Midterm Outcome of Septal Myectomy for Hypertrophic Obstructive Cardiomyopathy (HOCM): A Single-Center Observational Study

Background: For years, septal myectomy has been considered the best available treatment for hypertrophic cardiomyopathy. In Bangladesh, however, this technique is only nascent. We present a case series of septal myectomy with outcomes after 1 to 6 years at the National Heart Foundation Hospital & Research Institute. Methods: For this study, 21 patients who underwent septal myectomy from 2014 to 2019 were monitored retrospectively. Evidence was collected from the hospital database and followed up via telephone conversations using a structured questionnaire. Patients’ preoperative, postoperative, and follow-up clinical data were collected and analyzed. Results: The results reveal that after septal myectomy, there were significant improvements in terms of left ventricular outflow gradient (P ≤ .01), septal thickness (P ≤ .01), left ventricular ejection fraction (P = .001), pulmonary arterial systolic pressure (P ≤ .01), mitral regurgitation (P ≤ .01), systolic anterior motion (P ≤ .01), and New York Heart Association class (P ≤ .01). Conclusion: This study suggests that septal myectomy be offered to symptomatic hypertrophic obstructive cardiomyopathy patients, as its survival benefits and symptoms relief are excellent. This study suggests that septal myectomy that dynamic obstruction at the left ventricular outflow tract is the major hemodynamic problem. We hope that with appropriate measures, new myectomy programs in our country can provide extended longevity and restore the quality of life.

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

10.1510/mmcts.2021.013 ◽

2021 ◽

Keyword(s):

Left Ventricular Outflow Tract ◽

Therapeutic Option ◽

Ventricular Outflow Tract ◽

Hypertrophic Obstructive Cardiomyopathy ◽

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.

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A Pregnancy with Severe Hypertrophic Obstructive Cardiomyopathy after Surgery for an Implantable Cardioverter Defibrillator: A Case Report and Literature Review

Case Reports in Obstetrics and Gynecology ◽

10.1155/2016/4690790 ◽

2016 ◽

Vol 2016 ◽

pp. 1-5

Author(s):

Takashi Mitsui ◽

Hisashi Masuyama ◽

Kentaro Ejiri ◽

Kei Hayata ◽

Hiroshi Ito ◽

...

Keyword(s):

New York ◽

Heart Association ◽

Ventricular Myocardium ◽

Ventricular Outflow Tract ◽

Hypertrophic Obstructive Cardiomyopathy ◽

Left Ventricular ◽

Peripheral Oxygen Saturation ◽

Left Ventricular Outflow ◽

New York Heart Association ◽

Sudden Decrease

Hypertrophic obstructive cardiomyopathy (HOCM) is cardiac hypertrophy of ventricular myocardium with left ventricular outflow tract obstruction. We report a pregnancy with HOCM after defibrillator implantation surgery. The patient was a 33-year-old nulligravida and was categorized as New York Heart Association class II. Her brain natriuretic peptide (BNP) level was 724.6 pg/dL at preconception. She received careful pregnancy management. However, because frequent uterine contractions were observed at 25 weeks and 6 days of pregnancy, she was hospitalized, and magnesium sulfate was started as a tocolytic agent. At 27 weeks and 5 days of pregnancy, she had respiratory discomfort and orthopnea with a sudden decrease in peripheral oxygen saturation. Cardiac ultrasonography showed a worsened condition of HOCM and her BNP level was 1418.0 pg/mL. We performed an emergent cesarean section and she delivered a boy weighing 999 g. The Apgar score was 8 and 9 points at 1 and 5 minutes, respectively. The mother’s heart failure quickly improved after birth and she was discharged at 10 days postoperatively. Fluctuations in circulatory dynamics during pregnancy may sometimes exacerbate heart disease. Therefore, the risks should be fully explained and careful assessment of cardiac function should be performed during pregnancy in patients with severe HOCM.

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Case report of isolated cardiac sarcoidosis presenting as hypertrophic obstructive cardiomyopathy—a clinical picture printed on lenticular paper

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytab208 ◽

2021 ◽

Vol 5 (6) ◽

Author(s):

Isadora Sande Mathias ◽

Jorge Otávio Oliveira Lima Filho ◽

Daniel A Culver ◽

E Rene Rodriguez ◽

Carmela D Tan ◽

...

