scholarly journals P1286 A retrospective clinical and anatomical characteristics study of transaortic extended left ventricular myectomy for obstructive hypertrophic cardiomyopathy

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
A Furugen ◽  
H D Doi ◽  
K M Mitsube ◽  
M H Hashimoto ◽  
R K Koshima
Keyword(s):  
Mitral Valve ◽  
Beta Blockers ◽  
Good Control ◽  
Hypertrophic Obstructive Cardiomyopathy ◽  
Left Ventricular ◽  
Medium Term ◽  
Mitral Valve Leaflet ◽  
Anatomical Characteristics ◽  
Septal Myectomy ◽  
Stress Echo

Abstract Objective Surgical septal myectomy is the gold-standard therapy for hypertrophic obstructive cardiomyopathy (HOCM). The aims of our study are to investigate anatomical characteristics and make clear effectiveness of transaortic extended left ventricular (LV) myectomy for HOCM. Methods This study enrolled 28 consecutive patients (age 66.7 ± 12.1 years, 46% Female) from 2012 to 2018 who met the following inclusion criteria: symptoms of heart failure persisting despite optimal medical therapy including beta blockers and Class I anti-arrhythmic agent, LV outflow tract gradient (LVOTG) > 50mmHg at rest or with provocation using stress echo (exercise TTE or low-dose dobutamine stress echo). We evaluated LV dimension, LVOTG, mitral regurgitation (MR), systolic anterior motion of mitral valve (SAM), Mitral complex morphology, high echoic region of endocardium and appearance of abnormal muscle bundles including apical-basal muscle bundle. These parameters were evaluated based on changes in LVOTG, MR and SAM at after LV myectomy. Also, intraoperative findings and cardiomyocytes pathological findings were evaluated. Stress echo were performed to investigate sustained reduction of LVOTG at medium term. Results All patients were successfully underwent transaortic extended LV myectomy. SAM was identified in all and moderate MR in 14 patients. The anterior mitral valve leaflet height was large in all patients and 16 patients had LV abnormal muscle bundles. Postoperative LVOTG were controlled in 10mmHg or less. SAM disappeared completely in all patients and MR were decreased mild or less. LVOTG were sustained good control in 10mmHg or less under stress echo at medium term. Conclusion LV myectomy provides excellent relief from LVOT obstruction. The appearance of mitral valve anterior leaflet and abnormal band may be important keys of LVOT obstruction.

scholarly journals So Many Ways…

2021 ◽  
Author(s):  
Fayyaz Hashmi
Keyword(s):  
Mitral Valve ◽  
Excellent Result ◽  
Ventricular Outflow Tract ◽  
Hypertrophic Obstructive Cardiomyopathy ◽  
Left Ventricular ◽  
Pericardial Patch ◽  
Mitral Valve Leaflet ◽  
Septal Myectomy ◽  
Autologous Pericardial Patch ◽  
Left Ventricular Outflow

Enlargement of left ventricular outflow tract using an autologous pericardial patch for the anterior mitral valve leaflet and septal myectomy through trans-mitral approach for the hypertrophic obstructive cardiomyopathy Zhang et al (1) describe their experience in septal myectomy for hypertrophic obstructive cardiomyopathy. Of 247 consecutive cases with HOCM treated during 2016-2019 with a variety of techniques, this report is on 16 patients who underwent trans-mitral septal myectomy and enlargement of left ventricular outflow with an autologous pericardial patch in transverse configuration. The technique reportedly decreased the gradient from average 90+ to 10+ mm Hg and resolved systolic anterior leaflet motion in all with only mild residual mitral regurgitation. There were no deaths or any other major complications in this group. It is a small group of patients with excellent result but no definitive conclusion can be drawn regarding validity of the technique from this study. The controversy remains regarding the approach, trans-aortic vs. trans-mitral and whether leaflets should be left alone, plicated or lengthened as well as whether mitral valve should be repaired or replaced in addition to septal myectomy. One certainty remains, extended myectomy done either way, is the foundation of the surgical treatment of hypertrophic cardiomyopathy.

scholarly journals Enlargement Of Left Ventricular Outflow Tract Using An Autologous Pericardial Patch For The Anterior Mitral Valve Leaflet And Septal Myectomy Through Trans-mitral Approach For The Treatment Of Hypertrophic Obstructive Cardiomyopathy

2020 ◽  
Author(s):  
Hongqiang Zhang ◽  
Kai Zhu ◽  
Fanshun Wang ◽  
Xiaoning Sun ◽  
Shouguo Yang ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Ventricular Outflow Tract ◽  
Hypertrophic Obstructive Cardiomyopathy ◽  
Left Ventricular ◽  
Pericardial Patch ◽  
Valve Leaflet ◽  
Mitral Valve Leaflet ◽  
Septal Myectomy ◽  
Autologous Pericardial Patch ◽  
Left Ventricular Outflow

