Concomitant Septal Myectomy Research Articles

Symmetrical bicuspidization of the aortic valve in a child

We present the case of a 4-year-old patient who underwent an aortic valve repair and concomitant septal myectomy and ascending aorta enlargement. The aortic valve was severely stenotic, bicuspid with a fused left–right commissure and a rudimentary right coronary leaflet. This case report demonstrates how this problem was repaired with a good result.

Improvement in Left Ventricular Function of the Resected Myocardium after Septal Myectomy in Patients with Aortic Valve Replacement

Background: Some surgeons have previously advocated for a more aggressive concomitant septal myectomy to address left ventricular outflow tract obstruction; however, concerns about the surgical complications of post-septal myectomy remain. Here, we aimed to assess the clinical, echocardiographic, and pathological findings following concomitant septal myectomy with surgical aortic valve replacement. Methods: We reviewed 21 patients who underwent surgical aortic valve replacement and concomitant septal myectomy from April 2014 to September 2019. The global and regional left ventricular ejection fraction changes between the perioperative periods were analyzed using two-dimensional speckle-tracking echocardiography. The resected myocardium was pathologically assessed. Results: No operative mortality was observed during the study period. Transthoracic echocardiography showed no significant differences in preoperative and postoperative left ventricular ejection fraction (68.1 ± 9.9% vs. 68.6 ± 6.0%, p = 0.82) or interventricular septum thickness (11.9 ± 1.4 mm vs. 11.5 ± 1.5 mm, p = 0.23). Interventricular septum thickness at the end-systolic phase, which is the maximum septal wall thickness, was significantly reduced postoperatively (27.7 ± 9.3 mm vs. 22.6 ± 5.5 mm, p < 0.05). The basal, mid, and apical septal areas improved with septal myectomy by 80%, 230%, and 27%, respectively, compared to perioperative echocardiography (basal septal, 80 ± 23%; mid septal, 230 ± 830%; apical septal, 27 ± 350%). Pathological examination of the resected myocardium revealed marked endocardial thickness (mean, 914 µm) with focal fibrosis. Conclusions: In aortic valve stenosis patients with septal hypertrophy, concomitant septal myectomy with surgical aortic valve replacement improved regional myocardial function and eliminated left ventricular outflow tract obstruction by removing thickened endocardium and prominent fibrosis.

Transaortic septal myectomy at the time of aortic valve replacement for severe aortic stenosis: a case series of 55 cases

Abstract Introduction Symptomatic aortic valve stenosis (AS) is associated with asymmetric basal septal hypertrophy (ABSH) in 10% of cases. In this cohort, it has been suggested that rectification of the left ventricular outflow tract obstruction (LVOTO) by concomitant septal myectomy (CSM) can improve the results of aortic valve replacement (AVR). Objective This study aims to present the technique of AVR with CSM for severe AS with ABSH and to determine the associated early and late post-operative outcomes. Methods Fifty-five patients were prospectively recruited to undergo AVR with CSM between 2011 and 2021 at two centres. The primary outcomes were mortality within 30 days, incidence of post-operative ventricular septal defects (VSD) and prosthetic valve sizing. The secondary outcomes were in-hospital complications, permanent pacemaker implantation (PPI), survival at 15 months and changes on transthoracic echocardiogram. Results Post-operative mortality was 1.8% and this figure was unchanged at 15-month follow-up. No patients developed a post-operative VSD. Intra-operatively, it was found that in 94.6% cases the direct valve sizing increased by one, when compared to the measurement made before CSM. The indexed effective orifice area (iEOA) was > 85 cm2/m2 in 96.4% and no patients had an iEOA ≤ 0.75 cm2/m2. Four patients (7.3%) required PPI due to complete atrioventricular block. Conclusion AVR with CSM is a simple technique that can be utilised in severe AS with ABSH. There does not appear to be an increase in mortality or incidence of iatrogenic VSDs. Importantly, CSM allows for the implantation of a larger aortic valve compared to measurements made before CSM.

