Myectomy In Patients Research Articles

Usefulness of real-time three-dimensional echocardiography for evaluation of myectomy in patients with hypertrophic cardiomyopathy

Real-time 3-dimensional echocardiography was performed in 10 patients with obstructive hypertrophic cardiomyopathy (HC) before and after myectomy and in 6 controls. The exact location of systolic anterior motion of the mitral leaflet was shown in all patients with HC with a predominant involvement of the medial portion in 4 patients and the middle portion in 6 patients. The smallest area of the left ventricular outflow tract was significantly smaller in patients with HC than in controls (1.4 +/- 0.7 vs 5.1 +/- 1.2 cm(2), p <0.01), significantly increased after myectomy (4.8 +/- 1.8 cm2, p <0.01) and was associated with a reduction of the pressure gradient at rest from 63 +/- 41 to 15 +/- 5 mm Hg (p <0.01).

The meaning of myectomy in patients with aortic valve stenosis

Objectives: Hypothetically, in patients with high gradients between left ventricular outflow tract and ascending aorta, the subvalvular component in terms of flow characteristics and loss of energy plays an important role. Therefore, we investigated the effect of myectomy on 10 year survival after isolated aortic valve replacement.

Systolic anterior motion after mitral valve repair: myectomy as an alternative solution

by systolic anterior motion (SAM) of the mitral apparatus. 1 Correction of postrepair SAM is first medical: -blockers and calcium-channel blockers might be of some help in reducing left ventricular contractility. However, when a severe LVOT obstruction develops, a more aggressive approach is generally needed. In some cases obstruction of the LVOT disappears after removing the prosthetic ring; in other cases mitral valve replacement is necessary. When a hypertrophic septum is suspected to be a contributing factor leading to obstruction of the LVOT, a possible solution might be to perform a septal myectomy. Here we describe 2 cases of postrepair LVOT obstruction that were successfully treated by means of a transaortic septal myectomy in patients with no preoperative obstruction of the LVOT.

Orbicularis oculi muscle graft augmentation after protractor myectomy in blepharospasm.

To evaluate the effectiveness of free orbicularis oculi muscle grafts in correcting volume deficit deformities after protractor myectomy in patients with essential blepharospasm. Prospective case series. During the 13-month period from October 2000 through November 2001, all patients with essential blepharospasm undergoing primary eyelid protractor myectomy received an orbicularis oculi muscle graft to replace the volume deficit deformity created by the myectomy. Only patients who had at least 6 months of postoperative follow-up were included in the analysis. Forty-six patients underwent primary eyelid protractor myectomy and had a free orbicularis oculi muscle graft for volume replacement. All patients had significant functional improvement of their eyelid spasms after the myectomy. Of the 38 patients who underwent upper eyelid myectomy, 3 patients were overcorrected and no patients were undercorrected with the orbicularis muscle graft. Two of the overcorrected patients underwent surgical debulking of their muscle grafts. Of the 8 patients who underwent lower eyelid myectomy, no patients were overcorrected and 1 patient was undercorrected. None of the patients were observed to have any spasms, contractions, or other signs of muscular activity or aberrant innervation of the muscle graft. The orbicularis oculi muscle graft is a useful adjunct to protractor myectomy in improving the aesthetic outcomes for blepharospasm patients. Our study demonstrates the viability of the orbicularis oculi muscle graft and may lead to future applications of the graft in facial aesthetics.

Surgical pathology of subaortic septal myectomy not associated with hypertrophic cardiomyopathy: A study of 98 cases (1996–2000)

