Myectomy Procedure Research Articles

Surgical Outcome of Inferior Oblique Myectomy versus Recession-Anteriorization in the Treatment of Inferior Oblique Overaction.

This study aimed to compare the surgical outcome of inferior oblique myectomy, IOM versus inferior oblique recession-anteriorization, IORA in the treatment of inferior oblique overaction, IOOA. A retrospective chart review was performed over a 12-year period, from 2009 to 2021. Eighty-nine patients diagnosed with IOOA who underwent IOM or IORA were included. The primary outcome was postoperative residual IOOA (grade 0 to +4) and percentage favorable outcome, defined as IOOA grade ≤1+ at 6 months post operation, in each group. The outcomes were compared between the two surgical procedures (IOM and IORA). The secondary outcome was the percentage of postoperative anti-elevation syndrome cases for each surgical procedure. The median age at the time of surgery was 10.50 years (interquartile range, IQR: 2.83 to 28.33) in the IOM group and 5.08 years (IQR: 2.75 to 29.42) in the IORA group. The favorable outcome at 6 months was 90.91% in the IOM group, which was lower than the 95.74% in the IORA group but the difference was not statistically significant (P-value = 0.390, 95% CI: 0.07-2.82). The only surgical complication, anti-elevation syndrome, was detected in 3.77% of IOM cases and 5.80% of IORA cases, with an odds ratio of 0.64 on comparing the IOM group to the IORA group (P-value = 0.611, 95% CI: 0.11-3.62). These two weakening procedures are effective for treating IOOA. Although IORA seemed slightly superior to IOM in terms of favorable outcomes, the difference was not statistically significant. Moreover, the myectomy procedure was easier, was less time-consuming, had a lower risk of globe perforation and presented fewer complications such as anti-elevation syndrome.

Del nido versus conventional blood cardioplegia in patients with obstructive hypertrophic cardiomyopathy.

Myocardial protection is essential in cardiac surgery with cardiopulmonary bypass The Del Nido cardioplegia which was initially used in pediatric cardiac surgery, has been increasingly used in adult cardiac surgery recently. However, no literature has reported the efficacy of DNC in hypertrophic obstructive cardiomyopathy. This retrospective study involved elective patients who underwent extended surgical myectomy with or without concomitant cardiac surgical procedures between September 2017 and June 2022. Patients were distributed into two groups, the DNC and the CBC group. The primary outcome was high-sensitivity cardiac troponin I (hs-TnI) and creatine kinase-MB (CK-MB) levels at the 0, 1, and 2 postoperative days. The secondary outcomes contained: intraoperative LVEF, return to spontaneous rhythm; postoperative myocardial infarction, worsening or deteriorating of EF, mechanical circulatory support; new-onset atrial fibrillation; mechanical ventilation duration; intensive care unit hours; in-hospital days. Fifty-nine patients were included and divided into the CBC (n = 15) and the DNC group (n = 44). There was no statistical difference in patients' demographics and preoperative parameters between the two groups. No in-hospital mortality. The total cardioplegia volume [21.93(18.36,26.07) vs. 25.68(23.17,37.12), p = 0.012] and infusion times [1(1,1) vs. 2(2,3), p = 0.000] were less and the incidence of return to spontaneous rhythm after declamping was higher in the DNC group [97.7% vs. 73.3%, p = 0.013]. Postoperative hs-TnI and CK-MB levels were comparable between the two groups. A longer DNC infusion interval was associated with higher levels of CK-MB on postoperative day 1 and day 2 (p = 0.009 and p = 0.011, respectively). The use of DNC in extended surgical myectomy procedure was as safe and effective as CBC. However, DNC infusion interval over 60 minutes was associated with increased postoperative CK-MB levels.

Transaortic Shallow Septal Myectomy and Cutting of Secondary Fibrotic Mitral Valve Chordae-A 5-Year Single-Center Experience in the Treatment of Hypertrophic Obstructive Cardiomyopathy.

Background: Anomalies of the mitral apparatus have been shown to contribute to left ventricular outflow obstruction in patients with hypertrophic cardiomyopathy (HCM). We report our 5-year single-center experience with a shallow myectomy procedure associated with transaortic mitral valve repair in a cohort of HCM patients. Methods: We studied 83 consecutive patients who underwent surgical treatment of symptomatic left ventricular outflow obstruction. In all study patients, a transaortic shallow septal myectomy was performed. Fibrous or muscular structures connecting the papillary muscles to the septum or free wall were resected, and fibrotic secondary chordae of the anterior mitral valve were cut selectively. Results: We report one death (1.2%) during hospitalization, no iatrogenic ventricular septal defects, and two (2.4%) mitral valve replacements. At discharge, no patients were in New York Heart Association (NYHA) Class III/IV, from 49 (59%) preoperatively. Mean maximal septal thickness decreased from 24 ± 6 to 16 ± 3 mm. Mean outflow gradient decreased from 93 ± 33 to 13 ± 11 mmHg. Grade 3 or 4 mitral regurgitation was noticed in one patient postoperatively, from 32 (39%) before surgery. Conclusions: Shallow septal myectomy associated with secondary mitral valve chordal cutting and papillary muscle mobilization provided excellent results offering adequate treatment of outflow obstruction.

