Septal Myectomy In Patients Research Articles

Concomitant Ozaki procedure and septal myectomy in patients with severe aortic stenosis

Concomitant Ozaki procedure and septal myectomy in patients with severe aortic stenosis

Tricuspid valve surgery following septal myectomy in patients with a cardiac implantable electronic device

BackgroundPatients with hypertrophic cardiomyopathy (HCM) are at increased risk of developing cardiac arrhythmias and have a high prevalence of cardiac implantable electronic device (CIED) use. Tricuspid regurgitation (TR) is a potential complication of device leads and can be severe enough to prompt surgical intervention. MethodsWe identified 21 consecutive patients who underwent tricuspid valve (TV) surgery for device lead-induced TR late following septal myectomy (SM) for obstructive HCM. The primary endpoint was long-term all-cause mortality. ResultsThe median patient age was 63 years (range, 55-71 years), 19 patients (91%) had New York Heart Association class III or IV limitation, and all patients were receiving diuretics for right heart failure. The median interval between device implantation and TV surgery was 4 years (range, 1.5-8.5 years). Eight patients (38%) underwent pacemaker implantation due to complete heart block following SM. Preoperatively, TR was severe in 81% of the patients. The primary mechanism of lead-induced TR was leaflet impingement without adherence (n = 15; 75%). Nine patients (43%) underwent TV replacement, and 12 patients (57%) underwent repair. Only 1 patient died early postoperatively. Patients with lead-induced TR had markedly reduced long-term survival compared to the overall population of patients undergoing SM; 5-year survival was 58%, compared to 96% for the contemporary SM group. ConclusionsLate lead-induced TR is a potential complication of CIEDs in patients with HCM who have undergone SM. Although TV repair and replacement can be done with acceptable early mortality, late patient survival is poor.

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.

Outcomes of surgical septal myectomy for obstructive hypertrophic cardiomyopathy after previous septal reduction therapy

ObjectiveTo compare early and late outcomes of septal myectomy in patients with obstructive hypertrophic cardiomyopathy who presented with residual or recurrent left ventricular outflow tract (LVOT) obstruction after previous septal-reduction therapy (SRT). MethodsFrom January 1989 to March 2022, 145 patients underwent reintervention by septal myectomy for residual LVOT obstruction after previous SRT; 72 patients had previous alcohol septal ablation (ASA) and 73 had previous surgical septal myectomy. Baseline patient characteristics, echocardiographic parameters, and surgical outcomes were compared between these 2 groups. ResultsPatients who had previous ASA were more likely to be male (50.0% vs 30.1%; P = .015), be older (median age 57.5 years vs 48.3 years; P < .001), and have a greater body mass index (32.7 kg/m2 vs 30.0 kg/m2; P = .011). After repeat SRT by septal myectomy, there was no significant difference in the incidence of postoperative complete heart block, necessitating permanent pacemaker, between the 2 groups (8.3% vs 2.7%; P = .151). One (0.7%) patient died within 30 days of surgery. Over a median follow-up of 7.5 years (interquartile range, 3.0-13.8), there were 20 deaths. Kaplan-Meier 5-, 10-, and 15-year survival rates were 100%, 91%, and 76% for the previous septal myectomy group, and 93%, 81%, and 64% for the previous ASA group (P = .207). ConclusionsSeptal myectomy for residual or recurrent LVOT obstruction in patients who had previous ASA is safe, with an acceptably low rate of postoperative complete heart block. Surgical outcomes and late survival rates in patients with complete heart block ASA were satisfactory and comparable with patients who underwent repeat myectomy.