Background: No series have described the surgical pathology of subaortic septal myectomy in patients with conditions other than hypertrophic cardiomyopathy (HCM). Methods: Medical records and microscopic slides were reviewed from 98 non-HCM patients undergoing septal myectomy at Mayo Clinic Rochester from 1996 to 2000. Concurrently, 204 other patients had myectomy for HCM. Results: The study group (65 women, 33 men) ranged in age from 1.5 to 92 years (mean, 61). Seventy underwent surgery for aortic stenosis (Group 1), 25 for congenital subaortic stenosis (Group 2) and 3 for other conditions (Group 3). Group 1 patients were older than Group 2 patients (72 vs. 26 years; P<.0001). Microscopic evaluation showed myocyte hypertrophy (97%), vacuolization (35%), left bundle branch tissue (26%) (33% in Group 1 vs. 8% in Group 2; P=.02) and disarray (19%); interstitial fibrosis (92%), inflammation (10%) and amyloidosis (7%, all prealbumin type, all Group 1, >80 years old); arterial thickening (18%) and dysplasia (12%), and dilated venules (6%); and endocardial fibrosis (74%) (64% in Group 1 vs. 100% in Group 2; P=.0001) and chronic inflammation (17%). Conclusions: Of 302 patients undergoing subaortic septal myectomy, 32% had conditions other than HCM. Myocyte disarray was present in 19% of patients without HCM (and was absent in 21% of HCM patients in a companion study). Thus, disarray alone cannot be used reliably to include or exclude a diagnosis of HCM in small surgical specimens. Because amyloid was found unexpectedly in seven elderly patients, we recommend routine amyloid staining on surgical myectomy tissue from patients ≥65 years old.

Early Clinical Experience of Percutaneous Transluminal Septal Myocardial Ablation and Septal Myectomy in Patients with Hypertrophic Cardiomyopathy and Severe Left Ventricular Outflow Obstruction

Early Clinical Experience of Percutaneous Transluminal Septal Myocardial Ablation and Septal Myectomy in Patients with Hypertrophic Cardiomyopathy and Severe Left Ventricular Outflow Obstruction

Comparison of ethanol septal reduction therapy with surgical myectomy for the treatment of hypertrophic obstructive cardiomyopathy

OBJECTIVESThis study was designed to compare the hemodynamic efficacy of nonsurgical septal reduction therapy (NSRT) by intracoronary ethanol with standard therapy (surgical myectomy) for the treatment of hypertrophic obstructive cardiomyopathy (HOCM).BACKGROUNDNonsurgical septal reduction therapy has gained interest as a new treatment modality for patients with drug-refractory symptoms of HOCM; however, its benefits in comparison to surgery are unknown.METHODSForty-one consecutive NSRT patients at Baylor College of Medicine with one-year follow-up were compared with age- and gradient-matched septal myectomy patients at the Mayo Clinic. All patients had left ventricular outflow obstruction with a resting gradient ≥40 mm Hg and none had concomitant procedures.RESULTSThere were no baseline differences in New York Heart Association class, severity of mitral regurgitation, use of cardiac medications or exercise capacity. One death occurred during NSRT because of dissection of the left anterior descending artery. At one year, all improvements in both groups were similar. After surgical myectomy, more patients were on medications (p < 0.05) and there was a higher incidence of mild aortic regurgitation (p < 0.05). After NSRT, the incidence of pacemaker implantation for complete heart block was higher (22% vs. 2% in surgery; p = 0.02). However, seven of the nine pacemakers in the NSRT group were implanted before a modified ethanol injection technique and the use of contrast echocardiography.CONCLUSIONSNonsurgical septal reduction therapy resulted in a significantly higher incidence of complete heart block, but the risk was reduced with contrast echocardiography and slow ethanol injection. Surgical myectomy resulted in a significantly higher incidence of mild aortic regurgitation. Nonsurgical septal reduction therapy, guided by contrast echocardiography, is an effective procedure for treating patients with HOCM. The hemodynamic and functional improvements at one year are similar to those of surgical myectomy.

Internal anal sphincter achalasia: Outcome after internal sphincter myectomy

Background: Internal anal sphincter achalasia (IASA), also referred to as ultrashort segment Hirschsprung's disease (HD), is a clinical condition with presentation similar to HD, but with the presence of ganglion cells on rectal biopsy. The diagnosis of IASA is made on anorectal manometry, which shows the absence of rectosphincteric reflex on rectal balloon inflation. Altered intramuscular innervation has been reported in IASA. The purpose of this study was to review the outcome after internal sphincter myectomy in patients with IASA. Methods: Fifteen consecutive patients (age range, 2 years to 12 years) with IASA underwent posterior internal sphincter myectomy. All patients presented with severe constipation with or without soiling. The diagnosis of IASA was made by anorectal manometry. HD was excluded in these cases by the presence of ganglion cells and normal acetylcholinesterase activity on suction rectal biopsies. Internal sphincter (IS) specimens were examined using immunohistochemistry for the general neuronal marker PGP 9.5 and synapsin 1 (a presynaptic marker) and using general histochemistry for NADPH-diaphorase. All patients underwent follow-up for periods from 2 years to 6 years. Results: PGP 9.5, synapsin 1 and NADPH-diaphorase positive nerve fibers were either absent or markedly reduced in IASA specimens compared with controls, confirming previous reports of defective intramuscular innervation in IASA. At the time of follow-up, 7 patients have regular bowel motions and are not on any laxatives. Six patients have normal bowel habits but are on small doses of laxatives. One patient is able to stay clean with regular enema regimen. One patient required resection of dilated and redundant sigmoid colon and now has normal bowel habits with laxatives. Conclusion: The majority of patients with internal anal sphincter achalasia can be treated successfully by internal sphincter myectomy. J Pediatr Surg 36:736-738. Copyright © 2001 by W.B. Saunders Company.