Abstract Background: Modified Morrow procedure is the gold standard of surgical intervention for hypertrophic obstructive cardiomyopathy (HOCM). However, there are certain cases without clear exposure through the traditional trans-aortic approach; we therefore described a trans-mitral approach by enlarging left ventricular outflow tract (LVOT) using an autologous pericardial patch for the anterior mitral valve leaflet and septal myectomy. We aimed to retrospectively analyze this series of patients to reveal its safety and efficiency.Methods: We retrospectively analyzed 16 HOCM patients underwent enlargement of LVOT using an autologous pericardial patch for the anterior mitral valve leaflet and septal myectomy through trans-mitral approach in our center from January, 2016 to December, 2019. Baseline characteristics, operative details and postoperative data were extracted from our hospital medical records. Results: Of the 16 patients, there was no operative mortality. No new onset atrial fibrillation, no new onset stroke with symptoms, no permanent pacemaker implantation and no ventricular septal defects formation were observed during operation and three months follow-up. The peak pressure gradient of LVOT decreased from 97.56±23.81 mmHg to 7.56±2.13 mmHg (P < 0.01) after operation and 10.19±2.93 mmHg (P < 0.01) three months after operation. The average aortic cross-clamp time was 54.56±6.10 mins (range, 48 to 69 minutes). The systolic anterior motion (SAM) sign disappeared uneventfully in all cases. No patients had more than moderate MR.Conclusions: Enlargement of LVOT using an autologous pericardial patch for the anterior mitral valve leaflet and septal myectomy through trans-mitral approach is feasible and reliable for the treatment of certain types of HOCM cases.Trial registration: Not applicable.

scholarly journals P264 Alcohol septal ablation in hypertrophic obstructive cardiomyopathy with mitral insufficiency of mixed mechanism

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
D Penes ◽  
M Anton ◽  
C O Maresiu ◽  
S Boeangiu ◽  
C Margineanu ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Mitral Valve ◽  
Contrast Echocardiography ◽  
Interventricular Septum ◽  
Hypertrophic Obstructive Cardiomyopathy ◽  
Left Ventricular ◽  
Left Internal Carotid Artery ◽  
Mitral Insufficiency ◽  
Alcohol Septal Ablation ◽  
Mitral Valve Leaflet

Abstract Alcohol septal ablation is a percutaneous intervention for hypertrophic obstructive cardiomyopathy, aiming to relieve symptoms, as an alternative to surgical myomectomy, in optimally treated but still symptomatic patients, with high surgical risk. We present the case of 65-year-old female, with persistently elevated blood pressure, presenting with severe dyspnea and angina on exertion and frequent episodes of paroxysmal nocturnal dyspnea. Clinical examination revealed an intense left parasternal systolic murmur. Electrocardiographic findings were sinus rhythm and negative T waves in V2-V6. Transthoracic echocardiography showed a small LV cavity with severe asymmetric left ventricular hypertrophy (maximum basal interventricular septum thickness of 26 mm), with important obstruction in the left ventricular outflow tract - resting gradient 77mmHg, provoked gradient 100mmHg. TOE evaluation of the mitral valve revealed significant mitral regurgitation, with intermitent telesystolic anterior motion of the anterior mitral leaflet and also P2 scallop prolapse. Further evaluation revealed a 60% stenosis of left anterior descending (LAD) artery of second segment, 60% stenosis of the left internal carotid artery, chronic renal disease (creatinine clearance 80ml/min), and moderate pulmonary hypertension. Although surgery was initially proposed to the patient, given the high operative risk (EUROSCORE II 8.45%) for a complete surgical procedure (myomectomy, mitral valve repair and coronary bypass), we attempted a stepwise approach to alleviate her symptoms. Intensive medical treatment improved blood pressure control while angioplasty of the LAD alleviated her angina. Echo-guided alcohol ablation of the interventricular septal wall was performed. Catheter-based contrast injection of a secondary septal branch of the LAD produced a subendocardial contrast in the contact area of anterior mitral valve leaflet; subsequently, embolizing the artery, producing an isolated necrosis at this level, with equalizing the pressure curves between LV and aorta. Postintervention, initial gradients were 50mmHg at rest, 100mmHg on postextrasystolic measurement. Systolic movement of the anterior leaflet maintained a mezotelesystolic pattern. At 3-months follow-up, LVOT gradients were 27/100mmHg, without any increase in pulmonary artery pressure, but with significant improvement of dyspnea. Further risk assessment by Holter ECG monitoring identified non-sustained ventricular tachycardia, so an ICD was implanted. The modest reduction in gradient was associated with significant clinical improvement in the patient’s symptomatology. This procedure has been refined in the last years, especially with the introduction of myocardial contrast echocardiography for better localizing the area at risk of infarction and to reduce the amount of alcohol used. Alcohol septal ablation may be part of a stepwise plan to improve symptoms, with lower procedural risks as compared to classic surgery.