Efficacy and safety of a transaortic approach to midventricular and apical septal myectomy

ObjectiveThe study objective was to evaluate the safety and efficacy of a transaortic approach to midventricular and apical septal myectomy in patients with hypertrophic cardiomyopathy with left ventricular outflow tract or midventricular obstruction. MethodsFrom January 2018 to August 2023, 940 patients underwent transaortic septal myectomy at the Cleveland Clinic, of whom 682 (73%) had midventricular or apical resection. Patients who underwent isolated basal myectomies were excluded. Templated operative reports designated septal regions resected as basal (opposition to mitral valve up to the leaflet tips), midventricular (leaflet tips to just beyond the papillary muscle heads), and apical (apical third of the ventricle). Myocardial resection specimen weights, intraventricular gradients, and clinical outcomes were assessed. ResultsOf the 682 patients, 582 (85%) had basal plus midventricular resection and 78 (11%) had basal, midventricular, and apical resection. Mean preoperative intraventricular gradient was 102 ± 41 mm Hg. Median resection weight was 10 g (15th, 85th percentiles: 7, 15), and mean postoperative intraventricular gradient was 16 ± 10 mm Hg, with 625 (96%) patients achieving gradients 36 mm Hg or less. There were no iatrogenic mitral or aortic valve injuries. Permanent pacemaker placement was required in 38 patients (5.6%), of whom 8 (1.2%) had normal preoperative conduction. Operative mortality occurred in 1 patient (0.1%) after an intraoperative ventricular septal defect. ConclusionsMost patients undergoing septal myectomy for relief of obstruction required resection beyond the basal septum. With specialized instrumentation, detailed imaging and knowledge of variable septal anatomy, resecting midventricular and apical septal muscle can be safely and effectively achieved through a transaortic approach.

Mortality After Alcohol Septal Ablation vs. Septal Myectomy in Patients With Obstructive Hypertrophic Cardiomyopathy.

Background: Alcohol septal ablation (ASA) and septal myectomy (SM) are 2 options for septal reduction therapy (SRT) to treat medication-resistant symptomatic obstructive hypertrophic cardiomyopathy (HCM). Because differences in mortality rates after these different SRT methods have not been extensively investigated in real-world settings, in this study compared the 1-year mortality rates after ASA and SM using population-based database. Methods and Results: Utilizing New York Statewide Planning and Research Cooperative System (SPARCS) data from 2005 to 2016, we performed a comparative effectiveness study of ASA vs. SM in patients with HCM. The outcome was all-cause death up to 360 days after SRT. We constructed a multivariable logistic regression model and performed sensitivity analysis with propensity score (PS)-matching and inverse probability of treatment weighting (IPTW) methods. We identified 755 patients with HCM who underwent SRT: 348 with ASA and 407 with SM. The multivariable analysis showed that all-cause deaths were significantly fewer in the ASA group at 360 days after SRT (adjusted odds ratio=0.34; 95% confidence interval [CI] 0.13-0.84; P=0.02). The PS-matching and IPTW methods also supported a lower mortality rate in the ASA group at 360 days post-SRT. Conclusions: In this population-based study of patients with HCM who underwent SRT in a real-world setting, the 1-year all-cause mortality rate was significantly lower in patients who underwent ASA compared with SM.

Comparison of Early and Mid-Term Outcomes After Classic and Modified Morrow Septal Myectomy in Patients with Hypertrophic Obstructive Cardiomyopathy.

The aim of our study is to compare the early and mid-term outcomes of patients with hypertrophic obstructive cardiomyopathy who underwent classic and modified Morrow septal myectomy. Between 2014 and 2019, 48 patients (24 males; mean age 49.27±16.41 years) who underwent septal myectomy were evaluated. The patients were divided into two groups - those who underwent classic septal myectomy (n=28) and those who underwent modified septal myectomy (n=20). Mitral valve intervention was higher in the classic Morrow group than in the modified Morrow group, but there was no significant difference (P=0.42). Mortality was found to be lower in the modified Morrow group than in the classic Morrow group (P=0.01). In both groups, the mean immediate postoperative gradient was significantly higher than the mean of the 3rd and 12th postoperative months. The preoperative and postoperative gradient difference of the modified Morrow group was significantly higher than of the classic Morrow group (P<0.001). Classic Morrow and modified Morrow procedures are effective methods for reducing left ventricular outflow tract obstruction. The modified Morrow procedure was found to be superior to the classic Morrow procedure in terms of reducing the incidence of mitral valve intervention with the reduction of the left ventricular outflow tract gradient.

