title: Management and decision-making strategy for systolic anterior motion after mitral valve repair.
abstract: 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 beta-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.
authors.affiliation: Department of Cardiothoracic Anesthesia and Intensive Care, Università Vita-Salute San Raffaele, Milano, Italia e Istituto Scientifico San Raffaele, Milan, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Crescenzi
authors.forename: Giovanni
authors.initials: G
authors.lastname: Landoni
authors.forename: Alberto
authors.initials: A
authors.lastname: Zangrillo
authors.forename: Fabio
authors.initials: F
authors.lastname: Guarracino
authors.forename: Concetta
authors.initials: C
authors.lastname: Rosica
authors.forename: Giovanni
authors.initials: G
authors.lastname: La Canna
authors.forename: Ottavio
authors.initials: O
authors.lastname: Alfieri
mesh_terms: D000328:Adult; D000368:Aged; D006348:Cardiac Surgical Procedures; D003657:Decision Making; D017548:Echocardiography, Transesophageal; D005260:Female; D006349:Heart Valve Diseases / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000503:physiopathology* / Q000601:surgery*; D008944:Mitral Valve Insufficiency / Q000601:surgery*; D008945:Mitral Valve Prolapse / Q000601:surgery; D016343:Monitoring, Intraoperative; D012086:Reoperation; D013599:Systole; D014694:Ventricular Outflow Obstruction / Q000503:physiopathology