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J Thorac Cardiovasc Surg 2009;137:320-325
© 2009 The American Association for Thoracic Surgery

Acquired Cardiovascular Disease

Management and decision-making strategy for systolic anterior motion after mitral valve repair

^a Department of Cardiothoracic Anesthesia and Intensive Care, Università Vita-Salute San Raffaele, Milano, Italia e Istituto Scientifico San Raffaele, Milan, Italy
^b Department of Cardiac Surgery, Università Vita-Salute San Raffaele, Milano, Italia e Istituto Scientifico San Raffaele, Milan, Italy
^c Department of Cardiothoracic Anesthesia and ICU and Cardiac Surgery, Azienda Ospedaliera Universitaria Pisana, Cisanello Hospital, Pisa, Italy

Received for publication April 23, 2008; revisions received July 2, 2008; accepted for publication August 7, 2008.

^_* Address for reprints: Giovanni Landoni, MD, Department of Cardiothoracic Anesthesia and Intensive Care, Istituto Scientifico San Raffaele, Milano, Italia, Via Olgettina 60 Milano, 20132 Italy. (Email: landoni.giovanni{at}hsr.it).

Objective: Systolic anterior motion can complicate mitral valve repair. It can have no clinical consequence or cause low cardiac output syndrome and hypotension. The management of systolic anterior motion in the operating room remains controversial: some groups advocate nonsurgical management, and others propose immediate surgical correction. Conventional hemodynamic measures require time and can be unsuccessful. While describing our experience, we propose a simple and innovative management and classification of this complication.

Methods: Presenting the data of 608 consecutive patients who underwent mitral valve repair for degenerative mitral valve disease, we describe a novel 2-step conservative management consisting of intravascular volume expansion and discontinuation of inotropic drug (step 1) and increasing afterload by means of ascending aortic manual compression while administering β-blockers (step 2). We also describe a novel classification of systolic anterior motion: easy to revert (responding to step 1), difficult to revert (responding to step 2), or persistent.

Results: The overall incidence of systolic anterior motion was 9.8% (60/608): 40 patients had easy-to-revert systolic anterior motion, and 15 had difficult-to-revert systolic anterior motion. Five patients had a persistent condition and underwent surgical intervention within 48 hours.

Conclusions: Systolic anterior motion after repair of a degenerative mitral valve is common. Surgical revision in the minority of patients unresponsive to standard conservative management is suggested.