Extended septal myectomy and left ventricular outflow tract intervention for hypertrophic obstructive cardiomyopathy

Therapeutic Option ◽

Left Ventricular ◽

Outflow Tract ◽

Septal Myectomy ◽

Inherited Cardiomyopathy ◽

Left Ventricular Outflow ◽

Tailored Approach

Hypertrophic obstructive cardiomyopathy is the most common inherited cardiomyopathy. Septal myectomy is a low-risk operation and remains the first septal reduction therapeutic option. We present a patient with hypertrophic obstructive cardiomyopathy requiring extended septal myectomy and concomitant left ventricular outflow tract intervention. In addition to septal reduction therapy, this patient also underwent anterior mitral valve plication, trigonal release, and secondary chordal division to relieve the obstruction. A tailored approach to hypertrophic obstructive cardiomyopathy with a comprehensive left ventricular outflow tract intervention is necessary to ensure the best hemodynamic outcome. Preoperative heart failure and recurrent syncope fully resolved after this intervention.

SEPTAL MYECTOMY WITH SUBVALVULAR APPARATUS INTERVENTION IN PATIENTS WITH HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY: IMMEDIATE RESULTS

Siberian Medical Journal ◽

10.29001/2073-8552-2018-33-3-71-77 ◽

2018 ◽

Vol 33 (3) ◽

pp. 71-77

Author(s):

A. V. Afanasyev ◽

A. V. Bogachev-Prokophiev ◽

S. I. Zheleznev ◽

R. M. Sharifulin ◽

A. S. Zalesov ◽

...

Keyword(s):

Mitral Regurgitation ◽

Left Ventricular ◽

Outflow Tract ◽

Systolic Anterior Motion ◽

Septal Myectomy ◽

Ventricular Outflow Tract Obstruction ◽

Left Ventricular Outflow

Aim. Surgical septal myectomy is a standard treatment option for patients with hypertrophic obstructive cardiomyopathy. Subvalvular abnormalities of the mitral valve may play an important role in residual left ventricular outflow tract obstruction. This study aimed to evaluate the surgical outcomes of septal myectomy with subvalvular interventions.Material and Methods. Between July, 2015 and December, 2016, 40 eligible patients underwent septal myectomy with subvalvular intervention. The peak gradient was 92.3±16.9 mm Hg. The mean septum thickness was 26.8±4.5 mm. Moderate or severe systolic anterior motion syndrome-mediated mitral regurgitation was observed in all patients.Results. There was no residual mitral regurgitation. Residual systolic anterior motion syndrome was observed in 5%. The postoperative gradient was 8.7±4.5 mm Hg. At 12-month follow-up, all patients were alive. According to the New York Heart Association (NYHA) classification, 87.5 and 12.5% of patients had NYHA functional classes I and II, respectively. The prevalence rate of residual mitral regurgitation was 10%.Conclusions. Concomitant subvalvular intervention during septal myectomy effectively eliminated left ventricular outflow tract obstruction and provided high freedom from residual mitral regurgitation one year after surgery.

Myectomy versus alcohol septal ablation in patients with hypertrophic obstructive cardiomyopathy

Interactive Cardiovascular and Thoracic Surgery ◽

10.1093/icvts/ivaa075 ◽

2020 ◽

Vol 31 (2) ◽

pp. 158-165

Author(s):

Alexander V Afanasyev ◽

Alexander V Bogachev-Prokophiev ◽

Maxim G Kashtanov ◽

Dmitriy A Astapov ◽

Anton S Zalesov ◽

...

Keyword(s):

Mitral Regurgitation ◽

Left Ventricular ◽

Outflow Tract ◽

Class Iii ◽

Alcohol Septal Ablation ◽

Septal Myectomy ◽

Left Ventricular Outflow

Abstract OBJECTIVES There is very little evidence comparing the safety and efficacy of alcohol septal ablation versus septal myectomy for a septal reduction in patients with hypertrophic obstructive cardiomyopathy. This study aimed to compare the immediate and long-term outcomes of these procedures. METHODS Following propensity score matching, we retrospectively analysed outcomes in 105 patients who underwent myectomy and 105 who underwent septal ablation between 2011 and 2017 at 2 reference centres. RESULTS The mean age was 51.9 ± 14.3 and 52.2 ± 14.3 years in the myectomy and ablation groups, respectively (P = 0.855), and postoperative left ventricular outflow tract gradients were 13 (10–19) mmHg vs 16 (12–26) mmHg; P = 0.025. The 1-year prevalence of the New York Heart Association class III–IV was higher in the ablation group (none vs 6.4%; P = 0.041). The 5-year overall survival rate [96.8% (86.3–99.3) after myectomy and 93.5% (85.9–97.1) after ablation; P = 0.103] and cumulative incidence of sudden cardiac death [0% and 1.9% (0.5–7.5), respectively P = 0.797] did not differ between the groups. The cumulative reoperation rate within 5 years was lower after myectomy than after ablation [2.0% (0.5–7.6) vs 14.6% (8.6–24.1); P = 0.003]. Ablation was associated with a higher reoperation risk (subdistributional hazard ratio = 5.9; 95% confidence interval 1.3–26.3, P = 0.020). At follow-up, left ventricular outflow tract gradient [16 (11–20) vs 23 (15–59) mmHg; P < 0.001] and prevalence of 2+ mitral regurgitation (1.1% vs 10.6%; P = 0.016) were lower after myectomy than after ablation. CONCLUSIONS Both procedures improved functional capacity; however, myectomy better-resolved classes III–IV of heart failure. Septal ablation was associated with higher reoperation rates. Myectomy demonstrated benefits in gradient relief and mitral regurgitation elimination. The results suggest that decreasing rates of myectomy procedures need to be investigated and reconsidered.

Comprehensive left ventricular outflow tract management beyond septal reduction to relieve obstruction

Asian Cardiovascular and Thoracic Annals ◽

10.1177/02184923211034689 ◽

2021 ◽

pp. 021849232110346

Author(s):

Lara Gharibeh ◽

Nicholas G Smedira ◽

Juan B Grau

Keyword(s):

Left Ventricular ◽

Outflow Tract ◽

Papillary Muscles ◽

Chordae Tendineae ◽

Septal Myectomy ◽

Ventricular Outflow Tract Obstruction ◽

Left Ventricular Outflow

The surgical management of patients with hypertrophic obstructive cardiomyopathy can be extremely challenging. Relieving the left ventricular outflow tract obstruction in these patients is often achieved by performing a septal myectomy. However, in many instances, septal reduction alone is not enough to relieve the obstruction. Interventions on the sub-valvular apparatus, including the anomalous chordae tendineae and the abnormal papillary muscles, are often required. In this review, we summarize the embryology and the pathophysiology of the different elements that may contribute to the left ventricular outflow tract obstruction in the setting of hypertrophic obstructive cardiomyopathy. In addition, we highlight the different surgical procedures that a surgeon may adopt to relieve the left ventricular outflow tract obstruction, beyond the septal myectomy.