Urgent Myectomy for Hemodynamic Instability: Leveraging the Advantages of a Perceval Sutureless Valve for Unexpected Systolic Anterior Motion After Declamping the Aorta.

Sutureless aortic valve replacement (AVR) has been widely recognized for its ability to reduce aortic cross-clamp and cardiopulmonary bypass times while allowing for intraoperative repositioning or reimplantation. However, unexpected complications such as systolic anterior motion (SAM) can arise, necessitating additional surgical interventions. We report the case of a 61-year-old male with a history of hypertension and Behçet's disease in his youth, which had remained clinically inactive. He presented with worsening dyspnea, and preoperative echocardiography revealed moderate aortic stenosis with a bicuspid aortic valve and moderate mitral regurgitation secondary to chordal rupture. Although the patient did not strictly meet the criteria for SAM risk, he had a mildly hypertrophied interventricular septum measuring 13 mm. The patient underwent concomitant mitral valve repair and sutureless AVR using a Perceval valve. Following aortic declamping, intraoperative transesophageal echocardiography revealed severe SAM and left ventricular outflow tract obstruction with worsening mitral regurgitation. Notably, septal hypertrophy was more pronounced intraoperatively, and the left ventricular morphology was determined to be a significant contributing factor to SAM. Given the hemodynamic instability, a myectomy was performed through the aortic valve approach. The sutureless Perceval valve was easily removed and reimplanted, allowing for rapid completion of the procedure without excessive prolongation of myocardial ischemia. Compared to a standard bioprosthesis, the ease of valve removal and repositioning provided a crucial advantage in this setting, facilitating prompt surgical intervention. Postoperatively, the patient recovered well, with no residual SAM or mitral regurgitation on follow-up echocardiography. This case highlights the utility of sutureless AVR in complex cardiac surgery, particularly in scenarios requiring additional intraoperative interventions. The ability to promptly remove and reposition the valve enabled effective management of SAM while minimizing ischemic time, underscoring its advantage over conventional bioprosthetic valves in such situations.