Abstract
BACKGROUND: Systolic anterior motion (SAM) of the mitral valve is a well-known complication after mitral valve repair; however, late-onset SAM is extremely rare. CASE SUMMARY: A 72-year-old woman developed progressive dyspnea 8 years after mitral valve repair. Echocardiography revealed severe mitral regurgitation due to SAM, attributed to leaflet elongation, left ventricular reverse remodeling, and a sigmoid septum. The patient underwent totally endoscopic removal of the annuloplasty ring combined with an Alfieri stitch. Postoperative echocardiography confirmed complete resolution of SAM and mitral regurgitation. DISCUSSION: In this case, the removal of the annuloplasty ring allowed restoration of leaflet mobility, and the Alfieri stitch provided central coaptation, successfully eliminating SAM and mitral regurgitation. TAKE-HOME MESSAGES: Late-onset SAM can occur years after mitral valve repair owing to leaflet elongation, left ventricular reverse remodeling, and a sigmoid septum. Totally endoscopic ring removal combined with the Alfieri stitch is a feasible and effective treatment.