Abstract
Surgical therapies in aortic valve stenosis (AVS) and hypertrophic obstructive cardiomyopathy (HOCM) aim to relief intraventricular pressure overload and improve clinical outcome. It is currently unknown to what extent myocardial adaptation concurs with restoration of intraventricular pressures, and whether this is similar in both patient groups. The aim of this study was to investigate changes in myocardial adaptation after surgical therapies for AVS and HOCM. Ten AVS and ten HOCM patients were enrolled and underwent cardiac magnetic resonance cine imaging and myocardial tagging prior to, and 4 months after aortic valve replacement (AVR) and septal myectomy, respectively. Global left ventricular (LV) analyses were derived from cine images. Circumferential strain was assessed from myocardial tagging images at the septal and lateral wall of the mid ventricle. Pressure gradients significantly decreased in both AVS and HOCM after surgery (p < 0.01), with a concomitant decrease in left atrial volume (p < 0.05) suggesting lower diastolic filling pressures. Also, LV volumes, mass and septal wall thickness decreased in both, but to a larger extent in AVS than in HOCM patients. AVR improved wall thickening (p < 0.05) and did not change systolic strain rate. Myectomy did not affect wall thickening and reduced septal systolic strain rate (p = 0.03). Both AVR and myectomy induced positive structural remodeling in line with a reduction of pressure overload. A concomitant recovery in systolic function however was found in AVR only. The systolic functional deterioration in HOCM patients seems to be inherent to myectomy and the ongoing and irreversible disease.
Highlights
Left ventricular hypertrophy (LVH) is a common finding in clinical practice and is associated with morbidity and mortality
Previous studies have investigated the effect of Aortic valve replacement (AVR) and septal myectomy on the myocardium separately demonstrating a reduction in intraventricular pressures with subsequent improvement in clinical symptoms and outcome [10,11,12,13]
It is currently unclear to what extent myocardial structural and functional recovery concurs with restoration of intraventricular pressures, and whether this is comparable in patient groups with similar concentric hypertrophic remodeling, but a different cause
Summary
Left ventricular hypertrophy (LVH) is a common finding in clinical practice and is associated with morbidity and mortality. Sarcomeric mutations affect functional properties of the sarcomeres [5] and impair energy metabolism, leading to LVH, most often asymmetric [6, 7] This asymmetric hypertrophy in combination with systolic anterior motion of the mitral valve can cause left ventricular outflow tract (LVOT) obstruction, leading to heterogeneous symptoms, varying from angina and syncope, to congestive heart failure and sudden cardiac death [8]. The surgical treatment for LVOT obstruction is septal myectomy, which reduces the risk for sudden cardiac death and normalizes left ventricular (LV) pressures [9]. It is currently unclear to what extent myocardial structural and functional recovery concurs with restoration of intraventricular pressures, and whether this is comparable in patient groups with similar concentric hypertrophic remodeling, but a different cause (i.e. aortic stenosis vs genetic). We hypothesize that surgical therapies will improve myocardial function in both AVS and HOCM patients
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