Novel off-pump ventricular septal myectomy for obstructive hypertrophic cardiomyopathy: A paradigm shift in surgical management.

Septal myectomy in context: Clinical acumen and procedural expertise

2011;58;2703-2738; originally published online Nov 8, 2011; J. Am. Coll. Cardiol. W. Yancy Rakowski, Christine E. Seidman, Jeffrey A. Towbin, James E. Udelson, and Clyde Fifer, Mark S. Link, Srihari S. Naidu, Rick A. Nishimura, Steve R. Ommen, Harry Bernard J. Gersh, Barry J. Maron, Robert O. Bonow, Joseph A. Dearani, Michael A. Thoracic Surgeons Society for Cardiovascular Angiography and Interventions, and Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, of Thoracic Surgery, American Society of Echocardiography, American Society Developed in Collaboration With the American Association for Guidelines Cardiology Foundation/American Heart Association Task Force on Practice Cardiomyopathy: Executive Summary: A Report of the American College of 2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic This information is current as of May 14, 2012 http://content.onlinejacc.org/cgi/content/full/58/25/2703 located on the World Wide Web at: The online version of this article, along with updated information and services, is

New ESC guidelines on hypertrophic cardiomyopathy: new insights in invasive treatment?

A industria brasileira, apos intenso processo de crescimento e consolidacao durante seu periodo de industrializacao substitutiva de importacoes (1956-1979), passou a sofrer, dentro de um contexto de mudanca de paradigma produtivo, um constante processo de defasagem quanto a incorporacao de tecnologias a partir dos anos 80. Esse atraso se manifestou tanto na obsolescencia das maquinas e equipamentos, quanto nos modelos administrativos e nas relacoes capital-trabalho, devido principalmente ao Estado, principal fomentador do desenvolvimento da economia e da industria ter perdido a capacidade de realizar politicas industriais (PI) e tecnologicas (PT) que promovessem uma rearticulacao interna das forcas produtivas. Nesse sentido, na presente pesquisa se concentrou a discussao na apresentacao dos determinantes fundamentais do atraso tecnologico da industria brasileira decisivamente a partir dos anos 80, analisando-se, para isso, as condicionantes politicas, economicas e ideologicas, tendo-se como foco as politicas industriais e tecnologicas promovidas pelo Estado brasileiro que, mesmo fomentando um crescimento industrial acelerado da economia com base no paradigma da producao em massa, basicamente prezou pelo desenvolvimento de uma industria voltada para a capacidade produtiva. Nesse sentido, quando se tornou premente uma transicao para o novo paradigma de producao flexivel, esta embasada na geracao de capacidade tecnologica, emergiram inumeras barreiras a essa mudanca. Mesmo a economia tendo buscado desenvolver um nucleo de pesquisa e desenvolvimento e ciencia e tecnologia proprios, esses nao foram suficientemente dinâmicos o bastante a ponto de colocar o pais em movimentos de catching up tecnologico constante como ocorria nos paises mais desenvolvidos, buscando-se direcionar o desenvolvimento da economia para o novo paradigma produtivo. De outro lado, quanto as PI e PT adotadas no desenvolvimento da Coreia do Sul, o fomento do processo de catching up produtivo e tecnologico possibilitou a esse pais absorver de forma dinâmica a “janela de oportunidade” que se abriu com o surgimento do novo paradigma, possibilitando ao pais, que teve um processo de industrializacao tardia como o Brasil, desenvolvesse uma das principais industrias do mundo no que tange a geracao de produtos intensivos em alta tecnologia, votados ao mercado internacional, levando a economia coreana a se situar proximo ou sobre a fronteira tecnologica em expansao do novo paradigma. Assim, o estudo parte do referencial teorico da abordagem schumpeteriana a fim apontar alguns dos elementos que levaram a estrutura industrial brasileira a se conformar com um dinamismo relativamente lento no seu processo de desenvolvimento tecnologico formando uma estrutura com pouca competitividade nos setores mais dinâmicos da industria, os de alta tecnologia e que representam, atualmente o segmento chave da competicao empresarial internacional. Este cenario contrasta com o caso oposto da Coreia do Sul onde esse setor da economia, atualmente, se mostra bastante dinâmico em termos de geracao e disseminacao das inovacoes tecnologicas.

