Hartford HealthCare Heart & Vascular Institute

Systolic anterior motion (SAM) is a common and troublesome complication of mitral valve repair and it occurs in 10-15% of cases. SAM is defined as the displacement of the anterior mitral leaflet towards the left ventricular outflow tract causing left ventricular outflow tract obstruction. Part of any repair, is the placement of a ring to reshape and reduce the size of the annulus. The decrease in the annular surface area pushes the anterior leaflet into the left ventricular outflow tract causing obstruction.

In order to avoid SAM, the posterior leaflet needs to be reduced in height to create more space for the anterior leaflet. The classic treatment, called sliding leaflet technique, resects portions of the posterior leaflet. The technique is efficacious but is also time consuming and technically demanding. The ring advancement technique, described by Dr. Hashim, consists in excluding the excess posterior leaflet, placing it outside of the ring. This allows for more room within the annuls for the anterior leaflet. It requires no resection.

The treatment of mitral valve disease with severe mitral annular calcification (MAC) is challenging for surgeons. Surgical mitral valve replacement in patients with MAC is linked to increased cardiovascular mortality and morbidity because of the heightened risk of atrioventricular groove rupture, circumflex artery injury, perivalvular leak, or systemic embolism. These risks can occur during or following traditional debridement or removal of the MAC. Many patients with severe MAC are deemed inoperable.

To mitigate the risks associated with surgical mitral valve replacement in patients with severe MAC, surgeons at Hartford Hospital use the Cavitron Ultrasonic Surgical Aspirator (CUSA). The CUSA device allows for safe and effective debridement of severe MAC. The CUSA is a handheld device that converts electromagnetic energy into ultrasonic vibrations using a piezoelectric transducer. These ultrasonic vibrations are amplified down the body of the device to the surgical tip, where the ultrasonic vibrations create a low-pressure cavitation, pulverizing the tissue at the point of contact with the surgical tip. The use of CUSA needs to be meticulous and purposeful. Seventeen patients had successful mitral valve repair or replacement with the use of the CUSA for mitral valve disease with severe MAC at Hartford Hospital.