This letter was referred to Drs. Sternik and Zehr, who reply in this manner:
We appreciate the letter from Dr. Muresian regarding our technique for the prevention of SAM after repair.1 As Dr. Muresian correctly noted, the technique is easy to perform and is reproducible. We transferred mid-posterior-leaflet chordae tendineae of the resected portion of posterior leaflet to the underside of the mid-anterior leaflet approximately 2 cm from the free margin. This prevented the motion of the redundant edge of the anterior leaflet into the left ventricular outflow tract. It is helpful if the chordae tendineae chosen are mid-posteriorly oriented, as pointed out by Dr. Muresian.
We agree that our technique may prevent left ventricular and annular dilatation in patients with ischemic mitral insufficiency and may contribute to the maintenance of the normal ventricular geometry by stabilizing the septal-lateral dimension. Dr. Muresian also states that it would be tempting to evaluate this technique for use in hypertrophic cardiomyopathy. We concur that this is logical, because the mechanism of a redundant anterior leaflet's being dragged into the left ventricular outflow tract by the Venturi effect is similar to the SAM that occurs after posterior leaflet resection and band annuloplasty.
We believe that in most cases with a high risk of SAM—such as hyperdynamic ventricle with small cavity, hypertrophic cardiomyopathy, and redundant anterior leaflet—this technique could be important. Usually, the surgeon can identify a suitable secondary or even primary chorda tendinea from the resected portion of the posterior leaflet to transfer to the underside of the middle of the anterior leaflet. In addition, there is an option to add artificial chordae using expanded polytetrafluoroethylene suture rather than transfer native chordae to the underside of the anterior leaflet to prevent SAM. Dr. Muresian points out that the technique could be applied in select cases with intact chordae, but perhaps not in cases of myxomatous disease and fibroelastic deficiency that are characterized by elongated, thin, and frail chordae tendineae. In such cases, one can use papillary muscle repositioning, as described by Dreyfus,2 to shorten the transferred chordae tendineae.
We believe that a surgeon should first try this technique when resecting a portion of the posterior leaflet in patients with the risk of SAM as we have described. It would be interesting to expand the indications for this technique and to see the results in a larger group of patients with longer follow-up.
Leonid Sternik, MD
Department of Cardiac Surgery, Sheba Medical Center, Tel-Hashomer, Israel
Kenton J. Zehr, MD
Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
Footnotes
Letters to the Editor should be no longer than 2 double-spaced typewritten pages and should contain no more than 6 references. They should be signed, with the expectation that the letters will be published if appropriate. The right to edit all correspondence in accordance with Journal style is reserved by the editors.
References
- 1.Sternik L, Zehr KJ. Systolic anterior motion of the mitral valve after mitral valve repair: a method of prevention. Tex Heart Inst J 2005;32:47–9. [PMC free article] [PubMed]
- 2.Dreyfus GD, Bahrami T, Alayle N, Mihealainu S, Dubois C, De Lentdecker P. Repair of anterior leaflet prolapse by papillary muscle repositioning: a new surgical option. Ann Thorac Surg 2001;71:1464–70. [DOI] [PubMed]