33-Year-Old Man With Syncope

Septal Reduction Therapy for Obstructive Hypertrophic Cardiomyopathy: Volume Still Matters for Septal Myectomy

Hypertrophic cardiomyopathy is a relatively recent concept. It occurs not infrequently; ≈1 in 500 individuals within the general population is a carrier of the disease.1 The main genes responsible for hypertrophic cardiomyopathy have been characterized and can be determined with relative ease.2 Some patients develop subaortic obstruction. The original term, idiopathic hypertrophic subaortic stenosis, dates to 1964;3 since then, it has become obvious that the obstructive component has its own prognostic meaning. The obstruction occurs in ≈25% of all humans with hypertrophic cardiomyopathy,4 and the entity is now called hypertrophic obstructive cardiomyopathy. Article p 131 Surgery for elimination of the obstructive element via resection of the subaortic septal bulge (myectomy) has been, since its introduction by Cleland at the Brompton in London exactly half a century ago, the only rational option for patients with clinically relevant left ventricular outflow tract obstruction that is refractory to optimal medical therapy. At experienced centers, the operation can be performed with low mortality and excellent clinical improvement.5 The concept of using transluminal techniques to reduce septal hypertrophy in patients with hypertrophic obstructive cardiomyopathy was not based on the hope of achieving better results than with surgery, but primarily to reduce morbidity. In the early 1980s, while performing coronary angiography on patients with hypertrophic obstructive cardiomyopathy, I noticed that in some patients, the first septal perforator branches appeared to irrigate primarily the area of the septal bulge responsible for outflow tract obstruction. During systole, these branches seemed to be compressed by the surrounding hyperabundant myocardium. Interfering with the proper irrigation of this …

Indications for Surgery in Obstructive Hypertrophic Cardiomyopathy.

Mitral valve–sparing operation in subaortic stenosis caused by anomalous papillary muscle and discrete subaortic stenosis

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AB26-2: Surgical septal myectomy for symptomatic hypertrophic obstructive cardiomyopathy decreases the risk for SCD and appropriate ICD discharge

Ventricular Tachycardia in Hypertrophic Cardiomyopathy With Apical Aneurysm

Hypertrophic cardiomyopathy (HCM) is the most common genetic cardiovascular disease characterized by a thickened non-dilated ventricle in the absence of another cardiac or systemic condition. Its most important hemodynamic consequence is left ventricular outflow tract (LVOT) obstruction. The primary management strategy of this condition is surgical septal myectomy, but an acceptable alternative treatment in patients who are not suitable for (or who refuse) surgery is alcohol septal ablation (ASA). However, in patients with unfavorable coronary anatomy which precludes ASA (i.e. absence of major septal perforator branch of the left anterior descending (LAD) artery), another reasonable option is dual chamber pacemaker implantation to decrease LVOT outflow gradient. A 77-year-old female, known hypertensive, diabetic with a history of coronary artery disease, presented with 1-week history of worsening chest pain and shortness of breath. She was admitted as a case of acute coronary syndrome and pneumonia. On workup, 2DED revealed hypertrophic obstructive cardiomyopathy (HOCM) with a demonstrated systolic anterior motion (SAM) of the mitral valve with a peak instantaneous gradient of 194 mm Hg across the basal LV cavity. The patient refused surgical myectomy, and ASA was the preferred treatment option. On coronary angiography, there was an incidental finding of absent major septal perforator branch of the LAD coronary artery, rendering her unsuitable for septal ablation. She was referred to electrophysiology for evaluation. She underwent dual chamber pacemaker implantation and documented significant decrease in the peak instantaneous gradient from 194 to 37 mm Hg, with complete obliteration of SAM and improvement in overall wall motion. She remained stable and asymptomatic after pacemaker insertion until her recent outpatient follow-up (1 year after implantation). We present a case of HCM with congenitally absent major septal perforator branch coronary artery treated with dual chamber pacemaker implantation. To our knowledge, this is the first reported angiographically absent first (major) septal perforator coronary anatomy in the setting of HCM, and also the first description of dual chamber pacemaker implantation to relieve the LVOT obstruction. Although the role of dual chamber pacing has become limited in HCM because surgical myectomy and septal ablation have resulted in better decrease in LV outflow gradient and symptom improvement, this modality remains essential and may still be considered as the treatment strategy-of-choice in patients who are unsuitable for surgical myectomy and ASA.

Hypertrophic Cardiomyopathy