title: Management of systolic anterior motion after mitral valve repair: an algorithm.
abstract: OBJECTIVE
  To evaluate the effectiveness and outcomes of an intraoperative and postoperative algorithm for managing systolic anterior motion (SAM) after mitral valve repair (MVRr).
  
  
  METHODS
  All consecutive patients who underwent MVRr for degenerative disease from January 2002 to June 2011 were included, with the data collected retrospectively. Patients who underwent MVRr for primary SAM were excluded from the study. Patients who developed SAM after the repair were systematically treated according to the algorithm. The intraoperative algorithm first involved medical management techniques, followed by surgical correction for significant SAM (mild or greater mitral regurgitation, left ventricular outflow tract gradient > 50 mm Hg). The postoperative algorithm focused on medical management and symptoms to guide the treatment decisions.
  
  
  RESULTS
  The overall in-hospital incidence of SAM was 6.6% (52/785). In 41 patients, SAM was identified in the operating room, and in 11 patients, it was found postoperatively on the predischarge echocardiogram. Of the 41 patients with intraoperative SAM, 35 (85.4%) had resolution with medical management and 6 (14.6%) required surgical repeat repair while in the operating room. No patient required mitral valve replacement for persistent SAM. Postoperatively, 11 new cases were identified, and 7 cases of resolved intraoperative SAM recurred. These postoperative cases of SAM were managed according to the postoperative SAM algorithm. At last follow-up, 17 (94.4%) of 18 patients had resolution of SAM and 1 (5.6%) patient had mild SAM (less than mild mitral regurgitation, peak left ventricular outflow tract gradient < 50 mm Hg) and were asymptomatic. No patients with postoperative SAM required reoperation after their initial surgery. The median echocardiographic follow-up was 1.3 years. During follow-up, 1 early death (noncardiac) and 2 late deaths (1 noncardiac, 1 of unknown etiology) occurred.
  
  
  CONCLUSIONS
  SAM is a relatively frequent complication after MVRr and can occur intraoperatively or postoperatively. A systematic approach addressing perioperative SAM after MVRr yields excellent mid-term results.
authors.affiliation: Department of Cardiothoracic Surgery, Mount Sinai Medical Center, New York, NY 10029, USA. robin.varghese@mountsinai.org
authors.forename: Robin
authors.initials: R
authors.lastname: Varghese
authors.forename: Anelechi C
authors.initials: AC
authors.lastname: Anyanwu
authors.forename: Shinobu
authors.initials: S
authors.lastname: Itagaki
authors.forename: Federico
authors.initials: F
authors.lastname: Milla
authors.forename: Javier
authors.initials: J
authors.lastname: Castillo
authors.forename: David H
authors.initials: DH
authors.lastname: Adams
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D006348:Cardiac Surgical Procedures / Q000009:adverse effects*; D005260:Female; D006349:Heart Valve Diseases / Q000601:surgery*; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects; D006801:Humans; D007430:Intraoperative Care; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D058386:Mitral Valve Annuloplasty / Q000009:adverse effects; D008944:Mitral Valve Insufficiency / Q000209:etiology / Q000628:therapy; D008945:Mitral Valve Prolapse / Q000000981:diagnostic imaging / Q000209:etiology / Q000503:physiopathology / Q000628:therapy*; D009519:New York City; D011182:Postoperative Care; D012086:Reoperation; D012189:Retrospective Studies; D013599:Systole; D013997:Time Factors; D016896:Treatment Outcome; D014463:Ultrasonography; D014694:Ventricular Outflow Obstruction / Q000209:etiology / Q000628:therapy