A Case Report of Surgical Septal Myectomy of Hypertrophic Cardiomyopathy With Concomitant Left Ventricular Outflow Tract and Mid-Ventricular Obstructions

Abstract OBJECTIVES Left ventricular outflow tract obstruction causes symptoms of heart failure in most patients with hypertrophic cardiomyopathy. Resection of the secondary mitral valve (MV) chordae has recently been shown to move the MV apparatus posteriorly, thereby eradicating the outflow gradient. The aim of this study was to evaluate whether secondary chordal resection concomitant to septal myectomy improves outcomes. METHODS Between 2005 and 2020, a total of 165 patients underwent septal myectomy without MV repair or replacement in our Medical Center. Secondary MV chordal resection was performed in 60 patients, and their outcomes were compared with those of the remaining 105 patients who did not undergo chordal resection (controls). Mean age was 61 ± 13 and 58 ± 16 years, respectively (P = 0.205). RESULTS There were no in-hospital deaths throughout the entire cohort. Of those patients who underwent secondary chordal resection, New York Heart Association functional class decreased from 3 (interquartile range 2–3) preoperatively to 1 (interquartile range 1–2) postoperatively (P < 0.001), and resting outflow gradient decreased from 91 ± 39 mmHg to 13 ± 8 mmHg (86% change, P < 0.001). Compared with controls, patients who underwent secondary chordal resection had a significant lower resting outflow gradient at follow-up (14 ± 7 mmHg vs 21 ± 15 mmHg, P = 0.002). The rate of moderate or more than moderate mitral regurgitation at 5 years was 2% in the secondary chordal resection group and 5% in the controls (hazard ratio 1.05, confidence interval 0.11–10.32; P = 0.965). CONCLUSIONS In this observational study, we report that secondary chordal resection concomitant to septal myectomy for left ventricular outflow tract obstruction is safe, relieves heart failure symptoms and reduces left ventricular outflow tract gradient in appropriately selected patients.

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Septal myectomy complicated by an embolic stroke in a patient with hypertrophic cardiomyopathy: a case report

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytab365 ◽

2021 ◽

Author(s):

Muhammad Umer Butt ◽

Anas Alameh ◽

Hanad Bashir ◽

Ahmad Jabri

Keyword(s):

Hypertrophic Cardiomyopathy ◽

Left Ventricular Outflow Tract ◽

Ventricular Outflow Tract ◽

The United States ◽

Left Ventricular ◽

Outflow Tract ◽

Septal Wall ◽

Septal Myectomy ◽

Intraventricular Thrombus ◽

Left Ventricular Outflow

Abstract Background Hypertrophic cardiomyopathy is estimated to affect 1 out of every 500 adults in the United States. One of its main complications is left ventricular outflow obstruction, which may require surgical septal myectomy in severe cases. We report a rare complication of postoperative septal akinesis leading to thrombus formation presenting as an acute ischaemic stroke. Case summary A 48-year-old woman presented with acute stroke two years after surgical septal myectomy for hypertrophic obstructive cardiomyopathy. Diagnostic workup identified an intraventricular thrombus arising in the left ventricular outflow tract. After comprehensive evaluation, it was determined that the thrombus development was a complication of the prior septal myectomy causing focal septal akinesis. Treatment with anticoagulation resulted in improvement of neurological symptoms and resolution of the intraventricular thrombus. Discussion This case illustrates the rarity and unusual presentation of an intracardiac thrombus that arises from septal myectomy site. A thrombus arising in the left ventricular outflow tract, which is characterized by high gradient laminar flow, is highly unusual. This suggests microscopic and macroscopic alteration in the ventricular septal wall structure, as evident by the septal wall akinesis seen on echocardiography. Recognition of this complication is critical to the selection of appropriate anticoagulation as secondary stroke prevention in these patients.

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Hypertrophic cardiomyopathy: invasive management of left ventricular outflow tract obstruction

ESC CardioMed ◽

10.1093/med/9780198784906.003.0353 ◽

2018 ◽

pp. 1459-1462

Author(s):

Steve R. Ommen

Keyword(s):

Hypertrophic Cardiomyopathy ◽

Left Ventricular Outflow Tract ◽

Ventricular Outflow Tract ◽

Left Ventricular ◽

Outflow Tract ◽

Success Rates ◽

Alcohol Septal Ablation ◽

Septal Myectomy ◽

Ventricular Outflow Tract Obstruction ◽

Left Ventricular Outflow

Left ventricular outflow tract obstruction in hypertrophic cardiomyopathy can result in considerable symptoms. While pharmacological therapies are the first-line treatment for most patients, there are invasive therapies that have shown excellent success in relieving these drug-refractory symptoms. Surgical septal myectomy and percutaneous alcohol septal ablation, each with relative merits and risks, offer high success rates when performed in the context of specialized hypertrophic cardiomyopathy programmes.

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The Surgeon’s View of the Left Ventricular Outflow Tract in Congenital Heart Surgery

World Journal for Pediatric and Congenital Heart Surgery ◽

10.1177/2150135120936632 ◽

2020 ◽

Vol 11 (5) ◽

pp. 595-610

Author(s):

Elizabeth H. Stephens ◽

Joseph A. Dearani ◽

Jonathan N. Johnson ◽

Michael J. Ackerman ◽

Steve R. Ommen ◽

...

Keyword(s):

Hypertrophic Cardiomyopathy ◽

Congenital Heart ◽

Heart Surgery ◽

Left Ventricular Outflow Tract ◽

Ventricular Outflow Tract ◽

Left Ventricular ◽

Outflow Tract ◽

Subaortic Stenosis ◽

Septal Myectomy ◽

Left Ventricular Outflow

Left ventricular outflow tract (LVOT) obstruction is a component of many forms of congenital heart disease, including hypertrophic cardiomyopathy, membranous subaortic stenosis, tunnel subaortic stenosis, and outflow tract obstruction related to atrioventricular septal defects. We have gained a particularly extensive experience with the diagnosis and treatment of hypertrophic cardiomyopathy, having performed septal myectomy in over 3,800 patients. In the setting of this review of LVOT obstruction, we use hypertrophic cardiomyopathy as a template by which other pathologies causing LVOT obstruction can be understood. We review important surgical issues in patient selection, diagnostic evaluation, interpretation of imaging, and operative management. To this end, the review focuses on obstructive hypertrophic cardiomyopathy and then broadens to discuss other pathologies causing LVOT obstruction, with important similarities and differences in their management. These other pathologies share some similar presentations and operative techniques, and at times can be confused with hypertrophic cardiomyopathy, but also have important distinctions of which the surgeon should be aware.

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