Bulging Subaortic Septum: An Important Risk Factor for Systolic Anterior Motion After Mitral Valve Repair Sameh M. Said, MD, Hartzell V. Schaff, MD,

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Bulging Subaortic Septum: An Important Risk Factor for Systolic Anterior Motion After Mitral Valve Repair Sameh M. Said, MD, Hartzell V. Schaff, MD, Rakesh M. Suri, MD, DPhil, Kevin L. Greason, MD, Joseph A. Dearani, MD, Rick A. Nishimura, MD The Annals of Thoracic Surgery Volume 91, Issue 5, Pages 1427-1432 (May 2011) DOI: 10.1016/j.athoracsur.2011.01.084 Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Transthoracic echocardiography (TEE) of the patient in Case 2 during first cardiac procedure. (A) Posterior mitral valve leaflet prolapse and ventricular septal bulge (white arrow). No evidence of SAM was found at time of TEE. (B) The mitral valve regurgitant jet is eccentric and anteriorly directed. The Annals of Thoracic Surgery 2011 91, 1427-1432DOI: (10.1016/j.athoracsur.2011.01.084) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Intraoperative transthoracic echocardiography (TEE) of the patient in Case 2 during second cardiac procedure. (A) Severe systolic anterior motion (SAM) with prominent septal bulge (white arrow) before bypass. (B) Severe SAM with severe mitral valve regurgitation (MR) and severe left ventricular outflow tract (LVOT) obstruction before bypass. (C) After septal myectomy (white arrow), no evidence of SAM was found when LVOT was opened wide. (D) Postseptal myectomy TEE with no SAM, widely opened LVOT, and minimal MR. The Annals of Thoracic Surgery 2011 91, 1427-1432DOI: (10.1016/j.athoracsur.2011.01.084) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Intraoperative transesophageal echocardiography of the patient in Case 3 during first cardiac procedure. (A) Septal bulge (white arrow) before bypass. (B) Anteriorly directed mitral valve regurgitation (MR) jet and septal bulge (white arrow) but no systolic anterior motion (SAM) before bypass. (C) Severe SAM with mild LVOT obstruction noted initially after bypass. (D) Severe mitral valve regurgitation (MR). MR and left ventricular outflow tract (LVOT) obstruction improved with administration of vasopressors and fluids after bypass. The Annals of Thoracic Surgery 2011 91, 1427-1432DOI: (10.1016/j.athoracsur.2011.01.084) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Intraoperative transesophageal echocardiography of the patient in case 3 during second cardiac procedure. (A) Severe mitral valve regurgitation (MR) due to severe systolic anterior motion (SAM) with a posteriorly directed jet (white arrow) before bypass. (B) Septal bulge (white arrow) and severe SAM before bypass. (C) Postseptal myectomy with no SAM. (D) No MR and no left ventricular outflow tract (LVOT) obstruction after septal myectomy. The Annals of Thoracic Surgery 2011 91, 1427-1432DOI: (10.1016/j.athoracsur.2011.01.084) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions