Extended myectomy for apical hypertrophic cardiomyopathy: a case report

Background Apical hypertrophic cardiomyopathy is a variant of hypertrophic cardiomyopathy that predominantly affects the apex of the left ventricle and rarely involves the right ventricular apex or both apexes. Heart transplantation is the traditional treatment for apical hypertrophic cardiomyopathy. Although surgical myectomy approaching the apex has been available for decades, its safety and accuracy greatly depend on the surgeon’s skills and experience. Case presentation The first case involved a 63-year-old man with apical hypertrophic cardiomyopathy, wherein preoperative contrast computed tomography findings revealed apical hypertrophy and complete apical cavity obliteration. The patient underwent extended myectomy, which revealed the apex cavity filled with abnormal muscles. Using the transaortic approach, the location of the bilateral papillary muscle was confirmed, thereby providing the required orientation. The abnormal muscle mass was successfully resected, and the postoperative end-diastolic volume was extremely increased. The second case involved a 43-year-old man with an apical left ventricular aneurysm and mid-hypertrophic cardiomyopathy obstruction. The thin-walled apical aneurysm contained a large apical-basal band. Upon detecting the bilateral papillary muscle, mid-ventricular myectomy was performed from the apex. During postoperative catheterization, there was no pressure gradient between the left ventricle and aorta. Conclusions We reviewed two cases of apical hypertrophic cardiomyopathy, efficiently treated using extended apical myectomy. Although it is an uncommon procedure, the cases presented show how it can be used to successfully manage cases of apical hypertrophic cardiomyopathy. However, it is important to secure the postoperative left ventricular end-diastolic volume.

Unrecognized concomitant ventricular septal rupture and left ventricular aneurysm 10 months after myocardial infarction in a patient presenting with chronic heart failure

Background We report a rare case of concomitant inferior left ventricular aneurysm and ventricular septal rupture in a patient presenting with chronic heart failure. Case presentation An 81-year-old man suffered from congestive heart failure. His symptoms were alleviated by medical management; however, heart failure symptoms continued according to the New York Heart Association Functional Classification III. Ten months after presentation, ventricular septal rupture was diagnosed using echocardiography. The left ventricular aneurysm was also complicated. Surgical repair of the ventricular septal rupture and left ventricular aneurysm was successfully performed. The ventricular septal rupture consisted of multiple holes, and the infarcted myocardium had already progressed to firm, fibrotic scar tissue. We closed the ventricular septal rupture with a small bovine pericardial patch and performed an aneurysmectomy with a liner technique. Conclusions Cases of ventricular septal rupture can have various clinical scenarios, and treatment should be optimized for each patient, especially with respect to the timing of surgery.

Multimodal Visualization of the Left Ventricular Postinfarction Aneurysms: Current State of the Problem and Own Observation Results