Myectomies for Optimization of Function and Symmetry in Facial Paralysis

Myectomy, the surgical excision of a portion of the muscle, is a useful adjunct in the treatment of facial paralysis and its sequelae. Targeting the facial muscles specifically can address aesthetic and functional concerns for patients. It is a straightforward surgical option for the surgeon and may be used to optimize symmetry, release hypercontracture and limit synkinesis. Prior to myectomy, chemodenervation with botulinum toxin can be used to assess and confirm target muscles. If limited to the affected muscle or muscle groups, the procedure is low risk for creating further facial dysfunction and may provide significant benefit to a correctly-selected patient. In this chapter, we discuss the different muscle groups targeted with specific goals, common myectomy procedures, and considerations in treatment. Myectomy, the surgical excision of a portion of the muscle, is a useful adjunct in the treatment of facial paralysis and its sequelae. Targeting the facial muscles specifically can address aesthetic and functional concerns for patients. It is a straightforward surgical option for the surgeon and may be used to optimize symmetry, release hypercontracture and limit synkinesis. Prior to myectomy, chemodenervation with botulinum toxin can be used to assess and confirm target muscles. If limited to the affected muscle or muscle groups, the procedure is low risk for creating further facial dysfunction and may provide significant benefit to a correctly-selected patient. In this chapter, we discuss the different muscle groups targeted with specific goals, common myectomy procedures, and considerations in treatment.

Mini-invasive surgical instruments in transaortic myectomy for hypertrophic obstructive cardiomyopathy: a single-center experience with 168 cases

BackgroundAlthough septal myectomy is a standard strategy for managing patients with hypertrophic obstructive cardiomyopathy (HOCM) and drug-refractory symptoms, so far, only a few experienced myectomy centers exist globally. Mainly, this can be explained by the many technical challenges presented by myectomy. From our clinical experience, applying the mini-invasive surgical instruments during myectomy potentially reduces the technical difficulty. This study reports the preliminary experience regarding transaortic septal myectomy using mini-invasive surgical instruments for managing patients with HOCM and drug-refractory symptoms; also, we evaluate the early results following myectomy.MethodsBetween March 2016 and March 2019, consecutive HOCM patients who underwent isolated transaortic septal myectomy using the mini-invasive surgical instruments were enrolled in this analysis. Intraoperative, in-hospital and follow-up results were analyzed.ResultsWe included 168 eligible patients (83 males, mean 56.8 ± 12.3 years). The midventricular obstruction was recorded in 7 (4.2%) patients. All patients underwent transaortic septal myectomy with a mean aortic cross-clamping time of 36.0 ± 8.1 min. During myectomy, 9 (5.4%) patients received repeat aortic cross-clamping. Surgical mortality was 0.6%. Notably, 5 (3.0%) patients developed complete atrioventricular block, they needed permanent pacemaker implantation. The median follow-up time was 6 months; however, no follow-up deaths occurred with a significant improvement in New York Heart Association functional status. We reported a sharp decrease in the maximum gradients from the preoperative value (11.6 ± 7.4 mmHg vs. 94.4 ± 22.6 mmHg, p < 0.001). The median degree of mitral regurgitation fell to 1.0 (vs. 3.0 preoperatively, p < 0.001) with a significant reduction in the proportion of moderate or more regurgitation (1.2% vs. 57.7%, p < 0.001).ConclusionsMini-invasive surgical instruments may be beneficial in reducing the technical challenges of transaortic septal myectomy procedure. Of note, transaortic septal myectomy using the mini-invasive surgical instruments may present with favorable results.

Myectomy versus alcohol septal ablation in patients with hypertrophic obstructive cardiomyopathy.