Association between postoperative nadir platelet count and postoperative cardiovascular complications following septal myectomy in patients with hypertrophic cardiomyopathy: a retrospective cohort study

BackgroundPlatelet count is associated with cardiovascular risk and mortality in several cardiovascular diseases, but the association of the nadir platelet counts post-septal myectomy with the cardiovascular complication risk in hypertrophic obstructive cardiomyopathy patients remains unclear.MethodsThis retrospective cohort study reviewed all adult patients who underwent septal myectomy at a single tertiary referral center over a 5-year period. Postoperative nadir platelet count was defined as the lowest platelet count in the first 4 postoperative days or until hospital discharge. The composite outcome included cardiovascular death, myocardial infarction, heart failure, malignant arrhythmia, cardiac tamponade, and major bleeding events within 30 days postoperatively. Univariable and multivariable logistic regression and restricted cubic spline models were used to assess the association between postoperative nadir platelet count and the 30-day postoperative cardiovascular complication risk.ResultsAmong the 113 enrolled patients, 23 (20.4%) developed cardiovascular events within 30 days postoperatively. The incidence of postoperative cardiovascular complications was significantly higher in patients with a nadir platelet count ≤ 99 × 109/L than in those with a nadir platelet count > 99 × 109/L (33.3% vs. 7.1%, crude risk ratio: 4.67, 95% confidence interval: 1.69–12.85, P < 0.001). Multivariable logistic regression revealed that postoperative nadir platelet count was negatively associated with 30-day postoperative cardiovascular complications (adjusted odds ratio: 0.97; 95% confidence interval: 0.95–0.99; P = 0.005) and the association was linear (Pnonlinearity = 0.058) after full adjustment. The association between nadir platelet count and cardiovascular complications within 30 days post-surgery was consistent in all predefined subgroups (Pinteraction > 0.05).ConclusionThe postoperative nadir platelet count was significantly associated with the 30-day post-myectomy risk of cardiovascular complications in hypertrophic obstructive cardiomyopathy patients.Trial registrationThis trial was registered at ClinicalTrials.gov (NCT04275544).

Clinical Effect of the Modified Morrow Septal Myectomy Procedure for Biventricular Hypertrophic Cardiomyopathy.

Right ventricular involvement in hypertrophic cardiomyopathy is uncommon. This study aimed to evaluate clinical outcomes of the modified septal myectomy in patients diagnosed with biventricular hypertrophic cardiomyopathy (BHCM), a subject seldom explored in the literature. We conducted a retrospective cohort study from January 2019 to January 2023, enrolling 12 patients with BHCM. Each patient underwent a modified septal myectomy and was followed postoperatively. Clinical data and echocardiographic parameters, including the ventricular outflow tract peak pressure gradient and maximum interventricular septum thickness, were collected and analyzed. The study cohort had a median age of 43.0 (interquartile range 14.5-63.0) years at surgery, with four patients (33.3%) being children. Two patients (16.7%) previously underwent percutaneous transluminal septal myocardial ablation. Surgical relief of biventricular outflow tract obstruction (BVOTO) was achieved in five patients (41.7%), aside from those managed solely for left ventricular outflow tract obstruction. In five instances, three-dimensional (3D) printing technology assisted in surgical planning. The postoperative interventricular septum thickness was significantly reduced (21.0 mm preoperative vs. 14.5 mm postoperative, p 0.001), effectively eliminating residual ventricular outflow tract obstruction. There were no severe complications, such as septal perforation or third-degree atrioventricular block. During a mean follow up of 21.2 15.3 months, no sudden deaths, residual outflow tract obstruction, permanent pacemaker implantation, recurrent systolic anterior motion, or reoperations were reported. Our findings affirm that the modified septal myectomy remains the gold standard treatment for BHCM, improving patient symptoms and quality of life. BVOTO relief can be safely and effectively achieved through septal myectomy via transaortic and pulmonary valve approaches in selected patients. For intricate cases, the application of 3D printing technology as a preoperative planning tool is advised to optimize surgical precision and safety.

