In the clinical case reported herein, a 62‑year‑old female patient with hypertrophic cardiomyopathy and systolic anterior motion syndrome, with a EuroSCORE II risk of 4.07 percent, was treated with a transaortic Morrow myectomy.
Immediately after restoration of cardiac activity, the mitral valve functioned adequately, with complete absence of systolic anterior motion (SAM). Initial transesophageal echocardiography confirmed excellent leaflet coaptation. Unexpectedly, five minutes later, the leaflets stopped coapting and exhibited divergent, asynchronous motion, with no evidence of structural damage or residual outflow obstruction. However, five minutes thereafter, normal valve function returned spontaneously.
This five-minute on off cycling persisted for several consecutive cycles without any changes in hemodynamic status or inotropic support that could have explained the phenomenon. The erratic and entirely unpredictable behavior of the leaflets—alternating between competent and incompetent states—precluded any confidence in long‑term valve durability or safety. Given the impossibility of forecasting leaflet performance and the associated risk of acute mitral regurgitation, valve repair was abandoned, and mitral valve replacement was performed.
A mechanical prosthesis was implanted with good postoperative function. The patient had an uneventful recovery with no further coaptation abnormalities.
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