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SAM afterMitral Valve Repair
Marc Gillinov, M.D.
Department of Thoracic and Cardiovascular Surgery
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Disclosures• Consultant
- Medtronic- Edwards- CryoLife- Abbott- ClearFlow- AtriCure
• Equity- ClearFlow
• Cleveland Clinic- Right to royalties from AtriCure
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Case
• 58 year-old man
• Asymptomatic
• P2 prolapse
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Triangular Resection
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SAM!
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SAM• What happened?• Predictors• Prevention• Treatment
- Medical- Surgical
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What Is SAM?
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SAM• Definition
- Movement of anterior mitral leaflet into LVOT during
systole
• Mechanisms- AML pulled into LVOT (Venturi effect)- AML pushed
into LVOT (drag)
• Result- LVOT obstruction- MR
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SAM Occurrence
5-8%Repair for degenerative MR
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Predictors
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SAM Predictors• Coaptation-septum distance 15 mm• EDD < 45
mm• Hyperdynamic ventricle
Varghese et al. European J C-T Surg 2013
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P. Denti et al. / Interactive CardioVascular and Thoracic
Surgery
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SAM Predictors
Too much leaflet tissue
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SAM Predictors
Too much leaflet tissueRelative to the ventricle
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Prevention
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Prevention
• General principles- Posterior leaflet height < 15 mm- Avoid
small annuloplasty
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Prevention
• Manage posterior leaflet- Sliding repair- Folding repair-
Short neochordae
• Others- Large, open annuloplasty- Edge-to-edge repair
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Sliding Repair
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Folding Repair
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Jebara et al: Circulation, Vol 88, No 5, Part 2, Nov. 1993
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Treatment
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European Journal of Cardio-Thoracic Surgery 48 (2015)
344–346
SAM Treatment Algorithm
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Pharmacologic Treatment
• Volume load• Discontinue inotropes• B-blockers• Increase
afterload (MAP > 80 mm Hg)
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Pharmacologic Treatment
• Volume load• Discontinue inotropes• B-blockers• Increase
afterload (MAP > 80 mm Hg)
Successful in > 80%
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Surgical Treatment
• After medical management• LVOT gradient > 50 mm Hg• MR >
1+
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Surgical Treatment
• Re-repair valve• Sliding repair• Folding repair• Edge-to-edge
repair• Plicate posterior leaflet• Short posterior neochordae
• Replace valve
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European Journal of Cardio-Thoracic Surgery 48 (2015)
344–346
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Surgical Treatment
• Re-repair valve• Sliding repair• Folding repair• Edge-to-edge
repair• Plicate posterior leaflet• Short posterior neochordae
• Replace valve
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SAM Strategy
• Predict- Echo measurements- Big leaflets/small ventricle
• Prevent- Reduce posterior leaflet height- Large band
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Thank You
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Jebara et al: Circulation, Vol 88, No 5, Part 2, Nov. 1993
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Jebara et al: Circulation, Vol 88, No 5, Part 2, Nov. 1993
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European Journal of Cardio-Thoracic Surgery 48 (2015)
344–346
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European Journal of Cardio-Thoracic Surgery 48 (2015)
344–346
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European Journal of Cardio-Thoracic Surgery 48 (2015)
344–346
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Ann Thorac Surg POSTERIOR LEAFLET SHORTENING
2008;86:1699–700
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JACC Vol. 34, No. 7, 1999
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P. Denti et al. / Interactive CardioVascular and Thoracic
Surgery
SAM after�Mitral Valve RepairDisclosuresCaseSlide Number 4Slide
Number 5Slide Number 6Slide Number 7Slide Number 8Slide Number
9Slide Number 10Slide Number 11Slide Number 12SAMWhat Is
SAM?SAMSlide Number 17Slide Number 18SAM OccurrencePredictorsSlide
Number 21SAM PredictorsSlide Number 25SAM PredictorsSAM
PredictorsPreventionPreventionPreventionSlide Number 31Slide Number
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55TreatmentSlide Number 57Slide Number 58Pharmacologic
TreatmentPharmacologic TreatmentSlide Number 61Slide Number
62Surgical TreatmentSurgical TreatmentSlide Number 65Surgical
TreatmentSAM StrategyThank YouSlide Number 70Slide Number 71Slide
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