Emerging indications for permanent pacing.

New indications for pacing are being investigated in the areas of vasovagal syncope, hypertrophic obstructive cardiomyopathy, dilated cardiomyopathy, and atrial fibrillation. It is hoped that pacing will offer an alternative therapy to patients who are refractory to medical therapy. Although pacing for vasovagal syncope continues to be controversial, it appears that a highly symptomatic group with a predominately cardioinhibitory component can benefit. Current data indicate that dual-chamber pacing should not be considered therapeutically equal to septal myectomy in patients with hypertrophic obstructive cardiomyopathy, but may be considered in those more than 65 years of age, or in others who are not good surgical candidates. Biventricular or left ventricular pacing appears promising in heart failure patients and may be combined with implantable cardioverter-defibrillator therapy. Lead technology for coronary vein placement needs further improvement. Dual-site atrial pacing appears to help prevent recurrences of atrial fibrillation and may become a useful adjunct to drug, ablative, and implantable cardioverter-defibrillator therapies.

Outcome of Septal Myectomy in Patients with Hypertrophic Obstructive Cardiomyopathy

Objectives - To study the outcome of septal myectomy in patients with hypertrophic obstructive cardiomyopathy. Design

Comparison of dual-chamber pacing versus septal myectomy for the treatment of patients with hypertrophic obstructive cardiomyopathy : A comparison of objective hemodynamic and exercise end points

OBJECTIVESThe purpose of this study was to compare the treatment effects of septal myectomy with dual-chamber pacing in patients with hypertrophic obstructive cardiomyopathy (HOCM).BACKGROUNDThe optimal treatment for symptomatic patients with drug-refractory HOCM is unknown. Both dual-chamber pacing and surgical myectomy may result in subjective symptom improvement. However, no direct comparisons with objective end points have been reported.METHODSThirty-nine patients with symptomatic HOCM were analyzed in this concurrent cohort study. Twenty patients underwent surgical myectomy, and 19 received dual-chamber pacemakers based on patient preference. These patients had prospective baseline and follow-up evaluations including physician assessment, echocardiography and standardized metabolic treadmill exercise testing.RESULTSBaseline symptom status, left ventricular outflow tract gradients, exercise times and maximal oxygen consumption peak were similar between the two groups. Left ventricular outflow gradient was reduced from 76 ± 57 to 9 ± 17 mm Hg (p = 0.0001) after myectomy, and from 77 ± 61 to 55 ± 39 mm Hg (p = 0.07) after pacing (p = 0.02 for comparison with myectomy). Ninety percent of myectomy patients experienced symptomatic improvement as compared with 47% in the pacing group. Exercise duration increased significantly from 6.6 ± 2.8 to 8.7 ± 3.0 min (p = 0.0003) after myectomy compared with a change from 6.4 ± 2.1 to 7.0 ± 2.2 min (p = NS) in the pacing group. Maximal oxygen consumption increased from 19.4 ± 6.4 to 22.2 ± 6.5 ml/kg/min after myectomy (p = 0.004), whereas the pacing group did not experience any significant change (19.6 ± 6.5 vs. 20.1 ± 6.5 ml/kg/min, p = NS).CONCLUSIONSSurgical myectomy and dual-chamber pacing improve subjective measures of functional status in patients with symptomatic HOCM. In this nonrandomized study, myectomy offered greater reduction in left ventricular outflow tract gradients and larger improvements in objective measures of patient symptoms and functional status when compared with dual-chamber pacing.