There is very little evidence comparing the safety and efficacy of alcohol septal ablation versus septal myectomy for a septal reduction in patients with hypertrophic obstructive cardiomyopathy. This study aimed to compare the immediate and long-term outcomes of these procedures. Following propensity score matching, we retrospectively analysed outcomes in 105 patients who underwent myectomy and 105 who underwent septal ablation between 2011 and 2017 at 2 reference centres. The mean age was 51.9 ± 14.3 and 52.2 ± 14.3 years in the myectomy and ablation groups, respectively (P = 0.855), and postoperative left ventricular outflow tract gradients were 13 (10-19) mmHg vs 16 (12-26) mmHg; P = 0.025. The 1-year prevalence of the New York Heart Association class III-IV was higher in the ablation group (none vs 6.4%; P = 0.041). The 5-year overall survival rate [96.8% (86.3-99.3) after myectomy and 93.5% (85.9-97.1) after ablation; P = 0.103] and cumulative incidence of sudden cardiac death [0% and 1.9% (0.5-7.5), respectively P = 0.797] did not differ between the groups. The cumulative reoperation rate within 5 years was lower after myectomy than after ablation [2.0% (0.5-7.6) vs 14.6% (8.6-24.1); P = 0.003]. Ablation was associated with a higher reoperation risk (subdistributional hazard ratio = 5.9; 95% confidence interval 1.3-26.3, P = 0.020). At follow-up, left ventricular outflow tract gradient [16 (11-20) vs 23 (15-59) mmHg; P < 0.001] and prevalence of 2+ mitral regurgitation (1.1% vs 10.6%; P = 0.016) were lower after myectomy than after ablation. Both procedures improved functional capacity; however, myectomy better-resolved classes III-IV of heart failure. Septal ablation was associated with higher reoperation rates. Myectomy demonstrated benefits in gradient relief and mitral regurgitation elimination. The results suggest that decreasing rates of myectomy procedures need to be investigated and reconsidered.

Surgical Management of Primary Inferior Oblique Muscle Overaction: A Subgroup-Specific Surgical Approach.

Objectives:The aim of this research was to assess the surgical results of recession and myectomy procedures in a subgroup of patients who had primary inferior oblique muscle overaction.Methods:The records of 94 patients who had been treated due to primary inferior oblique muscle overaction were retrospectively analyzed. The patients were classified into 2 groups according to the severity of the inferior oblique hyperfunction. Recession was performed for patients with a low grade (+1 or +2) inferior oblique hyperfunction, and patients with high grade (+3 or +4) hyperfunction underwent myectomy surgery. Patients demonstrating a horizontal misalignment underwent conventional horizontal muscle surgery along with an inferior oblique weakening procedure.Results:A total of 134 eyes fulfilled the inclusion criteria. Recession was performed in 95 eyes and myectomy in 39. Surgical success was obtained in 96.8% of the eyes that underwent recession and 97.4% of the eyes that underwent myectomy. Residual inferior oblique hyperfunction was observed in 3 eyes after recession and in 1 eye after myectomy. After surgery, about one-quarter of the patients with unilateral inferior oblique overaction subsequently developed a contralateral inferior oblique overaction.Conclusion:The results of this study demonstrated that both recession and myectomy procedures are effective for treating primary inferior oblique hyperfunction with minimal complications when applied in the appropriate patient.

Transapical septal myectomy in the beating heart via a minimally invasive approach: a feasibility study in swine

The aim of this study was to establish an original transapical septal myectomy procedure that can be performed in the beating heart via a minimally invasive approach for the treatment of hypertrophic obstructive cardiomyopathy. We designed an original intracardiac septum resection device to conduct off-pump septal myectomy in swine. A subxiphoid minithoracotomy was performed to access the apex of the heart. This resection device was inserted into the left ventricular outflow tract of the heart via the apex. The basal anteroseptal myocardium beneath the right aortic cusp was identified using a combination of transoesophageal and transthoracic echocardiography and then resected and collected by the device. Six consecutive operations were successfully and accurately performed using the custom-made device under echocardiographic guidance. All pigs survived and appeared to be normal until planned euthanasia 1 week after operation. A 300-700 mg portion of the septal myocardium was resected from the normal swine heart. Echocardiography and electrocardiogram revealed no abnormalities after resection. One exception was the fifth pig, in which mild annular regurgitation of the aortic valve occurred after repetitive resection. Postmortem necropsy demonstrated that all resections were correctly located at the basal anteroseptal septum beneath the right aortic cusp. Our study provides the first proof-of-concept evidence for a novel beating heart transapical septal myectomy procedure, which showed promising translational potential for the treatment of hypertrophic obstructive cardiomyopathy. This procedure would probably reduce operative risks and improve outcomes and reduce the demanding expertise required to perform conventional surgical myectomy.