Left ventricular outflow tract obstruction in patients with Ebstein anomaly

ObjectiveIn this study, we investigated the clinical characteristics of patients with Ebstein anomaly and left ventricular outflow tract (LVOT) obstruction as well as possible mechanisms of obstruction as assessed by 2-dimensional echocardiography. MethodsWe queried our institutional echocardiography and surgical databases for patients with the diagnosis of Ebstein anomaly seen from 1985 through 2022. Fourteen patients had the additional diagnosis of LVOT obstruction identified from transthoracic echocardiography. ResultsThe mean age of the 14 patients at the time that LVOT obstruction was identified was 51.9 ± 9.9 years, and 11 (78%) were female. LVOT obstruction (mean gradient 61.0 ± 25.7 mm Hg) was documented at the time of initial diagnosis of Ebstein anomaly for 8, and in the remaining, was recognized on follow-up imaging. Dynamic LVOT obstruction with systolic anterior motion (SAM) was the most common mechanism and was mostly accompanied by leftward septal movement and septal hypertrophy. Seven of the 9 patients with SAM had the diagnosis of hypertrophic cardiomyopathy. Leftward bowing of the septum appeared to be the sole cause of LVOT obstruction in 3 and a contributing factor to SAM in 4. Among the 13 patients who underwent an operation for Ebstein anomaly, 7 had concomitant septal myectomy and 3 had a subsequent procedure. ConclusionsThere are multiple mechanisms of LVOT obstruction in patients with Ebstein anomaly, including SAM and leftward bowing of the interventricular septum, which may exist alone or in combination. Septal myectomy at the time of tricuspid valvuloplasty is safe and effectively reduces gradients in the outflow tract and may prevent the need for subsequent reintervention.

Surgical Outcomes of Septal Myectomy With and Without Mitral Valve Surgeries in Hypertrophic Cardiomyopathy: a National Propensity-Matched Analysis (2005 to 2020)

The management of concomitant mitral valve (MV) disease in patients with hypertrophic cardiomyopathy (HCM) remains controversial. The 2020 American Heart Association/American College of Cardiology HCM guidelines recommend that MV replacement (MVR) at the time of myectomy should not be performed for the sole purpose of relieving outflow obstruction. At the national level, limited data exist on the surgical outcomes of MV repair/replacement in patients with HCM who underwent septal myectomy (SM). Hospitalizations of patients with HCM who underwent SM between 2005 and 2020 were identified using International Classification of Diseases, Ninth and Tenth Revision codes (International Classification of Diseases, Ninth and Tenth Revision Clinical Modification/ProcedureCoding System). The 3 comparison cohorts were SM alone, MV repair, and MVR with concomitant SM. After propensity matching, 2 cohorts, SM+MVR versus SM+MV repair, were studied for surgical outcomes. Demographic characteristics, baseline co-morbidities, procedural complications, inpatient mortality, length of stay, and cost of hospitalization were compared between the propensity-matched cohorts. A total of 16,797 SM procedures were identified from 2005 to 2020. Among them, 11,470 hospitalizations had SM alone (68.2%), SM+MVR was seen in 3,101 (18.4%), and SM+MV repair comprised 2,226 (13.2%). After propensity matching, the MVR and MV repair formed the matched cohorts of 1,857. There were no significant differences in the odds of cardiogenic shock (adjusted odds ratio [aOR] 0.88, 95% confidence interval [CI] 0.63 to 1.24, p=0.49), mechanical circulatory support requirement (aOR 0.58, 95% CI 0.37 to 0.90, p=0.015), stroke (aOR 1.27, 95% CI 0.81 to 1.99, p=0.29), and major bleeding (aOR 0.52, 95% CI 0.34 to 0.79, p=0.0026) between the comparison groups. MVR, compared with MV repair, was associated with a higher risk of procedural mortality (8.02% vs 3.18%, aOR 2.98, 95% CI 2.05 to 4.33, p <0.0001), complete heart block (16.36% vs 12.15%, aOR 1.76, 95% CI 1.44 to 2.12, p <0.0001), and the need for permanent pacemaker (16.39% vs 10.62%, aOR 1.83, 95% CI 1.41 to 2.38, p <0.0001). The total length of hospital stay and median hospitalization cost was higher in the MVR group. SM in HCM concomitant with MVR is associated with higher procedural mortality and in-hospital complication risk. These real-world data support the 2020 American Heart Association/American College of Cardiology guidelines that in patients who are candidates for surgical myectomy, MVR should not be performed as part of the operative strategy for relieving outflow obstruction in HCM.