Improvement in Sexual Dysfunction in Patients With Hypertrophic Cardiomyopathy Undergoing Septal Myectomy: A Prospective Study

BackgroundSeptal myectomy improves symptoms in the majority of patients with obstructive hypertrophic cardiomyopathy (HCM), but there are limited prospective data on functional outcomes after operation. ObjectivesThe authors investigated quality of life measures and prevalence of sexual dysfunction before and after septal myectomy for obstructive HCM. MethodsBetween January 2018 and October 2019, 436 patients underwent transaortic septal myectomy at our clinic. All patients were screened for eligibility, and 197 (45.2%) were enrolled in this prospective survey study. Patients received a questionnaire pertaining to quality of life and sexual health before and within 4 to 6 months postoperatively, and 113 (57.4%) completed the follow-up survey. ResultsThe mean age of the 54 (47.8%) women and 59 (52.2%) men was 54.7 ± 14.1 years. Quality of life, including both mental and physical components, improved significantly in both men (P < 0.001) and women (P < 0.001). Women reported mild sexual dysfunction at baseline, and following septal myectomy, they experienced significant (P < 0.05) improvement in most domains pertaining to sexual health. In men, the International Index of Erectile Function median score was 23 (IQR: 7.0-29.5), which is consistent with mild dysfunction at baseline, and there was significant improvement following surgery in young (age ≤55 years) men (P < 0.001). ConclusionsQuality of life is significantly improved following septal myectomy in patients with obstructive HCM. Both women and men reported mild sexual dysfunction at baseline, and women and younger men (age ≤55 years) experienced significant improvements in sexual health.

First-in-Human Transapical Beating-Heart Septal Myectomy in Patients With Hypertrophic Obstructive Cardiomyopathy

BackgroundTo simplify surgical septal reduction therapy for hypertrophic obstructive cardiomyopathy (HOCM), we developed a novel transapical beating-heart septal myectomy (TA-BSM) procedure. ObjectivesIn this study, we sought to evaluate the clinical utility of TA-BSM in a first-in-human trial. MethodsPatients with HOCM were enrolled if they presented with drug-refractory disabling symptoms. TA-BSM was performed via minithoracotomy with the use of our beating-heart myectomy device under echocardiographic guidance, without the use of cardiopulmonary bypass. Repeated resections were performed to tailor the extent of the septal myectomy for sufficient abolishment of left ventricular outflow tract (LVOT) obstruction and mitral regurgitation (MR). The primary outcome measure was procedural success, defined by resting/provoked LVOT gradient <30/50 mm Hg and residual MR grade ≤1+ (of 4+) at 3-month follow-up. ResultsA total of 47 patients aged 12 to 77 years were enrolled. Of the 46 patients who were followed for 3 months, 42 achieved procedural success. The maximal LVOT gradient decreased from 86 mm Hg (IQR: 67-114 mm Hg) at baseline to 19 mm Hg (IQR: 14-28 mm Hg) at 3 months. MR grade was ≤1+ in 3 patients at baseline and in 45 patients at 3 months. One patient died on postoperative day 10 owing to device-unrelated reasons. Other major adverse events included 1 delayed ventricular septal perforation and 1 intraoperative left ventricular apical tear. ConclusionsTA-BSM is a safe and efficient minimally invasive procedure for septal reduction of heterogeneous HOCM. Compared with conventional septal myectomy, TA-BSM provides real-time evaluation to guide resection while reducing surgical trauma. (Transapical Beating-Heart Septal Myectomy in Patients With Hypertrophic Obstructive Cardiomyopathy; NCT05332691)

Alcohol septal ablation versus surgical septal myectomy of obstructive hypertrophic cardiomyopathy: systematic review and meta-analysis.