Keyword(s):

Fdg Pet ◽

Cardiac Sarcoidosis ◽

Ventricular Outflow Tract ◽

Hypertrophic Obstructive Cardiomyopathy ◽

Left Ventricular ◽

Septal Myectomy ◽

Positron Emission ◽

Oral Corticosteroids ◽

Left Ventricular Outflow ◽

Pathology Specimen

Abstract Background Cardiac sarcoidosis (CS) is an inflammatory granulomatous process of the myocardium that can be asymptomatic or have several different clinical phenotypes. One of its rarely described presentations consists of hypertrophy of the septal myocardium, similar to hypertrophic cardiomyopathy (HCM). Isolated cardiac sarcoidosis that haemodynamically mimics hypertrophic obstructive cardiomyopathy (HOCM) has been rarely described in the literature. Case summary A 64-year-old Caucasian female previously diagnosed with non-critical aortic stenosis presented with pre-syncope, and echocardiography showed significant obstruction based on left ventricular outflow tract gradients, confirmed by cardiac magnetic resonance (CMR), concerning for a phenocopy of HCM. Septal myectomy was performed and pathology specimen revealed non-caseating granulomata consistent with cardiac sarcoidosis. She was started on oral corticosteroids and initial cardiac fluorodeoxyglucose positron emission tomography (FDG-PET) done after 1 month of treatment was negative. Repeat FDG-PET 15 months later, in the setting of haemodynamic decompensation, demonstrated diffuse FDG uptake in the myocardium without extra-cardiac involvement. Discussion Our case brings together two entities: isolated cardiac sarcoidosis and its presentation mimicking HOCM, which has been very rarely described in the literature. And it also shows the scenario of surgical pathology diagnosis of sarcoidosis that was not suspected by initial CMR or FDG-PET, despite adequate preparation, only appearing on repeat FDG-PET done 15 months later. Isolated cardiac sarcoidosis should remain a differential diagnosis for any non-ischaemic cardiomyopathy without a clear cause, despite imaging evidence of HCM.

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Muscular Mitral Chord Contribution to Left Ventricular Outflow Tract Obstruction in HOCM

The Thoracic and Cardiovascular Surgeon Reports ◽

10.1055/s-0039-1692155 ◽

2019 ◽

Vol 08 (01) ◽

pp. e18-e19

Author(s):

Olayinka Ogunmuyiwa ◽

Philipp Rellecke ◽

Artur Lichtenberg ◽

Alexander Assmann

Keyword(s):

Papillary Muscle ◽

Ventricular Outflow Tract ◽

Hypertrophic Obstructive Cardiomyopathy ◽

Left Ventricular ◽

Outflow Tract ◽

Systolic Anterior Motion ◽

Mitral Leaflet ◽

Anterior Mitral Leaflet ◽

Septal Myectomy ◽

Left Ventricular Outflow

AbstractPapillary muscle anomaly with a muscular chord directly attached to the anterior mitral leaflet is a rare mitral valve disease. A 62-year-old man with systolic anterior motion of the anterior mitral leaflet and hypertrophic obstructive cardiomyopathy presented to surgical intervention after unsuccessful transcoronary ablation of septal hypertrophy with alcohol. Intraoperative findings revealed a primarily not detected anomalous muscular mitral chord (0.8 × 2.2 cm) connecting the base of the A1 segment to the anterolateral papillary muscle. Resection of this chord and additional septal myectomy treated systolic anterior motion and obstruction of the outflow tract. In spite of the infrequent occurrence, anomalies of the subvalvular apparatus, such as muscular chords, should be ruled out by thorough transesophageal echocardiography imaging before decision on the therapeutical strategy.

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The Use of MitraClip for Symptomatic Patients with Hypertrophic Obstructive Cardiomyopathy

Cardiology ◽

10.1159/000454800 ◽

2017 ◽

Vol 137 (1) ◽

pp. 58-61 ◽

Cited By ~ 6

Author(s):

Felix Thomas ◽

Florian Rader ◽

Robert J. Siegel

Keyword(s):