Concomitant Septal Myectomy with Aortic Valve Replacement for Severe Aortic Stenosis with Left Ventricular Outflow Tract Obstruction

Objectives Septal myectomy confers survival benefits on patients with hypertrophic cardiomyopathy. However, its role in the treatment of severe aortic stenosis (sAS) with left ventricular outflow tract obstruction (LVOTO) remains under investigation. Another challenging question in the era of transcatheter aortic valve replacement is who would benefit more from traditional surgical aortic valve replacement (SAVR) with myectomy. Therefore, this study aimed to investigate myectomy cases at our hospital in Japan.

Septal Thickness Does Not Impact Outcome After Hypertrophic Obstructive Cardiomyopathy Surgery (Septal Myectomy and Subvalvular Mitral Apparatus Remodeling): A 15-Years of Experience.

BackgroundThe aim of this study was to assess the impact of septal thickness on long-term outcomes of surgical treatment for hypertrophic obstructive cardiomyopathy (HOCM) and correction of mitral subvalvular anomalies.MethodsSixty-six consecutive patients (58 ± 12 years, 56% female) undergoing extended septal myectomy and subvalvular mitral apparatus remodeling from 2007 to 2021 were retrospectively reviewed. Patients were divided into 2 groups according to septal thickness: moderate [< 18 mm, 29 patients (44%)] and severe [≥ 18 mm, 37 patients (56%)]. End points included survival, symptom improvement, reduction of left ventricle outflow tract (LVOT) gradient, resolution of mitral regurgitation (MR), and reoperation.ResultsThe mean interventricular septal thickness was 19 ± 3 mm, 15.8 ± 0.8 mm in patients with moderate and 21.4 ± 3.2 mm in those with severe hypertrophy. Preoperative data, intraoperative variables, postoperative complication rates, pre-discharge echocardiographic and clinical parameters did not differ between the two study groups [except for procedures involving the posterior mitral leaflet (p = 0.033) and septal thickness after myectomy (p = 0.0001)]. Subvalvular apparatus remodeling (secondary chordae of mitral valve resection and papillary muscle and muscularis trabecula procedures including resection, splitting, and elongation) was invariably added to septal myectomy (100%). Four (6%) procedures involved the posterior mitral leaflets. Mitral valve replacement was carried out in two patients (3%, p = 0.4). Reoperation for persistent MR was necessary in one patient (1%, p = 0.4). Neither iatrogenic ventricular septal defect nor in-hospital mortality occurred. During follow-up (mean 4.8 ± 3.8 years), two deaths occurred. NYHA class was reduced from 2.9 ± 0.7 to 1.6 ± 0.6 (p < 0.0001), the LVOT gradient from 89.7 ± 34.5 to 16.3 ± 8.8 mmHg (p < 0.0001), mitral valve regurgitation grade from 2.5 ± 1 to 1.2 ± 0.5 (p < 0.0001), and septal thickness from 18.9 ± 3.7 to 13.9 ± 2.7 mm (p < 0.0001).ConclusionsRegardless of septal thickness, subvalvular apparatus remodeling with concomitant septal myectomy can provide satisfactory long-term outcomes in terms of symptom improvement, LVOT obstruction relief, and MR resolution (without mitral valve replacement in most cases) in patients with HOCM.

