Mitral Valve Repair Surgery—When the Right Ventricle is Not Just an Innocent Bystander: A Case Report

JOURNAL TITLE: Journal of Perioperative Echocardiography

Author
1. Azeez Aspari
2. Kartheek Hanumansetty
3. Bineesh Radhakrishnan
4. Diana Thomas
5. Unnikrishnan P Koniparambil
ISSN
2320-527X
DOI
10.5005/jp-journals-10034-1133
Volume
9
Issue
2
Publishing Year
2021
Pages
4
Author Affiliations
    1. Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
    1. Department of Cardiovascular and Thoracic Anaesthesiology, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum, Thiruvananthapuram, Kerala, India
    1. Department of Anesthesia, Postgraduate Institute of Medical Education and Research, Chandigarh, India
    1. Department of Cardiovascular and Thoracic Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Thiruvananthapuram, Kerala, India
    1. Department of Cardiovascular and Thoracic Anaesthesiology, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum, Thiruvananthapuram, Kerala, India
  • Article keywords
    Case report, Intraoperative echo, Mitral valve repair, Mitral valve surgery, Right ventricle dysfunction, Systolic anterior motion, Transesophageal echocardiography

    Abstract

    Aim: To assess rare causes of systolic anterior motion (SAM) of the mitral valve (MV) after MV repair. Background: A preoperative assessment of the MV apparatus is done to predict postoperative SAM in all patients undergoing MV surgery. These parameters include the lengths of MV leaflets and the ratio between them, the aortomitral angle, the distance between the coaptation point and septum, and septal thickness. When predicted, surgical repair is planned with the goal of avoiding the occurrence of SAM. Case description: A 45-year-old man with MV prolapse and severe mitral regurgitation (MR) underwent MV repair after intraoperative transesophageal echocardiography (TEE) assisted confirmation of feasibility. The postoperative risk of SAM was ruled out. Although there was no SAM in the immediate postrepair TEE, he developed hemodynamic instability, which, on reevaluation, was found to be due to new onset SAM. Transgastric imaging revealed inferior wall hypokinesia and right ventricle (RV) dysfunction, which infrequently causes SAM. Medical management was sufficient to address this manifestation. Conclusion: Systolic anterior motion (SAM) may be caused by right ventricular dysfunction even in the absence of other TEE-described predictors. Clinical significance: It is important to identify medically reversible causes of SAM so as to avoid a redo of surgical intervention with a return to cardiopulmonary bypass, especially in the absence of preoperative predictors.

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