Morbidity outcome in patients with hypertrophic obstructive cardiomyopathy undergoing cardiac septal myectomy: Early-extubation anesthesia versus high-dose opioid anesthesia technique

Objective: Anesthetic management of patients with hypertrophic obstructive cardiomyopathy (HOCM) undergoing septal myectomy is challenging. The morbidity outcome of early-extubation anesthesia (EEA), or fast tracking, versus high-dose opioid (HDO) anesthesia was studied. Design: Retrospective study. Setting: University teaching hospital. Participants: One hundred seventy-five cardiac septal myectomy patients (EEA, n = 53; HDO, n = 122). Interventions: EEA technique consisted of low-dose fentanyl, 10 to 15 μg/kg; propofol infusion; midazolam; and inhalation agent. HDO technique consisted of fentanyl, 50 to 100 μg/kg, and benzodiazepines, with or without an inhalation agent. Demographic data, preoperative symptoms, and data on anesthesia management and postoperative complications were recorded. Measurements and Main Results: There were no differences between the groups (EEA v HDO, respectively) regarding age, sex, preoperative symptoms (dyspnea, 89% v 79%; palpitations, 28% v 26%; angina, 47% v 61%; syncope, 47% v 41%), redo surgery, or combined surgery. Mean ± standard deviation time to tracheal extubation was 7.2 ± 5.3 hours in EEA versus 19.4 ± 10.5 hours in HDO patients ( p < 0.0001). Intensive care unit (ICU) stay was significantly shorter in EEA versus HDO patients (2.2 v 3.0 days; p < 0.005), with the trend toward earlier hospital discharge (9.7 v 11.3 days; p = 0.09). There was a high requirement for temporary pacing in both groups immediately postoperatively (EEA, 60% v HDO, 48%; p > 0.08). Permanent pacemaker insertion postoperatively was required in 7 of 53 patients (13%) in the EEA group and 11 of 122 patients (9%) in the HDO group ( p > 0.25). Atrial arrhythmias occurred postoperatively in 25% of EEA patients versus 34% of HDO patients ( p > 0.08). Conclusion: EEA facilitates earlier tracheal extubation by 12 hours in patients with HOCM undergoing septal myectomy, significantly shortening ICU stay by 1 day without increasing perioperative cardiac morbidity or mortality.

Detrusor myectomy for detrusor overactivity: a minimum 1-year follow-up.

To evaluate the clinical and urodynamic outcome of partial detrusor myectomy in patients with idiopathic detrusor instability and neuropathic hyper-reflexia. Seventeen patients with idiopathic detrusor instability and 10 with hyper-reflexia and symptoms not responding to non-surgical treatment underwent partial detrusor myectomy. The clinical and urodynamic results before and after myectomy were compared and the patient's subjective assessment of the outcome documented. There was an overall improvement in 17 of 27 patients (63%) but the success rate was higher in those with idiopathic instability (12 of 17) than in those with neuropathy (five of 10). There was urodynamic evidence of reduced bladder contractility and an improvement in the storage characteristics of the bladder in most of the patients treated. Partial detrusor myectomy is relatively simple and is associated with minimum morbidity and an acceptable success rate. The procedure alters the urodynamic behaviour of the bladder and leads to symptomatic and objective improvement, giving better results with idiopathic than with neuropathic detrusor overactivity. Detrusor myectomy may be offered to patients with detrusor overactivity unresponsive to conventional management. The option of enterocystoplasty is still open to patients with an unsuccessful outcome. However, the long-term results and surgical variations of the technique should be evaluated further.

Initial results of combined anterior mitral leaflet extension and myectomy in patients with obstructive hypertrophic cardiomyopathy