Optimal Management of Mitral Regurgitation Due to Ruptured Mitral Chordae Tendineae in Patients With Hypertrophic Cardiomyopathy

There is continued controversy regarding surgical management of patients with hypertrophic cardiomyopathy (HCM) and intrinsic mitral valve disease; some clinicians favor prosthetic replacement as this corrects left ventricular outflow tract (LVOT) obstruction and valve leakage. In this study, we investigated the management and late outcome of operation for mitral regurgitation (MR) due to ruptured chordae tendineae in patients with HCM. We analyzed 49 consecutive patients with HCM and MR due to ruptured mitral valve chordae. Echocardiograms and operative reports were reviewed to classify valve anatomy and surgical methods. Information on late outcomes was obtained from electronic medical records and follow-up surveys. The mean age of the 36 men and 13 women was 61.9 ± 12.5 years; significant resting or provoked LVOT obstruction was present at the time of surgery in 46 patients. During the index operation, mitral valve repair was performed in 45 patients, and prosthetic replacement was necessary for 4 patients. Concomitant septal myectomy was performed in 46 patients. There were no hospital deaths or deaths within 30 days of operation. Five and ten-year survival estimates (Kaplan-Meier) were 92% and 71%. During follow-up at a median of 7.9 years, 3 patients underwent reoperation for MV replacement, 5 days, 3 years, and 14 years following valve repair. Ruptured mitral chordae may result in severe mitral valve regurgitation in patients with hypertrophic cardiomyopathy. Valvuloplasty at the time of septal myectomy is safe with an acceptably low rate of recurrent MR requiring prosthetic replacement.

Short-term outcomes of surgical atrial ablation and septal myectomy

Background. Hypertrophic cardiomyopathy is one of the most common types of cardiomyopathy. The appearance of atrial fibrillation in patients with hypertrophic obstructive cardiomyopathy is associated with significant clinical worsening. Outcomes of surgical ablation and septal myectomy in these patients are limited.Aim. This retrospective study aimed to evaluate short-term outcomes of concomitant surgical ablation and septal myectomy in patients with obstructive hypertrophic cardiomyopathy and atrial fibrillation.Methods. Fifty-five patients with hypertrophic obstructive cardiomyopathy and atrial fibrillation who underwent concomitant surgical ablation and septal myectomy between 2014 and 2019 were analysed. Patients with paroxysmal atrial fibrillation predominantly underwent left atrial ablation, and those with nonparoxysmal atrial fibrillation predominantly underwent the Maze IV procedure. Surgical ablation was performed using cryoablation alone (83.6%) or in combination with radiofrequency energy (16.4%).Results. Hospital mortality was 1.8%. Incidence of major adverse events was 3.6%. Sinus node dysfunction and atrioventricular block occurred in 7.3% and 1.8% of patients, respectively. Bleeding requiring revision occurred in 2 (3.6%) patients. Forty-nine (89.1%) patients had stable sinus rhythm and five (9.1%) were on dual-chamber pacemaker stimulation at the time of discharge.Conclusion. Concomitant septal myectomy and surgical ablation are feasible and safe in patients with hypertrophic obstructive cardiomyopathy and atrial fibrillation.Received 5 April 2021. Revised 16 May 2021. Accepted 17 May 2021.Funding: The study did not have sponsorship.Conflict of interest: The authors declare no conflicts of interests.Contribution of the authorsConception and study design: A.S. Zalesov, A.V. Bogachev-ProkophievData collection and analysis: A.S. Zalesov, S.A. Budagaev, A.V. SapeginStatistical analysis: A.S. Zalesov, A.V. Afanasyev, R.M. SharifulinDrafting the article: A.S. ZalesovCritical revision of the article: A.V. Bogachev-Prokophiev, S.I. Zheleznev, I.I. DeminFinal approval of the version to be published: A.S. Zalesov, A.V. Bogachev-Prokophiev, A.V. Afanasyev, R.M. Sharifulin, A.V. Sapegin, S.A. Budagaev, S.I. Zheleznev, I.I. Demin

