Transient systolic anterior motion with junctional rhythm after mitral valve repair in the intensive care unit

Kimiya Fukui,Takeshi Nomura,Nobuo Sato,Masahi Nakagawa,Junya Ishikawa,Yusuke Seino

doi:10.1186/s13089-018-0111-6

Abstract

Systolic anterior motion (SAM) after mitral valve repair (MVR) can adversely affect hemodynamics due to exacerbation of left ventricular outflow tract obstruction and mitral regurgitation. Intraoperative transient SAM after MVR can usually be managed with hemodynamic maneuvers under continuous monitoring by transesophageal echocardiography (TEE). However, during postoperative intensive care management, transient SAM is seldom diagnosed and the start of treatment may be delayed. We present a case of transient SAM after MVR with abrupt deterioration due to junctional rhythm in the intensive care unit (ICU). TEE revealed that conversion from normal sinus rhythm into junctional rhythm induced the exacerbation of SAM. TEE was useful for identifying the etiology of unstable hemodynamics after cardiac surgery in the ICU, similar to its use in the operating room.

Highlights

Systolic anterior motion (SAM) after mitral valve repair (MVR) can adversely affect hemodynamics due to exacerbation of left ventricular outflow tract obstruction (LVOTO) and mitral regurgitation (MR) [1]
transesophageal echocardiography (TEE) is useful for the identification of causes of unstable hemodynamics after cardiac surgery in the intensive care unit (ICU) as well as in the operating room
Some authors reported that ventricular pacing or atrioventricular sequential pacing can affect the severity of SAM [5, 6]

Summary

Background

Systolic anterior motion (SAM) after mitral valve repair (MVR) can adversely affect hemodynamics due to exacerbation of left ventricular outflow tract obstruction (LVOTO) and mitral regurgitation (MR) [1]. Despite difficulty weaning from cardiopulmonary bypass and some persistent surgical bleeding, he was hemodynamically stabilized on admission to the ICU without evidence of SAM and LVOTO He became hemodynamically unstable on the first postoperative day, with parameters as follows: heart rate 87 beats/min (bpm), sinus rhythm, arterial pressure 80/48 mmHg, pulmonary artery pressure 28/20 mmHg, central venous pressure 17 mmHg, cardiac index 1.7 L/ min/m2, right ventricular stroke work index (RVSWI) 1.6 g/m2/beat, and mixed venous oxygen saturation (SvO2) 54%. When normal sinus rhythm converted into junctional rhythm, SAM, LVOTO and severe MR recurred and hemodynamic parameters again became unstable The hemodynamics stabilized and SAM, LVOTO, and MR did not recur (Fig. 4) He discharged from ICU on the 22nd postoperative day and from the hospital on the 43rd postoperative day

Conclusions

Additional files