P893Alcohol septal ablation in patients with hypertrophic obstructive cardiomyopathy: experience at a reference center in Chile

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
F Verdugo ◽  
P Cataldo ◽  
C Dauvergne ◽  
J Sandoval
Keyword(s):  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Average Length ◽  
Beta Blockers ◽  
Nyha Class ◽  
Ventricular Outflow Tract ◽  
Hypertrophic Obstructive Cardiomyopathy ◽  
Left Ventricular ◽  
Alcohol Injection ◽  
Septal Thickness

Abstract Background Depending on the severity of septal hypertrophy and mitral valve derangements, patients with hypertrophic cardiomyopathy may develop left ventricular outflow tract (LVOT) obstruction and mitral regurgitation, which have major impact on symptoms and prognosis.Surgical myomectomy has been considered standard treatment in patients with hypertrophic obstructive cardiomyopathy (HOCM) who remain symptomatic despite medical therapy.Alcohol septal ablation (ASA), is a minimally invasive therapy for HOCM. Purpose Our aim was to assess short and long term outcomes and complications of ASA performed to symptomatic HOCM patients in our center. Methods We performed a retrospective observational study of patients undergoing ASA for HOCM between January 2002 and September 2018. According to local protocol, clinical evaluation and echocardiography were performed at baseline and 6 months after ASA. Local databases were reviewed, along with direct patient contact when required. Results ASA was performed in 73 patients with HOCM.Mean age was 57.5±12.8 years; 63% were male; 83.5% were on III-IV NYHA class, 32.9% had syncope; 12.3% had family history of sudden cardiac death, 93.6% received beta blockers, 6.8% had implantable cardioverter defibrillator.Mean alcohol injection per procedure was 2.45±1.03 cc. Invasive resting gradients were acutely reduced from 61.2±36.3 mmHg to 23.4±27.5 mmHg (p<0.001), and dynamic gradients from 106.5±37.3 mmHg to 31.0±28.0 mmHg (p<0.001). Hemodynamic success (reduction in resting gradient to <30 mmHg or dynamic gradient >50%) was achieved in 82.2% patients. We observed improvements in mitral regurgitation at ventriculography (Figure 1A, p<0.001), a decline of ≥1 severity degree was noticed in 53 patients (72.6%). Maximal creatine kinase after ASA was 2055±851 U/l. Average length of hospitalization was 4.4±5.0 days. Reablation was performed in 12 patients, 7 were planned staged procedures and 5 due to unsuccessful ASA. We observed no in-hospital mortality. Permanent pacemaker were implanted in 9 patients. Vascular access complications occurred in 3 patients. Coronary dissection and cardiac tamponade occurred in 1 patient respectively. Complications were more frequent after reablation (50% vs 17%, p<0.01).At 6 months, we observed improvements in NYHA class (Figure 1B, p<0.001), a decline of ≥1 NYHA class was found in 68 patients (93.2%). Echocardiographic assessment exposed reductions in septal thickness (25.0±5.5 vs 17.1±5.3 mm, p<0.001), LVOT gradients (86.7±27.3 vs 38.4±15.1 mmHg, p<0.001) and systolic anterior motion of the mitral valve prevalence (61.6% vs 27.4%, p=0.002). At 12 months, we detected only 1 death due to COPD.No cardiovascular deaths were noted in patients achieving 5 years of follow-up (n=49). Figure 1 Conclusion ASA was a safe and effective procedure in symptomatic HOCM, resulting in reductions of septal thickness, LVOT gradients and mitral regurgitation severity, as well as an improvement in NYHA class.

scholarly journals P1698 Mitral valve endocarditis in hypertrophic obstructive cardiomyopathy

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
E Shirka ◽  
H Gjergo ◽  
O Avdullari ◽  
A Goda
Keyword(s):  
Heart Disease ◽  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Hypertrophic Obstructive Cardiomyopathy ◽  
Left Ventricular ◽  
Outflow Tract ◽  
Valve Leaflet ◽  
Systolic Anterior Motion ◽  
Mitral Valve Leaflet ◽  
History Of