Concomitant Cox-Maze IV and Septal Myectomy in Patients With Hypertrophic Obstructive Cardiomyopathy

BackgroundIn patients with hypertrophic obstructive cardiomyopathy, atrial fibrillation is associated with heart failure and increased late mortality. However, the role of surgical ablation in these patients is not well defined. The aim of this study was to evaluate the efficacy of the concomitant Cox-Maze IV procedure in patients undergoing septal myectomy for hypertrophic obstructive cardiomyopathy. MethodsBetween 2005 and 2019, 347 patients who underwent septal myectomy at a single institution (Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, MO) were retrospectively reviewed. For patients with hypertrophic obstructive cardiomyopathy and atrial fibrillation who underwent a concomitant Cox-Maze IV procedure, freedom from atrial tachyarrhythmias (ATAs) on or off antiarrhythmic drugs (AADs) was evaluated annually. Predictors of ATA recurrence were identified using Fine-Gray regression, with death as a competing risk. ResultsA total of 42 patients underwent concomitant septal myectomy and Cox-Maze IV procedures. The majority of patients, 69% (29 of 42), had paroxysmal atrial fibrillation with a 2.5-year median duration. Operative mortality was 7% (3 of 42). New York Heart Association functional class was reduced after surgery (P < .01). Rates of freedom from recurrent ATAs at 1- and 5-year intervals were 93% (27 of 29) and 100% (14 of 14), respectively. Rates of freedom from ATAs and AADs were 83% (24 of 29) and 100% (14 of 14) at the same time points, respectively. Increased left atrial diameter predicted first ATA recurrence (P < .01). Cerebrovascular accident risk was lower in patients with atrial fibrillation who underwent concomitant Cox-Maze IV and septal myectomy relative to myectomy only (P = .02). ConclusionsLate freedom from ATAs on or off AADs was excellent after Cox-Maze IV and septal myectomy. Although there was a higher than expected rate of perioperative complications, the study results suggest that concomitant surgical ablation should be considered in selected patients with hypertrophic obstructive cardiomyopathy and atrial fibrillation.

Immediate results of concomitant septal myectomy during aortic valve replacement

Immediate results of concomitant septal myectomy during aortic valve replacement

DUAL-CHAMBER PACING FOR POSTOPERATIVE RESIDUAL LEFT VENTRICULAR GRADIENT AFTER AORTIC VALVE REPLACEMENT AND CONCOMITANT SEPTAL MYECTOMY FOR SEVERE AORTIC STENOSIS AND SUBVALVULAR OBSTRUCTION

Aortic stenosis (AS) is occasionally associated with subvalvular obstruction and it is possible that remaining obstruction may at times be found after aortic valve replacement (AVR) and concomitant septal myectomy. A 69-year-old woman with a history of several episodes of unconsciousness was

Mid-term outcomes of concomitant surgical ablation of atrial fibrillation in patients undergoing cardiac surgery for hypertrophic cardiomyopathy†.