Comparing graded anterior transposition with myectomy in primary inferior oblique overaction – A clinical trial

PurposeTo compare the effects of graded anterior transposition with myectomy in primary inferior oblique overaction (IOOA). MethodsIn a randomized clinical trial study, patients entered into two groups: graded anterior transposition (Group 1) and myectomy (Group 2). In the myectomy method, 8 mm of the inferior oblique (lO) muscle was excised in the lower temporal side, and in the graded anterior transposition group, the IO muscle was recessed according to Wright's method. Patients were followed up for at least 1.5 months. IOOA was graded from 0 to +4. Surgical success was defined as reduced IOOA to a grade of +1 or less. ResultsIn a randomized clinical trial study, a total of 30 patients (60 eyes) were included in the study (32 eyes in Group 1 and 28 eyes in Group 2). Pre-operation IOOA was 3.18 ± 0.78 and 3.25 ± 0.70 in Groups 1 and 2, respectively. Mean IOOA in Group 1 and 2 was 0.95 ± 0.24 and 0.40 ± 0.10 at 6 months after the surgery, which means the mean correction of the overaction was statistically significant in both methods (P < 0.001). The success rate in the myectomy procedure was higher than graded recession. The weakening effect was better in higher grades of overaction (P < 0.001). The overall success rate of Groups 1 and 2 was 75% and 96.4%, respectively (P = 0.029). ConclusionsIn both groups, IOOA significantly decreased after the operation. The success rate of the myectomy procedure was found to be significantly higher than graded anterior transposition.

Minimally invasive trans-mitral septal myectomy for diffuse-type hypertrophic obstructive cardiomyopathy.

Despite excellent long-term results reported for a trans-aortic septal myectomy for hypertrophic obstructive cardiomyopathy (HOCM), surgery for patients with diffuse hypertrophy is very challenging. In addition, a left ventricular outflow obstruction is often aggravated by an abnormal mitral valve and subvalvular apparatus. We performed video-assisted minimally invasive trans-mitral septal myectomy procedures in 3 patients with diffuse-type HOCM, who were highly symptomatic despite maximal medical therapy. Each had at least moderate mitral regurgitation (MR) due to systolic anterior motion (SAM). Using a right mini-thoracotomy, the anterior mitral leaflet was detached, through which an extended septal myectomy could easily be performed. Abnormal bridging chordae between the septum and papillary muscle (PM) were divided, then anterior mitral leaflet continuity was restored with direct closure or augmentation using a glutaraldehyde-treated autologous pericardium. A PM reorientation procedure was performed in 1 case in which both PMs were approximated and sutured onto the posterior ventricular wall. The postoperative course was uneventful in all patients, with marked improvement of symptoms in each. The peak ventricular outflow gradient decreased from 134 ± 40 to 23 ± 5mmHg with significantly diminished SAM, especially in the patient who underwent the PM reorientation procedure. During a mean follow-up period of 42 ± 14 months, no MR has been detected in any case. We believe that a minimally invasive trans-mitral septal myectomy is preferable for HOCM-patients with diffuse hypertrophy and mitral valve abnormality. Aggressive PM reorientation may also be useful for those with an abnormal PM orientation.

Perioperative Transesophageal Echocardiography in Myectomy Procedure -4 Cases Report

Perioperative Transesophageal Echocardiography in Myectomy Procedure -4 Cases Report

Postoperative Atrial Fibrillation in a Patient With Hypertrophic Obstructive Cardiomyopathy After Morrow Septal Myectomy May Evolve Into Lethal Ventricular Arrhythmia

Postoperative atrial fibrillation (AF) is a common complication for patients undergoing cardiac surgery. However, in patients undergoing a Morrow septal myectomy procedure, postoperative AF can be disastrous. A 42-year-old man underwent a Morrow septal myectomy procedure for hypertrophic obstructive cardiomyopathy that was resistant to medical treatment. Doppler echocardiography demonstrated that the peak left ventricular outflow tract gradient dropped from 96 to 7 mm Hg at rest after the procedure. The patient was doing well until the sudden onset of AF on the fifth night after surgery. Although medical conversion measures were promptly provided, the AF nonetheless evolved into ventricular fibrillation about 13 minutes after AF onset. The medical staff had to perform non-synchronized defibrillation to restore effective circulation. At 2 years after the procedure, the patient had not experienced AF recurrence and has recovered well.