To elucidate the optimal septal reduction therapy for obstructive hypertrophic cardiomyopathy, we conducted a meta-analysis comparing alcohol septal ablation (ASA) and septal myectomy. MEDLINE, EMBASE and Cochrane CENTRAL were searched to identify studies investigating the outcomes of ASA and septal myectomy in patients with obstructive hypertrophic cardiomyopathy in January 2023. The primary outcome of interest was all-cause mortality in studies with ≥1 year of follow-up. The secondary outcomes of interest comprised left ventricular outflow tract (LVOT) pressure gradient reduction and reoperations of LVOT. A subgroup analysis of all-cause mortality including studies with follow-up ≥5 years was performed. 27 observational studies were included (15 968 patients). Analysis demonstrated similar all-cause mortality [hazard ratio (HR) (95% confidence interval) (CI) 1.24 (0.88-1.76); P = 0.21; I2 = 56%]. In contrast, ASA was associated with less reduction of LVOT pressure gradient and a reoperation rate [weighted mean difference (95% CI) 11.04 mmHg (5.60-16.48); P < 0.01; I2 = 64%, HR (95% CI) 9.14 (6.55-12.75); P < 0.001; I2 = 0%, respectively]. The subgroup analysis with follow-up ≥5 years revealed higher long-term mortality with ASA [HR (95% CI) 1.50 (1.04-2.15); P = 0.03; I2 = 52%]. Although both septal reduction therapies were associated with similar all-cause mortality, ASA was associated with a higher rate of reoperation and less reduction of LVOT pressure gradient. Furthermore, all-cause mortality with follow-up ≥5 years showed favourable outcomes with septal myectomy, although the result is only hypothesis-generating given a subgroup analysis.

Abstract 12901: Cardiac Reverse Remodeling and Functional Changes Assessed by Speckle Tracking Echocardiography After Septal Myectomy in Patients With Symptomatic Hypertrophic Obstructive Cardiomyopathy

Introduction &amp; Hypothesis: Surgical septal myectomy is an effective treatment in patients with symptomatic hypertrophic obstructive cardiomyopathy (HOCM). Reducing the hemodynamic burden through septal myectomy in HOCM patients is expected to result in cardiac reverse remodeling, but it is unknown whether it improves myocardium functional parameters, which are proven prognosticators for clinical outcome. Therefore, this study aimed to investigate the left atrial (LA) and left ventricular (LV) size and function using conventional and speckle tracking echocardiography (STE) before and after septal myectomy in patients with HOCM. Methods: A total of 65 patients with symptomatic HOCM who underwent surgical septal myectomy from 2006 to 2021 were retrospectively analyzed. Patients were excluded if they underwent a valve repair or replacement at the same time. Finally, clinical, echocardiographic, and electrocardiographic variables before and after the surgery were comprehensively analyzed. Results: After septal myectomy, there were significant decreases in LA volume index (72±22 vs. 57±18 ml/m 2 , p &lt;0.001) suggestive of improvement of diastolic function. In the analysis of STE, there was no significant difference in LA strain (19.3±8.5 vs. 19.1±8.2%, p=0.883) and LV global longitudinal strain (LS) (-10.3±3.6 vs. -9.6±3.4%, p=0.150) before and after septal myectomy. When we analyzed LV regional LS by dividing into septum and non-septum, septal LS showed a little aggravation (-8.7±4.5 vs. -7.6±3.7 %, p=0.077) with marginal statistical significance. In addition, non-septal LS was not significantly different after septal myectomy (-10.9±4.5 vs. -10.5 ±4.2 %, p= 0.458). The change of LA volume index was significantly correlated with change of QRS duration. Interestingly, the septal LS was deteriorated and non-septal LS tended to be improved as widening of QRS duration. Conclusions: After septal myectomy, as hemodynamic load due to LVOT obstruction relieves, there is a significant reduction in LA volume. However, there is no improvement in the global LA and LV mechanical function. Widening of QRS duration, a marker of effective septal myectomy, is associated with LA volume reduction and improvement of longitudinal strain in non-septal LV.

