Comprehensive left ventricular outflow tract management beyond septal reduction to relieve obstruction

Figure 1.. Intra-operative resting and after provocation demonstrating SAM and severe MR. (a) At rest and (b) following provocation intra-operative trans-esophageal echocardiography images showing a long axis view of the left ventricle prior to intervention and after isoproterenol provocation. The white asterik shows severe SAM. (c) Intra-operative trans-esophageal echocardiogram image demonstrating significant LVOT flow acceleration (black asterik) following isoproterenol infusion with significant MR at a posteriorly directed jet. SAM: systolic anterior motion; MR: mitral regurgitation; LVOT: left ventricular outflow tract.

Figure 2.. Techniques that deal with the anterior leaflet of the MV and itsw attachments in the setting of HOCM: plication and Alfieri techniques. (a) Plication technique. Resection of hypertrophied septum is carried out with a number 10 blade knife, starting at the level of the right coronary ostia and moving anteriorly (leftward). Traction is supplied by a trefoil hook placed deeply within the ventricular cavity. (b) The hypertrophied papillary muscles are released and thinned with a pituitary rongeur. Often the papillary muscles have grown into the anterior septum or there are abnormal attachments, which can be divided without fear of causing mitral insufficiency. (c), (d) Plication of elongated anterior mitral leaflet. Base (c) versus free edge (d). (c) Plication of the anterior leaflet of the MV is accomplished with the placement of four to six horizontal mattress sutures of 5-0 proline. (e), (f) Alfieri technique. View from the aortic orifice and (e) sagittal view. The edge-to-edge U suture is placed in the central portion of the leaflets (A2 and P2) on either side. (a)–(c) Were reprinted with permission from Swistel and Balaram. 31 (d) Was reprinted with permission from Hodges et al.…

Figure 3.. Techniques that deal with the anterior leaflet of the MV and its attachments in the setting of HOCM: mitral leaflet extension and resection of ectopic secondary chordae. (a) Mitral leaflet extension technique. Detached anterior mitral leaflet for exposure. (b) View of septum after septal myectomy. (c) Final view of the MV. (a)–(c) were reprinted with permission from Bayburt et al. 38 MV: mitral valve; HOCM: hypertrophic obstructive cardiomyopathy.

Figure 4.. (a), (b) Resection of ectopic secondary chordae causing tethering of the anterior leaflet of the MV and SAM. Tethering secondary chordae are often present on the anterior mitral leaflet that pull the leaflet into the left ventricular outflow tract. Resectioning these chordae allows the zone of coaptation to move posteriorly, away from the outflow tract. (c)–(e) Technique that addresses the MV sub-valvular apparatus by re-aligning the papillary muscles posteriorly using a plegeted 4-0 Goretex suture. Large, excessively mobile or anteriorly displaced papillary muscles can contribute directly to the LVOTO and pull the anterior leaflet toward the outflow tract, potentiating SAM. Papillary muscle reorientation is performed by tacking anterior papillary muscle heads to posterior heads, moving the papillary muscles and MV zone of coaptation away from the outflow tract. (a), (c) were reprinted with permission from Hodges et al.32 SAM: systolic anterior motion; LVOTO: left ventricular outflow tract obstruction; MV: mitral valve.

Figure 5.. Myxomatous valve. (a) P2 prolapse with a tall prolapsing segment. (b)–(d) Mitral valve repair. (b) posterior chordae significantly reduced in height. (c), (d) Coaptation of the posterior leaflet inside the ventricle.