Abstract Introduction Endocarditis complicating hypertrophic cardiomyopathy (HCM) is not commonly reported but occurs almost universally in patients showing evidence of outflow tract obstruction. The estimated cumulative 10 year probability of developing endocarditis in obstructive HCM is &lt; 5%. We report a rare case of mitral valve endocarditis in a young man with hypertrophic obstructive cardiomyopathy. Case report A 45 years old man was admitted to the emergency room after a 7 days history of weakness, thoracic discomfort, short of breath, cough and temperature up to 40 °C. He was treated with oral antibiotics in ambulatory setting, but symptoms persisted. He had no previous history of hypertension or known heart disease, family history of coronary heart disease and excessive smoker. On clinical examination, the patient was afebrile with a harsh systolic murmur. Initial blood tests showed normal inflammatory markers (C reactive protein 0.2 mg/l and fibrinogen 202 mg/dL) and normal blood sample. An ECG showed major left ventricular hypertrophy and abnormal lateral repolarisation. Transthoracic echocardiography showed localized septal hypertrophy (2.4 cm) and systolic anterior motion of the anterior mitral leaflet. Continuous wave Doppler ultrasound in the left ventricular cavity and outflow tract, had given a maximal predicted gradient of 73 mmHg. There was suspicion of vegetation on the anterior mitral valve leaflet and mitral regurgitation was quantified as moderate. Transoesophageal echocardiography confirmed the presence of vegetation on the anterior mitral valve leaflet, posterior leaflet prolapse and moderate mitral regurgitation. We found normal coronary arteries on coronary angio-CT. Treatment with intravenous antibiotics was initiated and the case was discussed with a microbiologist and a cardiothoracic surgeon. Discussion Infective endocarditis is a rare complication of hypertrophic cardiomyopathy (HCM). It is clear from morphological studies that systolic anterior motion of the anterior mitral valve leaflet is relevant to the pathogenesis of endocarditis. Pathogenesis of infective endocarditis in obstructive HCM can be explained by endocardium damage of the mitral or aortic valve, consequence of turbulence of blood flow during ejection and of the contact between the mitral anterior leaflet and the septum during systole as well as mitral regurgitation. Antibiotic therapy is the mainstay of the treatment. Surgery should be considered promptly whenever there is traditional indication (haemodynamic, emboli, persistent fever, abscess). Surgical procedure may consist of valve replacement or repair, and some authors reported relieve of outflow tract obstruction after mitral valve replacement which may be explained by the removal of systolic anterior motion of the mitral valve. Valve surgery combined with septal myectomy seems logical but requires great expertise and carries a higher operative mortality Abstract P1698 Figure.

Minimally Invasive Septal Myectomy for the Treatment of Hypertrophic Obstructive Cardiomyopathy and Intrinsic Mitral Valve Disease

2015 ◽  
Vol 10 (2) ◽  
pp. 106-113 ◽  
Author(s):  
Daniyar Sh. Gilmanov ◽  
Stefano Bevilacqua ◽  
Marco Solinas ◽  
Matteo Ferrarini ◽  
Enkel Kallushi ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Minimally Invasive ◽  
Mitral Valve Disease ◽  
Ventricular Outflow Tract ◽  
Hypertrophic Obstructive Cardiomyopathy ◽  
Left Ventricular ◽  
Valve Disease ◽  
Invasive Approach ◽  
Septal Myectomy ◽  
Left Ventricular Outflow

Objective Transaortic left ventricular septal myectomy described by Morrow is a classical procedure for the treatment of systolic anterior motion of the mitral apparatus associated with hypertrophic obstructive cardiomyopathy (HOCM). We aimed to review our results of transmitral septal myectomy and mitral valve repair/replacement in patients with intrinsic mitral valve disease associated with HOCM, operated on through a minimally invasive approach. Methods Between 2005 and 2014, 19 patients [7 men (37%); mean (SD) age, 69.4 (14.5) years] were treated with minimally invasive approach for degenerative mitral regurgitation and HOCM. Preoperative peak left ventricular outflow tract (LVOT) gradient was 66 (24) mm Hg. Severe mitral regurgitation was diagnosed in 16 cases (84%). New York Heart Association functional class III to IV heart failure was present in 13 patients (68%). Results Fifteen patients (79%) underwent mitral valve replacement, and four patients (21%) underwent mitral valve repair. Left ventricular outflow tract obstruction was corrected directly in all patients via the mitral valve with septal myectomy/myotomy, avoiding aortotomy in majority of the patients. No significant prolongation of extracorporeal circulation/aortic cross-clamping times was observed ( P = 0.41 and P = 0.67, respectively) when compared with a similar population without HOCM. No iatrogenic ventricular septal defect developed in treated patients. No hospital mortality occurred. Resting LVOT gradient reduced at discharge to 13 (22) mm Hg ( P = 0.025). Conclusions Transmitral left ventricular septal myectomy in patients with degenerative mitral valve disease is quite a simple, feasible, and effective technique and does not require aortotomy in most cases. It can be performed with low early mortality and satisfactory resolution of LVOT obstruction in a minimally invasive setting.

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