Abstract 14313: Improved NYHA Class and KCCQ-12 After Septal Myectomy in Patients With Obstructive Hypertrophic Cardiomyopathy

Introduction: Patients with obstructive hypertrophic cardiomyopathy (oHCM) frequently present with heart failure symptoms refractory to medical therapy and require septal myectomy (SM). The magnitude of benefit from SM is thought to be better than the recently reported data from EXPLORER-HCM and REDWOOD-HCM trials. We prospectively investigated the association between SM, patient-reported 12-item Kansas City Cardiomyopathy Questionnaire (KCCQ-12) and physician-reported NYHA class in a community-based cohort of oHCM. Hypothesis: SM ± submitral valve repair is associated with improvement in NYHA class and KCCQ-12 but with a varying magnitude of benefit. Methods: We conducted a prospective cohort study of 108 patients with oHCM who underwent SM (48% women, age 59 (45, 67) years). KCCQ-12 and NYHA class were assessed prospectively prior to SM, at 1-3 months post-SM and at 4-12 months post-SM. KCCQ-12 is reported as an additive score. Data are reported as median values (IQR). Results: Pre-SM, LVEF was 70% (65, 75) while resting and Valsalva LVOT gradients were 42 (22, 90) and 87 (53, 119) mm Hg, respectively. Post-SM, median LVEF was 65% (60, 69) with respective resting and Valsalva LVOT gradients of 11 (8, 16) and 16 (11, 28) mm Hg (all p&lt;0.001). NYHA Classes ≥III decreased in prevalence from 71% to 13% to 3% after SM (p&lt;0.001). Pre-SM, KCCQ-12 was 39 (31, 48), which improved to 51 (41, 57) at 1-3 months post-SM and 58 (52, 63) at 4-12 months post-SM (p&lt;0.001). Changes in NYHA Class distribution and KCCQ-12 scoring after SM are shown in Figure 1. Conclusion: SM was associated with significant improvement in KCCQ-12 and NYHA class in a community-based cohort of oHCM. The inability to conduct blinded NYHA class and KCCQ-12 assessment post-SM is a major limitation given EXPLORER-HCM showed 31% placebo effect on NYHA class. Further contemporary comparative studies of SM and cardiac myosin inhibitors are needed.

Analysis of electrocardiographic signs in hypertrophic cardiomyopathy before and after septal myectomy. New criterion for proximal left bundle branch block

Aim. To analyze 20 electrocardiographic (ECG) signs of left bundle branch block (LBBB) before and after septal myectomy in patients with hypertrophic cardio myopathy (HCM) and develop a criterion for proximal LBBB based on the selected signs.Material and methods. This retrospective non-randomized study included 50 patients with obstructive HCM who underwent septal myectomy. There were following inclusion criteria: QRS width &lt;120 ms before surgery, transaortic access during septal myectomy, and QRS width ≥120 ms in the early postoperative period. For each patient, ECGs were analyzed before septal myectomy and in the first week after surgery. At the same time, 20 ECG signs proposed earlier in the LBBB criteria were independently assessed.Results. Exsection of a small myocardial area of the basal interventricular septal parts, weighing an average of 4,9±2 grams, led to a significant increase in the QRS width (by 61±14,6 ms) and the prevalence of almost all ECG signs of LBBB. In 100% of cases (n=50), the following signs demonstrated significant dynamics after surgery: (1) midQRS notching or slurring in ≥2 contiguous leads (I, aVL, V1-V2, V5-V6); (2) absence of q wave in V5-V6 and (3) discordant T wave in at least two leads (I, aVL, V5, V6). Based on the design of the study, (4) QRS width ≥120 ms was additionally included. These ECG characteristics were combined into a new criterion for proximal LBBBConclusion. A new criterion for proximal LBBB was developed using the pathophysiological model of iatrogenic conduction block of left bundle branch. Further estimation of this criterion on a set of candidates for CRT with heterogeneous level of LBBB is necessary.