Atrial fibrillation (AF) is common in patients with hypertrophic cardiomyopathy (HCM) and it is often poorly tolerated because of loss of atrial contraction and reduced filling time with rapid ventricular rates. Restoring sinus rhythm is of great clinical benefit to HCM patients. Very few data exist regarding surgical ablation of concomitant AF in this setting. The aim of this study was to evaluate the mid-term outcome of surgical AF ablation in patients who underwent cardiac surgery due to HCM. Thirty-one consecutive patients with primary HCM and drug-refractory symptomatic AF underwent surgical ablation with concomitant septal myectomy (77%) and/or mitral valve repair/replacement (39%). Follow-up was 97% complete with a median of 6.4 years [3.8-9.1]. Hospital mortality was 6% and the overall survival at 7 years was 87 ± 6.1%. No stroke and thromboembolic events were documented at follow-up. The arrhythmia-free survival off antiarrhythmic drugs was 82 ± 7.3% at 1 year and 52 ± 10.2% at 6 years. The 1- and 6-year arrhythmia control (maintenance of sinus rhythm with or without antiarrhythmic drugs) was 96 ± 3.5 and 80 ± 8.1%, respectively. The recurrent arrhythmia was AF in all patients. No predictors of AF recurrence were detected. Concomitant surgical ablation of AF is a reasonable treatment option for drug refractory AF in patients with HCM undergoing surgical myectomy and/or mitral valve surgery. However, chronic antiarrhythmic drugs are needed to achieve a satisfactory mid-term arrhythmia control.

Abstract 13210: Concomitant Septal Myectomy Can Improve Left Ventricular and Atrial Function Detected by 2d Speckle Echocardiography as Well as Long term Survival In Patients Undergoing Aortic Valve Replacement With Marked Ventricular Hypertrophy

Introduction: Patients requiring aortic valve replacement (AVR) frequently have left ventricular hypertrophy (LVH) /sigmoid septum, which causes persistent outflow obstruction (LVOTO) postoperatively. Surgical AVR enables such patients to undergo concomitant septal myomectomy. However, the effect on their postoperative myocardial function and long-term outcome is yet to be elucidated. Hypothesis: Concomitant myectomy may be beneficial for selected patients undergoing surgical AVR and possible LVOTO. Methods: Postoperative outcome and myocardial functional changes before and after surgery were assessed by conventional and 2D speckle tracking echocardiography in patients undergoing AVR and myectomy (Group M, n=16, male 21%, mean age 76.0 years) The results were compared with age/sex-matched controls who had marked LVH/LVOTO undergoing AVR alone (Group C, n=27). The relation between preoperative echo-derived local myocardial function and histology of resected myocardium in Group M was also investigated. Results: Preoperative echo parameters were not different between the groups. However, a decrease in LV E/E’ and an increase in the absolute value of basal septum longitudinal strain were seen postoperatively only in Group M (17.3±4.3 to 15.2±2.6, p=0.013, -9.3±4.5 to -12.8±3.8%, p=0.008, respectively). Peak LA strain values increased in both groups, but the improvement was more apparent in Group M (Group M; 20.6±5.3 to 28.3±7.1%, p=0.008, Group C; 21.9±5.9 to 26.9±6.0%, p=0.046,). Survival following surgery was better in Group M than Group C (30 days, 1 and 5 year, 100.0% vs 88.2%, 100.0% vs 75.6%, 100.0% vs 68.8%, respectively, p=0.028). Histology of resected myocardium in Group M showed remarkable fibrosis (mean 6.8%, range 1-17%) and thickness of endocardium (mean 1031μm, range 287-2505μm), and the degree of fibrotic area was significantly correlated with preoperative basal septum strain value (r2=0.6, p=0.041). Conclusions: Concomitant septal myectomy with AVR improves postoperative LV diastolic function, as well as LA function. Furthermore, it improved short and long-term survival as compared to those undergoing AVR alone. AVR with myectomy may be a beneficial option for patients with marked LVH /sigmoid septum-related LVOTO.

Percutaneous Closure of an Iatrogenic Ventricular Septal Defect Following Concomitant Septal Myectomy at the Time of Aortic Valve Replacement

A 77-year-old female patient underwent aortic valve replacement (AVR) with concomitant septal myectomy and tricuspid annuloplasty. Her symptoms did not improve after a successful operation. Echocardiogram demonstrated the presence of an iatrogenic ventricular septal defect (VSD). It was muscular in location and not the usual AVR with membraneous type of VSD, suggesting a complication from the myectomy. Percutaneous closure of the VSD remained the only feasible option due to her poor overall medical status. A 14-mm Amplazter VSD occluder was deployed successfully, by means of the trans-septal technique. She has improved very well postoperatively.

