed through the anterior head to realign both anterolateral and posteromedial papillary muscles. PML: posterior mitral valve leaflet