Left ventricular remodeling following septal myectomy in hypertrophic obstructive cardiomyopathy

ObjectivesThe purpose of this study is to determine whether or not left ventricular remodeling can be induced after septal myectomy in patients with obstructive hypertrophic cardiomyopathy, and if so, how it occurs, using gated cardiac computed tomography. MethodsFifty patients with hypertrophic obstructive cardiomyopathy who underwent septal myectomy along the septal band between March 2016 and July 2020 were retrospectively reviewed. Recent consecutive 19 patients underwent postoperative cardiac computed tomography. In these patients, volumes of the septal band and thickness of 17 left ventricular myocardial segments were measured to determine the changes after surgery. ResultsThe resection volume predicted by preoperative computed tomography and the actual resection volume were 6.7 ± 3.3 mL and 6.4 ± 2.7 mL. In-hospital mortality was 0%. Moderate or greater mitral valve regurgitation and systolic anterior motion decreased from 56% to 6% and 86% to 6%, respectively. Median preoperative ventricular septal thickness and left ventricular outflow tract pressure gradient at rest decreased from 20.0 mm (interquartile range, 17.0-24.0 mm) and 74.0 mm Hg (interquartile range, 42.5-92.5 mm Hg) to 14.0 mm (interquartile range, 11.5-16.0 mm) and 15.5 mm Hg (interquartile range, 12.1-21.5 mm Hg), respectively. Postoperative computed tomography confirmed a reduction in septal band volume of 5.7 ± 2.8 mL. Total left ventricular myocardial volume was reduced by 12.9 ± 8.8 mL, which exceeded the volume reduction of the resected septal band. All segments except the basal inferior and basal inferolateral regions showed a significant decrease in wall thickness by a median of 6.4%. ConclusionsProperly performed septal myectomy may induce remodeling of the entire left ventricle, not just the resected area.

Improvement in gastrointestinal bleeding after septal myectomy for hypertrophic cardiomyopathy

ObjectivePatients with obstructive hypertrophic cardiomyopathy may have occult gastrointestinal bleeding. In this study, we analyzed outcomes of septal myectomy in patients who had a history of gastrointestinal bleeding preoperatively to understand patient characteristics and impact of septal reduction on recurrent gastrointestinal bleeding. MethodsWe analyzed 73 adult patients who had a history of gastrointestinal bleeding before transaortic septal myectomy for obstructive hypertrophic cardiomyopathy and compared outcomes to 219 patients without gastrointestinal bleeding preoperatively. ResultsPatients with preoperative history of gastrointestinal bleeding were older (median (IQR) age, 65 (59-69) years, P < .001) and were more likely to have systemic hypertension (70% vs 53%, P = .020) and coronary artery disease (25% vs 13%, P = .026). Preoperatively, patients with gastrointestinal bleeding had a larger left atrial volume index (median, 53 mL/m2; interquartile range, 42-67; P = .006) and greater right ventricular systolic pressure (median, 36 mm Hg; interquartile range, 32-49; mm Hg, P = .005) but no significant difference in severity of outflow tract obstruction (P = .368). There were no perioperative deaths. The estimated 5- and 10-year survivals were 96.6% and 81.8%, respectively. At a median of 3.4 (interquartile range, 1.9-9.1) years after septal myectomy, 11 patients (15%) had recurrence of gastrointestinal bleeding, which was attributed to angiodysplasia or unknown causes in 6 patients (8%). ConclusionsPatients with a preoperative history of gastrointestinal bleeding have favorable short- and long-term outcomes after septal myectomy for obstructive hypertrophic cardiomyopathy. Remission of gastrointestinal bleeding was observed in 85% of patients postprocedure, and only 8% of the patients had recurrent gastrointestinal bleeding due to angiodysplasia or unknown causes.