Objectives. The purpose of this study was to describe the clinical and functional results of combined anterior mitral leaflet extension and myectomy in patients with hypertrophic obstructive cardiomyopathy.Background. Septal myectomy is the most commonly performed surgical procedure in patients with hypertrophic cardiomyopathy and left ventricular outflow tract obstruction. Because of the role of the mitral valve in creating the outflow tract gradient, mitral valve replacement or plication is performed in selected cases in combination with myectomy, often with better hemodynamic results than those of myectomy alone. Mitral valve leaflet extension, in which a glutaraldehyde-preserved autologous pericardial patch is used to enlarge the mitral valve along its horizontal axis, is a novel surgical approach in patients with hypertrophic obstructive cardiomyopathy.Methods. Eight patients with hypertrophic obstructive cardiomyopathy were treated with mitral leaflet extension and myectomy. Preoperative and postoperative data (New York Heart Association functional class, number of drugs prescribed, width of the interventricular septum, severity of mitral valve regurgitation, severity of systolic anterior motion of the mitral valve and outflow tract gradient) were compared with those of 12 patients undergoing myectomy alone.Results. Preoperative evaluation demonstrated that mitral regurgitation and systolic anterior motion of the mitral valve were more severe in the group undergoing mitral valve extension (p < 0.001 and p < 0.05, respectively). There were no deaths associated with either surgical procedure. Two patients, both treated by myectomy alone, died during the follow-up period. Postoperatively, patients treated with mitral valve extension had less mitral regurgitation (p < 0.005), less residual systolic anterior motion (p < 0.01), greater improvement in functional class (p = 0.05) and greater reduction in the number of drugs (p < 0.005) and in septal thickness (p < 0.05).Conclusions. Mitral leaflet extension in combination with myectomy is a promising new surgical approach that may provide superior results to those of myectomy alone. Further studies are needed to determine the clinical value of this procedure.

Spark erosion myectomy in hypertrophic obstructive cardiomyopathy

The design features of the cutting electrode and the electrical characteristics of a monopolar electrosurgical device were specially adapted for performing a septal myectomy in patients with hypertrophic obstructive cardiomyopathy. Both the cutting behavior and electrode design were found to facilitate myectomy.

Defaecating video proctography.

Defaecating video proctography is a method of examining the physiology and function of the rectum and pelvic floor muscles during attempted defaecation. This paper describes a quantitive method of assessing rectal emptying and the approach to defining the ano-rectal angle. In particular, the effect of the surgical procedure of ano-rectal myectomy for patients with chronic constipation associated with outlet obstruction on the ano-rectal angle are described, employing the use of video tape and a microcomputer.

Left ventricular myotomy and myectomy in patients with obstructive hypertrophic cardiomyopathy and previous cardiac arrest

Left ventricular myotomy and myectomy was carried out in nine patients with obstructive hypertrophic cardiomyopathy solely because of a previously documented episode of cardiac arrest. Before cardiac arrest, each patient had either no or only minimal functional limitation and therefore would not have met the usual criteria for operation, namely, severe symptoms unresponsive to medical therapy. Of the nine patients, one died in the perioperative period, and one died suddenly and unexpectedly 9 months postoperatively. The remaining seven patients have survived 9 months to 5.5 years after operation; six of the seven are asymptomatic and one has only mild symptoms. Operation resulted in a marked decrease or abolition of the left ventricular outflow gradient under basal conditions in seven of the eight patients studied postoperatively. Significant residual outflow obstruction was demonstrated after operation in the patient who later died. Sudden death in patients with obstructive hypertrophic cardiomyopathy appears usually to result from ventricular arrhythmia, and prevention of recurrent fatal arrhythmia is the goal of treatment in patients who have had cardiac arrest and have been resuscitated. Such patients should be treated indefinitely with antiarrhythmic drugs. In addition, when severe outflow obstruction is present, we postulate that effective operative relief of obstruction and consequent reduction of left ventricular systolic pressure will provide additional protection.

Exercise performance after septal myotomy and myectomy in patients with obstructive hypertrophic cardiomyopathy

The effect of left ventriculomyotomy and myectomy on exercise capacity and cardiac function in patients with obstructive hypertrophic cardiomyopathy has not previously been determined. In this study, 29 patients were evaluated during graded treadmill exercise before and after operation. Postoperatively, 27 of 29 patients reported symptomatic improvement and had greatly reduced left ventricular outflow gradient. Twenty-five of 28 patients (89 percent) attained higher exercise levels after operation, arid this was accompanied by an increase in total body oxygen consumption from 16 to 21 ml/min per kg ( P < 0.005). A significant increase in cardiac index during maximal exercise also accompanied this improved exercise performance (5.0 to 5.7 liters/min per m 2, P < 0.05). The increase in maximal cardiac index was associated with greater desaturation of mixed venous blood (34 to 24 percent, P < 0.02) in patients with preoperative angina. At a given level of mixed venous oxygen saturation (30 percent), overall mean cardiac index was higher postoperatively (4.6 to 5.2 liters/min per m 2, P < 0.05). These results suggest that, although several mechanisms probably contribute to symptomatic improvement after myotomy and myectomy, enhanced cardiac performance plays an important role in the majority of patients.