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Complexity and MV Repair Risk for SAM

Complexity and MV Repair Risk for SAM. Spectrum of Repair Difficulty. INCREASED COMPLEXITY.

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Complexity and MV Repair Risk for SAM

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  1. Complexity and MV RepairRisk for SAM

  2. Spectrum of Repair Difficulty INCREASED COMPLEXITY

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

  4. 4.3cm 3.2cm

  5. SAM • Systolic Anterior Motion of the anterior leaflet of the mitral valve • Produces left ventricular outflow track (LVOT) obstruction. • May produce mitral regurgitation.

  6. Post Repair SAM ME AV LAX

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

  8. Risk Factors for SAM 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

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

  10. Sizing Ring Determining mitral annular ring size has been done by two methods • According to height of the anterior leaflet • Used more in degenerative disease • Especially in patients at risk for SAM • Especially with large anterior leaflets/Barlow type valve • Under sizing ring based on anterior leaflet can increase risk of SAM in degenerative disease with Carpentier Type I and II pathology • According to the intertrigonal distance • Most commonly used in Type IIIb (restrictive leaflet motion in systole) of ischemic and non ischemic cardiomyopathy. • Note in these states typically have dilated LV so risk of SAM is less • Size to normal intertrigonal distance or one size below

  11. Calculating Normal Intertrigonal Distance Intertrigonal Distance = Surgical Annulus Diameter (MELAX) 0.8 Duran et al: J Heart Valve Dis. 1998 Sep;7(5):593-7

  12. Know how the manufacture defines the ring size - Commissure to Commissure(Carpentier classical ring) - Trigone to Trigone(Duran flexible ring)

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