Erratum: Iatrogenic aortic insufficiency following concomitant septal myectomy and aortic valve replacement

Erratum: Iatrogenic aortic insufficiency following concomitant septal myectomy and aortic valve replacement

Iatrogenic aortic insufficiency following concomitant septal myectomy and aortic valve replacement

Regurgitation immediately after valve replacement surgery is not an unusual complication. It is caused mostly by an incomplete disc closure with the use of a mechanical valve, or by paravalvular leakage. Rarely, it can be caused from injury of the prosthesis during surgery, which is prone to happen in patients undergoing concomitant surgery or having an unfavorable anatomy. We experienced a case of prosthetic injury in a patient who underwent aortic valve replacement and septal myectomy with concomitant coronary artery bypass graft (CABG) surgery. A 68-year-old woman who was diagnosed with severe aortic stenosis and coronary artery disease combined with asymmetrical left ventricular (LV) basal wall hypertrophy (maximal diameter at systolic phase: 20 mm) was referred to us for surgery. The operation was performed through the median sternotomy under standard general anesthesia. After accomplishing a conventional cardiopulmonary bypass (CPB) and aortic cross clamping, a transverse aortotomy was made just above the sinus of the Valsalva. Additionally, the removal of the calcified aortic valve leaflets and resection of the LV septal muscle were performed. A 19 mm Epic supra annular tissue valve (St. Jude Medical, Inc., St. Paul, MN, USA) was chosen, but the patient's aortic annulus and root were so narrow and rigid that aortic root enlargement had to be performed for the implantation of the prosthesis. After closure of the aortotomy, CABG surgery was performed by anastomosing the saphenous vein graft from the ascending aorta to the right coronary artery and the internal mammary artery to the left anterior descending artery. After weaning the patient off CPB, the transesophageal echocardiography (TEE) revealed a ventricular septal defect (VSD) on the mid-esophageal right ventricular (RV) inflow-outflow view (Fig. 1A). The VSD was membranous in location, 6-7 mm beneath the prosthetic aortic valve, and measured 5-6 mm in diameter. The CPB was reinstituted, and patch repair of the VSD was performed through a right atriotomy. At the end of the second CPB, no VSD was evident, but a newly appeared periprosthetic regurgitant was seen on the TEE (Fig. 1B). The color-flow Doppler showed a high-velocity, eccentric turbulent regurgitant jet, suggesting pathological leakage. We recommended against proceeding with the surgery since the leakage occurred to a mild extent and further prolongation of the CPB time might have been excessively harmful to the patient. The total CPB time was 4 hr 37 min. She was transported to the intensive care unit, receiving norepinephrine and vasopressin. She progressively deteriorated, resulting in multiorgan failure, and expired the day after the surgery. Fig. 1 Transesophageal echocardiography finding: (A) Mid-esophageal RV inflow-outflow view shows a turbulent flow across the ventricular septal defect during ventricular systole. (B) Mid-esophageal aortic valve long-axis view, after the patch repair of the ventricular ... One of the common causes of pathological regurgitation through a prosthetic valve that can be seen immediately after surgery is a paravalvular regurgitation. Its origin is typically outside the sewing ring, but in this case, the origin of the leakage was within the orifice of the sewing ring. Another common cause is an incomplete disc closure of the mechanical valve, but a bioprosthetic valve, as used in this case, rarely causes valve dysfunction early after the surgery [1]. In this case, prosthetic valve insufficiency occurred due to injury from the repeated manual manipulations of the prosthesis. Because of her small aortic annulus, the prosthesis was implanted very tightly and with difficulty, even though aortic root enlargement preceded the procedure. In addition, septal myectomy is a technically challenging cardiac operation, because of the limited exposure of the septal bulge through the aortotomy view, leading to many complications including inadvertent injury to the aortic valve leaflet [2,3]. We detected the VSD following the myectomy, and a repair surgery was performed. The additional procedure caused the CPB time to be prolonged, which leads to deterioration in the vast majority of cardiac surgeries [4]. In addition, a surgery that is performed in the vicinity of the aortic valve, such as repair of the VSD, also involves the risk of inadvertent injury to the aortic valve, resulting in leaflet perforation with regurgitation [3]. This case report provides cautions for the potential risks of performing multiple concomitant surgical procedures in patients with complicated diseases or an unfavorable anatomy. For those patients, adequate preventive procedures to eliminate intraoperative complications have to be considered before the surgery. Moreover, a more careful assessment of valvular lesions, periprosthetic leakage, and other complications of surgery by intraoperative TEE is mandatory.

