1. Complexity and MV Repair Risk for SAM

2. Complexity of RepairRepair TypeMitral Valve Pathology SimpleAnnular RingDilated Annulus More ComplexAnnular Ring Quadrangular resectionDilated Annulus Flail Posterior Scallop Increased ComplexityAnnular Ring Quadrangular Resection Posterior leaflet height adjustment to Prevent SAM Dilated Annulus Flail Posterior Scallop Increased Posterior Scallop height More ComplexAnnular Ring +/- Quad Resection Artificial Chords vs. Transfer ?Larger Ring Dilated Annulus Torn Chordae Risk for Sam More ComplexAbove Plus Anterior Leaflet - resection - shortening - artificial chords Barlow’s Above plus anterior leaflet pathology More ComplexClosing CommissureCommissural Scallop Prolapse More ComplexRings and StringsIschemic MR Complex--Assessing mechanism of post Repair SAM How to fix it Do you want to fix it INCREASED COMPLEXITY Spectrum of Repair Difficulty

3. u 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 u Systolic Anterior Motion of the anterior leaflet of the mitral valve u Produces left ventricular outflow track (LVOT) obstruction. u 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. 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 Risk Factors for SAM

9. Measuring the AL/PL Ratio u 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 1.According to height of the anterior leaflet u Used more in degenerative disease –Especially in patients at risk for SAM –Especially with large anterior leaflets/Barlow type valve u Under sizing ring based on anterior leaflet can increase risk of SAM in degenerative disease with Carpentier Type I and II pathology 2.According to the intertrigonal distance u 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)