A surgeon's toolkit for mitral valve-induced left ventricular outflow tract obstruction with minimal septal hypertrophy.

Abstract

Even in the absence of significant left ventricular hypertrophy, abnormalities of the mitral valve leaflets and subvalvular apparatus can contribute to left ventricular outflow tract obstruction. We present a toolkit of techniques for mitral valve repair and replacement in this setting. Our approach to mitral valve repair for left ventricular outflow tract obstruction follows 2 key principles: modification of the abnormal effects of flow vortices that displace the leaflets into the left ventricular outflow tract and restoration of a more posterior leaflet coaptation zone. Selection of surgical techniques is guided by the patient's pathoanatomical abnormalities. Over the past 3 decades, tailored techniques for mitral valve repair to relieve left ventricular outflow tract obstruction with minimal or no left ventricular hypertrophy have been developed. These include anterior leaflet shortening, posterior leaflet height reduction, reorientation of mobile and anteriorly displaced papillary muscle heads, and relocation and partial resection of excessively hypertrophied papillary muscle heads. When required, often due to leaflet and annular rigidity, mitral valve replacement can be performed using techniques that enable stent-mounted bioprosthetic valve implantation. Mitral surgery can relieve left ventricular outflow tract obstruction in patients with minimal septal hypertrophy. Repair is often feasible in most cases. When necessary, mitral valve replacement can be performed using techniques that allow for safe and effective stent-mounted bioprosthetic valve implantation, minimizing the risk of stent-induced left ventricular outflow tract obstruction while sparing patients lifelong anticoagulation.