Concomitant Septal Myectomy at the Time of Aortic Valve Replacement for Severe Aortic Stenosis

Left ventricular outflow tract obstruction may be unmasked after a successful aortic valve replacement (AVR) for severe aortic stenosis in the setting of asymmetrical basal septal hypertrophy (ABSH). The quantitative assessment of the obstructive potential of ABSH adjacent to a severely stenotic valve can be challenging. We reviewed our experience with patients who underwent concomitant septal myectomy at the time of AVR for severe aortic stenosis. During the 10-year period ending January 2009, 3,523 patients underwent AVR for the primary indication of severe aortic stenosis. Forty-seven of these patients underwent concomitant septal myectomy. Preoperative and postoperative echocardiograms, operative data, hospital course, morbidity, and mortality were assessed. The mean age of the group was 73 +/- 11 years. The mean aortic valve area was 0.74 cm(2) preoperatively. On preoperative transthoracic echocardiography, only 28% of the patients were considered to be at risk for possible left ventricular outflow tract obstruction. The mean left ventricular mass index decreased from 113.7 +/- 24.3 g preoperatively to 90.0 +/- 17.2 g at 1 year after the surgery (p < 0.001). The operative mortality was 2%. Complete heart block was observed in 2 patients (4.2%), and no iatrogenic ventricular septal defect was noted. A quantitative assessment of the obstructive ABSH in the setting of severe aortic stenosis may be difficult preoperatively. Surgeons should inspect left ventricular outflow tract for possible obstructive ABSH at the time of AVR. Concomitant myectomy is a safe and effective procedure without additional complications and should be considered for patients with a preoperative or intraoperative diagnosis of ABSH even though dynamic obstruction was not demonstrated.

Coronary artery to left ventricle fistula

BackgroundCoronary cameral fistulas are an uncommon entity, the etiology of which may be congenital or traumatic. They involve abnormal termination of a coronary artery, usually the right coronary, into a cardiac chamber, usually the right ventricle.Case PresentationWe describe a case of female patient with severe aortic stenosis and interventricular septal hypertrophy that underwent bioprosthetic aortic valve replacement with concomitant septal myectomy. On subsequent follow-up an abnormal flow traversing the septum into the left ventricle was identified and Doppler interrogation demonstrated a continuous flow, with a predominantly diastolic component, consistent with coronary arterial flow.ConclusionThe literature on coronary cameral fistulas is reviewed and the etiology of the diagnostic findings discussed. In our patient, a coronary artery to left ventricle fistula was the most likely explanation secondary to trauma to the septal perforator artery during myectomy. Since the patient was asymptomatic at the time of diagnosis no intervention was recommended and has done well on follow-up.

Effectiveness of atrial fibrillation surgery in patients with hypertrophic cardiomyopathy

We report the results of atrial fibrillation surgery in 10 patients with hypertrophic cardiomyopathy, which is the largest case series to date. The Maze procedure, with concomitant septal myectomy if indicated, appears to be feasible in patients with hypertrophic cardiomyopathy and refractory atrial fibrillation.