Postoperative Atrial Fibrillation in a Patient With Hypertrophic Obstructive Cardiomyopathy After Morrow Septal Myectomy May Evolve Into Lethal Ventricular Arrhythmia

Postoperative atrial fibrillation (AF) is a common complication for patients undergoing cardiac surgery. However, in patients undergoing a Morrow septal myectomy procedure, postoperative AF can be disastrous. A 42-year-old man underwent a Morrow septal myectomy procedure for hypertrophic obstructive cardiomyopathy that was resistant to medical treatment. Doppler echocardiography demonstrated that the peak left ventricular outflow tract gradient dropped from 96 to 7 mm Hg at rest after the procedure. The patient was doing well until the sudden onset of AF on the fifth night after surgery. Although medical conversion measures were promptly provided, the AF nonetheless evolved into ventricular fibrillation about 13 minutes after AF onset. The medical staff had to perform non-synchronized defibrillation to restore effective circulation. At 2 years after the procedure, the patient had not experienced AF recurrence and has recovered well. J Med Cases. 2016;7(1):26-27 doi: http://dx.doi.org/10.14740/jmc2152w

A new technique to avoid the intraoperative complications of septal myectomy in patients with obstructive hypertrophic cardiomyopathy

Although transaortic septal myectomy in obstructive hypertrophic cardiomyopathy (OHC) is accepted as a safe procedure, it may end up with serious peroperative complications. We developed a practical method to avoid this unfavorable outcome by using a 20-cc syringe body. We believe this apparatus will provide safe and effective septal myectomy procedures without additional cost.

Use of Alfieri stitch technique in a patient with hypertrophic obstructive cardiomyopathy

Systolic anterior motion of the anterior mitral leaflet plays an important role in the dynamic outflow tract obstruction encountered in patients with hypertrophic obstructive cardiomyopathy. Here we present a 58-year-old male patient who was successfully treated with a myectomy procedure applied along with the edge-to-edge Alfieri stitch technique. The use of the Alfieri technique provides satisfactory short-term results and can be considered as an alternative adjunct to abolish systolic anterior motion.

内転型痙攣性発声障害に対する両側甲状披裂筋切除術

Bilateral thyroarytenoid myectomies were performed on 14 patients with adductor spasmodic dysphonia. During the operation bleeding was controlled by use of a Laser. Fat tissue was removed from abdomen and inserted into vocal fold to fill in the defect after myectomy procedures and to prevent scarring. The patients' voices were restored to normal without recurrence of dysphonia. This operation is one of the most effective treatment for adductor spasmodic dysphonia.

Comparison of inferior oblique muscle weakening by anterior transposition or myectomy: a prospective study of 20 cases

BACKGROUND/AIMS Among the various weakening techniques of inferior oblique muscle overaction, the most commonly used techniques include myectomy, recession, and anterior transposition. Anterior transposition and myectomy were compared to evaluate...

Hemifacial Spasm: Results of Unilateral Myectomy

Hemifacial spasm (HFS) is a disorder characterized by unilateral involuntary spasm of the muscles innervated by the facial nerve (cranial nerve VII). The etiology is often a redundant or ectatic artery in the cerebellopontine angle that compresses the facial nerve. Neurosurgical decompression with implantation of a sponge between the ectatic artery and the facial nerve produces good results, but has a high complication rate and a poor patient acceptance rate. Various modes of peripheral neurectomy have also been advocated, but the recurrence rate is high and the preexisting functional and cosmetic eyelid deformities are exacerbated. The results of unilateral periorbital myectomy in 21 HFS patients are presented. Follow-up ranging from 1 to 7 years was available on 16 patients. Excellent or good resuls were obtained in 94% of these cases, and postoperative complications were minor. Transient lymphedema and forehead anesthesia are the most common complications. An unforseen benefit of periorbital myectomy surgery is the improvement or relief of lower facial contractions that occurred in 75% of patients. The authors believe the myectomy procedure is a safe, effective, predictable therapy for those HFS patients unwilling to risk a neurosurgical operation, and allows simultaneous reconstruction of associated eyelid and eyebrow deformities.

Surgical Weakening of the Inferior Oblique

1. The inferior oblique may be weakened effectively by recession, disinsertion, or myectomy, disrupting the muscle continuity between Lockwood's ligament and the muscle's insertion. 2. A successful unilateral inferior oblique weakening produces 20 prism diopters less hypertropia or more hypotropia in the field of action and has less effect away from the muscle's field of action; a bilateral weakening of the inferior oblique produces 20 prism diopters less exotropia or more esotropia in upgaze. 3. Complications of inferior oblique weakening are persistent overaction, operation on the wrong muscle, and the adherence syndrome. 4. The adherence syndrome is not related to the myectomy procedure specifically but is probably related to (or caused by) fat rupture with hemorrhage, which may accompany any type of inferior oblique weakening. 5. The adherence syndrome can be avoided by careful surgical technique.