Background. Left ventricular aneurysm (LVA) is a complication occurring in 5–10% of acute myocardial infarction (AMI) patients significantly complicating AMI acute stage course and leading to advanced congestive heart failure (CHF) progress. Non-invasive LVA visualization includes echocardiography, cardiac magnetic resonance imaging (MRI), radio-nuclide ventriculography, and multi-slice computed tomography (MSCT). It can also be detected during heart catheteriza-tion by coronary ventriculography (CVG). Each method has its advantages and drawbacks. The aim. To analyze multimodal non-invasive LVA visualization methods (echocardiography and MSCT) in order to establish accuracy of these methods compared to CVG regarding the diagnosis of LVA and LVA thrombosis. Methods. We examined 60 patients after AMI with LVA admitted for surgical revascularization and left ventricular aneurysm resection (LVAR). Control group included 110 patients after AMI prior to revascularization without history of LVA. All the patients underwent CVG, heart MSCT and echocardiography prior to surgery. Results. Mean patients’ age was 60.9±11.4 years (46 [76.7%] men and 14 [23.3%] women, mean LVEF was 42.7±11.1%. Significant CAD according to coronary angiography (CAG) before surgery was proved in 59 (98.3%) pa-tients, and 1 (1.7%) patient had no significant coronary lesions. The majority of patients had anterior LVA localization after AMI in LAD area (57 [95.0%] patients), 2 (3.3%) patients were diagnosed with inferior LVA after AMI in RCA area, and 1 (1.7%) patient had posterior-lateral LVA in Cx area. There was high correlation between LVEF obtained with echo-cardiography and that obtained with MSCT (r=0.955, p<0.0001), although mean LVEF obtained with echocardiography was significantly higher compared to MSCT results (42.7±11.1% vs. 32.7±9.3%, p<0.0001). Comparison of accuracy of the methods in LVA diagnosis showed that MSCT was the most precise method with significantly higher sensitivity compared to CVG and echocardiography (94.9% vs. 75.0%, p=0.002, and 88.0%, p=0.023, respectively), and MSCT significantly ex-ceeded CVG in all diagnostic method accuracy indices. Echocardiography also significantly exceeded CVG in all diagnostic accuracy indices. Comparison of accuracy of the methods in LVA thrombosis diagnosis showed similar results: echocar-diography was much more precise in terms of sensitivity (79.4% vs. 58.8%, p<0.0001) and the rest of indices. MSCT was much more precise in terms of all indices compared to CVG, and also significantly exceeded echocardiography results in terms of sensitivity (97.1% vs. 79.4%, p<0.0001), positive (PPV) (100.0% vs. 93.1%, p=0.0005) and negative predictive value (NPV) (99.1% vs. 93.9%, p=0.0091), integral “area under curve” index (AUC) (0.99 vs. 0.89, p=0.0001) and odds ratio (OR) (3630 vs. 208, p<0.0001). Conclusions. High correlation of LVEF according to echocardiography and MSCT results allows to skip CVG as a global LV contractility evaluation method enabling to reduce the procedure time. The lowest accuracy of CVG in the diagnosis of LVA and LVA thrombosis also allows to reduce the duration and volume of the invasive procedure to selective CAG and to reduce radiation exposure for patients and operators in favor of non-invasive and more accurate methods (MSCT and echocardiography). MSCT is the most accurate method for LVA thrombosis diagnosis, but it is completely comparable to echocardiography in LVA diagnosis per se, making echocardiography the method of choice in screening and stratification of patients after AMI regarding myocardial revascularization only or combined surgical revascularization with LVAR due to its rapidness, low cost and absence of patient-related adverse effects.

Surgical Treatment of Left Ventricular Aneurysm Combined with Ischemic Mitral Regurgitation Using a Modified Technique

Background. Ischemic mitral regurgitation (IMR) is the second most common cause of mitral regurgitation (MR). IMR occurs in patients with myocardial infarction due to a rupture of the subvalvular apparatus. Pathological remodel-ing, dilatation and dysfunction of the left ventricle (LV) play a significant role in the development of IMR. The presence of a postinfarction LV aneurysm can lead to the development of MR due to dysfunction, relative and true shortening of the papillary muscles. There are various methods of surgical correction of IMR. The aim. To show the effectiveness of surgical treatment of left ventricular aneurysm combined with ischemic mitral regurgitation using a modified technique. Materials and methods. From January 2011 to December 2019, 20 patients with IMR combined with LV aneurysm underwent surgical intervention using a modified technique at the National Amosov Institute of Cardiovascular Surgery of the NAMS of Ukraine. According to this technique, access to the mitral valve was performed through the left ventricle. The mean age of the patients was 61.2 ± 10.1 years. Among patients with IMR, the majority were men (60.0%). The overwhelming majority of patients (80.0%) had the history of hypertension. Diabetes mellitus was detected in 35.0% of patients. Mitral ring dilatation was observed in 25.0% (5) of the cases, papillary muscle displacement in 40.0% (8), chords rupture in 15.0% (3), papillary muscle infarction in 20.0% (4) of the cases. All the patients had reduced LV ejection fraction with a mean value of 34.5 ± 7.8%. Results. Aortic cross-clamp time through ventricular access was 112.9 ± 18.7 minutes. The duration of mechanical ventilation was 19.1 ± 20.6 hours. The length of stay of patients in the ICU was 99.2 ± 43.5 hours. There were no signs of acute heart failure in the early postoperative period in one in five patients (20.0%). The rate of degree III heart failure after intervention using the modified technique was 20.0% (4). The study of the incidence of cardiac arrhythmias after combined intervention showed that 85.0% (17) of patients operated using the modified technique had no cardiac arrhythmias. Conclusions. In patients who underwent surgery using the modified technique, the mortality rate was 5.0%. This is 1.6-2.8 times less than that in patients undergoing conventional operation. Postoperative occurrence of arrhythmias is much less common than that described in the literature.

Traumatic Left Ventricular Aneurysm and Ventricular Septal Defect in a Child

Cardiac injuries following blunt trauma are rare but potentially lethal in children. We present a 23-month-old child who sustained an aneurysm of the left ventricle free wall and ventricular septum with associated ventricular septal defect following blunt trauma. She underwent successful surgical repair 6 weeks following her date of injury. Surgical decision-making surrounding this case is discussed.