Trapezoidal resection of an elongated anterior mitral leaflet and Alfieri stitch in hypertrophic cardiomyopathy

Fig. 1. (Top) Preoperative transthoracic echocardiography revealed a left ventricular outflow obstruction caused by systolic anterior motion of the anterior mitral leaflet. The septal thickness was 17 mm at the contact point. (Lower) Postoperatively, echocardiography showed the absence of systolic anterior motion and mitral regurgitation. Accelerated flow in the left ventricular outflow tract was not detected

Fig. 2. Cardiac magnetic resonance imaging in late systole. In this patient, two mechanisms of SAM were postulated. One was that the tips of papillary muscles anomalously deviated anteriorly. The papillary muscles were connected with the septum with abnormal fibrous tissue and touching the septum in systole. The other mechanism involves the elongated anterior leaflet. It was turned over by the blood flow through LVOT, as described by Schwammenthal et al. [1]

Fig. 3. After subvalvular manoeuvres, the coaptation of A2 and P2 was evaluated using a blue marker (top). A 5–0 expanded polytetrafluoroethylene horizontal mattress suture was placed, with the elongated portion of the anterior leaflet below the stitch (middle). The segment (solid line) with the attached chorda was resected (middle and bottom). Finally, the ePTFE stitch was tied, and the mitral valve remained competent