Nyha Class ◽

Ventricular Outflow Tract ◽

Hypertrophic Obstructive Cardiomyopathy ◽

Left Ventricular ◽

Cardiac Conduction ◽

Published Data ◽

Alcohol Septal Ablation ◽

Septal Myectomy ◽

Conduction Abnormalities ◽

Left Ventricular Outflow

Objectives: Current nonpharmacological therapies for symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM), including septal myectomy and alcohol septal ablation (ASA), carry significant risks for serious cardiac conduction abnormalities. We present a review of the currently available published data regarding the novel use of the relatively low-risk MitraClip® system in the treatment of symptomatic patients. Methods: Data were collected from 4 separate studies on the use of the MitraClip on 15 symptomatic HOCM patients with systolic anterior motion (SAM) of the mitral valve apparatus. Information regarding the degree of mitral regurgitation (MR), left-ventricular outflow tract (LVOT) gradient, and NYHA class was consolidated. Results: After MitraClip treatment, all patients had a resolution of SAM, a reduction in MR, and a reduction in the LVOT gradient from a mean of 75.8 ± 39.7 to 11.0 ± 5.6 mm Hg. Nearly all patients demonstrated improvements in symptoms by either new NYHA class designations or improved exercise tolerance. The procedure was not associated with conduction abnormalities or arrhythmias. Conclusion: MitraClip therapy may be a safe and effective treatment for symptomatic HOCM patients; it can help to avoid the potential risks associated with alternative therapies in high-risk surgical patients.

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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 ◽

Ventricular Outflow Tract ◽

Hypertrophic Obstructive Cardiomyopathy ◽

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.

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So Many Ways…

10.22541/au.163252962.28962756/v1 ◽

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.

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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

10.21203/rs.3.rs-43582/v1 ◽

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.

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Exercise Echocardiography following Septal Myectomy for Hypertrophic Obstructive Cardiomyopathy

The Thoracic and Cardiovascular Surgeon ◽

10.1055/s-0040-1716896 ◽

2020 ◽

Author(s):

Johan Novén ◽

Martin Stagmo ◽

Per Wierup ◽

Shahab Nozohoor ◽

Henrik Bjursten ◽

...

Keyword(s):

Ventricular Outflow Tract ◽

Hypertrophic Obstructive Cardiomyopathy ◽

Left Ventricular ◽

University Hospital ◽

Mitral Insufficiency ◽

Exercise Echocardiography ◽

Term Survival ◽

Septal Myectomy ◽

Left Ventricular Outflow

Abstract Objectives To investigate outcome after septal myectomy and to evaluate long-term hemodynamics with exercise echocardiography. Methods This study included 40 consecutive patients operated with septal myectomy for hypertrophic obstructive cardiomyopathy from January 1998 to August 2017 at Skane University Hospital, Lund, Sweden. Perioperative clinical data and echocardiography measurements were reviewed retrospectively. Patients (n = 36) who were alive and living in Sweden were invited for exercise echocardiography to evaluate exercise capacity and hemodynamics, of whom 19 patients performed exercise echocardiography. Results Overall survival was 100% at 1 year and 96% at 5 years following surgery. Preoperative median resting peak LVOT (left ventricular outflow tract) gradient was 80 mm Hg. Septum thickness was reduced from 22 ± 4 mm preoperatively to 16 ± 3 mm postoperatively (p < 0.001). During exercise echocardiography, the peak LVOT gradient was 8 mm Hg at rest, and increased to 13 mm Hg during exercise echocardiography (p = 0.002). None of the patients had dynamic LVOT obstruction during exercise echocardiography, and there was no clinically significant systolic anterior motion or severe mitral insufficiency during exercise. Conclusions Long-term survival following septal myectomy is very good. At long-term follow-up, LVOT gradients were low and exercise echocardiography demonstrated good hemodynamics.

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Transaortic extended left ventricular septal myectomy in an adult with hypertrophic obstructive cardiomyopathy

10.1510/mmcts.2020.074 ◽

2020 ◽

Keyword(s):

Hypertrophic Cardiomyopathy ◽

Ventricular Outflow Tract ◽

Hypertrophic Obstructive Cardiomyopathy ◽

Left Ventricular ◽

Current Case ◽

Alcohol Septal Ablation ◽

Septal Myectomy ◽

Septal Thickness ◽

Left Ventricular Outflow ◽

Maximal Medical Therapy

In symptomatic patients with an obstructive variant of hypertrophic cardiomyopathy and no response to maximal medical therapy, we recommend a septal myectomy. It is considered the gold standard for treatment of the basal variant of hypertrophic cardiomyopathy. It has several advantages over alcohol septal ablation, such as the immediate relief of the obstruction and the ability to reduce the septal thickness significantly, to eliminate the potential for midventricular obstruction, and to rule out any other etiologies of left ventricular outflow tract obstruction, which include the presence of abnormalities in the mitral valve subvalvular apparatus such as the presence of anomalous chords, which occured in the current case, and anomalous papillary muscles. In experienced hands, the technique is safe and is associated with excellent outcomes with improved quality of life and potential for survival benefit.

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