Ventricular Posterior Free Wall Research Articles

Thoracoscopic Trans-mitral Septal Myectomy for Hypertrophic Obstructive Cardiomyopathy in the Elderly

BackgroundThe thoracoscopic trans-mitral approach can not only facilitate exposure of the ventricular septum, mitral valve, and subvalvular apparatus, it also enables the surgeons to perform concomitant mitral valve intervention. This study aimed to determine the safety and efficacy of thoracoscopic trans-mitral septal myectomy in elderly patients with hypertrophic obstructive cardiomyopathy (HOCM).MethodsWe reviewed the demographic to clinical characteristics and outcomes of patients who underwent thoracoscopic trans-mitral septal myectomy in our center between April 2019 and April 2021. The population was divided into a younger group (<60 years) and an elderly group (≥60 years).ResultsThere were 46 and 20 patients in the younger and elderly groups, respectively. The majority of patients in the elderly group were female (39.1 vs. 80.0%, P < 0.01). Patients in the elderly group were more likely to be in New York Heart Association Class IV (2.2 vs. 80.0%, P < 0.01). The European System for Cardiac Operation Risk Evaluation II predicted mortality rates were significantly higher (3.97 ± 1.81 vs. 1.62 ± 0.86%, P < 0.01) in the elderly group. In the elderly group, a patient converted to median sternotomy due to left ventricular posterior free wall rupture following septal myectomy and mitral bioprosthetic valve replacement. The patient then underwent double-patch sandwich repair for rupture and mitral mechanical valve replacement and was eventually discharged. All patients in the elderly group were discharged, while one in the younger group died. No patient in the elderly group required permanent pacemaker implantation vs. one in the younger group. Patients in the elderly group were more likely to spend more time in the intensive care unit than those in the younger group (5.44 ± 5.80 days vs. 3.07 ± 2.72, P < 0.05). However, there was no significant intergroup difference in in-hospital mortality or complications. Importantly, the left ventricular outflow tract pressure gradient was significantly decreased from 96.15 ± 32.89 mmHg to 8.2 ± 3.42 mmHg with no residual obstruction in the elderly group. The interventricular septal thickness was significantly decreased from 19.73 ± 3.14 mm to 11.30 ± 2.23 mm. Postoperative mitral regurgitation severity was significantly improved in the elderly group.ConclusionThis study demonstrated that thoracoscopic trans-mitral septal myectomy is a feasible option for selected elderly patients with satisfactory outcomes similar to those of young patients.

Reference Values and Repeatability of B-Mode and M-Mode Echocardiographic Parameters in Healthy Donkey (Equus asinus)—The Guide to Assess Healthy Heart

Donkey (Equus asinus), the cheapest form of agricultural power in Egypt, is used principally as draught or pack animals and may also be ridden, or used for threshing, raising water, milling, and other work. The aim of the present study was to provide B-mode and M-mode echocardiographic reference ranges from a sample of population of donkeys (E. asinus) based on the probability theory and statistics. In the present study, B-mode and 2-dimensional guided M-mode echocardiography were performed on 44 clinically healthy donkeys (E. asinus) (22 males and 22 females), without any neither clinical nor echocardiographic evidence of cardiovascular diseases, aged 2–25 year old, and weighed 150–350 kg. The echocardiographic dimensions, including interventricular septum thickness at end diastole, interventricular septum thickness at end systole, left ventricular internal diameter at end diastole, left ventricular internal diameter at end systole, left ventricular posterior wall thickness at end diastole, and left ventricular posterior wall thickness at end systole were assessed. The cardiac function indices, including end diastolic volume, end systolic volume, stroke volume, ejection fraction, and fractional shortening were also measured. B-mode and guided M-mode echocardiographic examination of healthy donkeys revealed that both the interventricular septum thickness and the left ventricular posterior free wall were greater during systole than diastole. However, the left ventricular dimension during diastole was greater than systole. Furthermore, the recorded data of cardiac function indices, including end diastolic volume, end systolic volume, stroke volume, ejection fraction, and fractional shortening using B-mode echocardiography were closer to those recorded by guided M-mode echocardiography. To our knowledge, this is the first Egyptian study to report the echocardiographic reference ranges of donkeys (E. asinus) based on the probability theory and statistics, the coefficient of variation. The results of the present study can be used as standard and reference values for further echocardiographic studies in donkeys and represent a step in the identification, interpretation, and evaluation of cardiovascular disorders in such animals.