Septal myectomy with mitral valve surgery in patients after alcohol septal ablation.

OBJECTIVESWe studied 16 patients after failed alcohol septal ablation who underwent extended septal myectomy to analyse the results of surgical correction and identify technical pitfalls the surgeons may be confronted by.METHODSBetween October 2017 and March 2019, 16 patients underwent surgical extended septal myectomy with accompanying anomalous secondary chordae resection, papillary muscles mobilization [in 9 (56.3%) patients], and anterior mitral leaflet plication after previously failed alcohol septal ablation. Routine preoperative computed tomography or cardiac magnetic resonance planning and intraoperative transoesophageal echocardiography were performed in each of the studied patients. Major technical features were identified and complemented during septal myectomy of the calcified interventricular septum.RESULTSThe mean age of the studied patients accounted 50.5 ± 14.6, median—54; males—5 (31.3%). Mean cross-clamp time accounted 52 ± 7.2 min. Calcified basal interventricular septum was identified in 2 (12.5%) patients. No iatrogenic ventricular septal defect (0%) was made during surgical correction. Peak systolic pressure gradient decreased from 86 (interquartile range: 75–104.7) to 20 (16–22) mmHg (P< 0.001). No patients with moderate or severe mitral regurgitation were identified, whereas before the procedure, the number of those accounted 13 (81.2%) individuals. In-hospital and overall mortality after septal myectomy accounted 0%.CONCLUSIONSExtended septal myectomy in patients who previously underwent alcohol septal ablation is a safe procedure that affects all pathological manifestations of the disease. Routine preoperative computed tomography or cardiac magnetic resonance provides detailed anatomy of the anomalous left ventricle and subvalvular structures and allows to measure the extension of myectomy preventing the occurrence of iatrogenic ventricular septal defect. Septal myectomy of the calcified interventricular septum requires avoidance of ‘one-piece technique’ since fragmental myectomy allows visually control the adequacy of the left ventricle outflow tract release.

Early post-septal myectomy outcomes for hypertrophic obstructive cardiomyopathy.

We aimed to evaluate early outcomes of septal myectomy in patients with hypertrophic cardiomyopathy. We retrospectively analyzed data collected over a 9-year period from 583 patients who underwent septal myectomy for hypertrophic cardiomyopathy at our institution. The mean age was 55.7 ± 13.1 years, and 338 (58%) patients were in New York Heart Association class III or IV. There were 11 (1.9%) early deaths, including 3 (0.5%) intraoperative deaths. Early mortality was lowest after isolated septal myectomy (0.8%) and highest after concomitant mitral valve replacement (6.1%). There were 4 (0.7%) and 9 (1.5%) patients with left ventricular wall rupture and ventricular septal defect, respectively, after myectomy. New pacemaker implantation caused by atrioventricular disturbances was required in 29 (5.0%) patients, and was associated with previous alcohol septal ablation (odds ratio 3.34, 95% confidence interval 1.02-11.0, P = 0.047). Left ventricular wall rupture, intraoperative residual (15.5% moderate, 0.3% severe) mitral regurgitation, and pre-discharge residual outflow tract gradient >30 mm Hg (4.6%) occurrences were surgeon-dependent. The early results are consistent with example targets reported in the 2020 American College of Cardiology/American Heart Association guidelines for septal reduction therapy outcomes. Septal myectomy safety and efficacy are surgeon-dependent. Previous alcohol septal ablation increases the risk of permanent pacemaker implantation due to postoperative complete atrioventricular block. Therefore, continuous education, mentoring, and learning by doing may play an important role in achieving reasonable septal myectomy safety and efficacy.

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