Postoperative transient left ventricular outflow tract obstruction after mitral valve surgery: A systematic review of anatomical and hemodynamic factors.

Abstract

Transient left ventricular outflow tract obstruction (LVOTO) is a rare but potentially life-threatening complication after mitral valve surgery. It is primarily caused by systolic anterior motion (SAM) of the mitral valve and postoperative geometric changes involving the left ventricle and aorto-mitral angle. Despite advances in perioperative imaging, evidence regarding the mechanisms, predisposing factors, and management of postoperative LVOTO following mitral interventions remains limited. This systematic review was registered in International Prospective Register of Systematic Reviews (PROSPERO) (CRD420251127617) and conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Google Scholar, and ProQuest were searched for reports of postoperative LVOTO following mitral valve surgery published through July 2025. Eligible studies comprised observational studies, case series, and case reports describing clinically or imaging-confirmed LVOTO after mitral valve intervention. Thirty studies (28 case reports, one case series, and one cohort study) comprising 58 patients were included. Most patients were elderly women with degenerative or rheumatic mitral disease. Predisposing anatomical features included an elongated anterior mitral leaflet, a small native or neo-LV outflow tract, a narrow aorto-mitral angle, and basal septal hypertrophy. SAM was documented in more than two-thirds of cases. Management strategies ranged from medical therapy to surgical or transcatheter septal or leaflet modification, with generally favorable clinical outcomes. Postoperative LVOTO following mitral valve surgery results from complex geometric interactions among the mitral leaflets, interventricular septum, and LVOT. Identification of high-risk anatomical features through quantitative imaging may support anticipatory procedural planning and facilitate timely intervention, potentially improving perioperative safety.