P251 Right ventricular free wall dissection clearly detected and recorded by echocardiography: a fatal complication after inferior myocardial infarction

Abstract An 81-year-old man was transferred to our institution by ambulance because of poor feeding, general fatigue and slight disorientation lasting for a week. On arrival, he was awake and able to speak, however, his blood pressure was low at 61/43 mmHg in spite of his medical history of hypertension. His ECG showed abnormal Q waves and ST elevation in II, III, aVF leads. The echo exam detected severe hypokinesis in the left ventricular inferior wall and reduced ejection fraction at 30%. Pericardial effusion was not observed in the first echo exam. The patient was diagnosed as cardiogenic shock due to recent inferior myocardial infarction. Coronary angiography was performed, which detected total occlusion of mid right coronary artery, followed by a successful percutaneous coronary intervention (PCI) with a drug-eluting stent under the support of intra-aortic balloon pumping. Nevertheless, his blood pressure remained low and intravenous adrenaline administration was necessary during and even after PCI. To detect the cause of prolonged low blood pressure, echo was performed again immediately after PCI. The echo exam detected new findings: right ventricular posterior free wall was dissected and abnormal shunt flows were obviously observed from left ventricle to right atrium through the dissection cavity during systole. An urgent surgical repair was considered as the only option for his survival, however, his family did not accept it because the operation itself was too risky. On the next day of his admission, he passed away. Right ventricular free wall dissection is a very rare but fatal complication after inferior myocardial infarction, nevertheless, we could detect it by echocardiography with clearly recorded images. Abstract P251 Figure.

Ultrastructural myocardial changes in seven cats with spontaneous hypertrophic cardiomyopathy

ObjectivesHypertrophic cardiomyopathy (HCM) is the most common heart disease in cats and shares clinical and pathological characteristics with human HCM. Little is known about the pathogenic mechanisms underlying development of spontaneous feline HCM. AnimalsThe study population consisted of seven cats diagnosed with HCM and eight age-matched cats with no evidence of cardiac disease. MethodsFresh myocardial biopsies taken from the middle of the left ventricular posterior free wall were obtained and examined with transmission electron microscopy. ResultsElectron microscopic examination showed ultrastructural aberrations of the myocardial cytoarchitecture and of the interstitium in the seven cats with HCM. In the most severely affected cats the myofibrils were disorganized and subsarcolemmal mitochondria were depleted. In control cats, contraction band artifacts were commonly seen. ConclusionsIn this preliminary study we show that ultrastructural changes of the myocardium in seven cats with HCM involve the cytoskeleton and mitochondria. We suggest that our findings are important for future research aiming at elucidating the pathogenic mechanisms underlying the phenotypic expression of feline HCM.The results of this study prompt for a larger scale study, including quantitative measurements of mitochondrial distribution and cytoskeletal derangements in feline HCM.

Repair of Acute Postinfarct Posterior Ventricular Septal Rupture Without Left Ventriculotomy: A Stable Suture Preserving Left Ventricular Geometry

The present article describes the case of a man operated upon for emergency closure of an acute postinfarction defect in the posterior septum. We used a novel technique. The rupture was approached by disconnection of the right ventricular posterior free wall with the exposure of the right side of the septum. First, the edges of the defect were joined together by a single purse-string pledgetted suture. Then an on-site tailored double-folded patch was applied with the aim of closing both the septal defect and the RV access. In our limited experience the technique proved to be safe and effective, allowed optimal exposure of the defect and placement of stable stitches, reducing postoperative complications.

Operative treatment of hypertrophic obstructive cardiomyopathy and aortic valve disease in infants.

The indications for operative intervention for symptomatic hypertrophic obstructive cardiomyopathy (HOCM) in infancy and childhood are not well defined because of the rarity of the lesion. The traditional surgical procedure consists of septal myectomy. In an attempt to further improve the outcome of HOCM associated with concentric left ventricular hypertrophy and aortic valve disease in infancy, we have combined resection of the left ventricular septum and free wall with a Ross-Konno procedure. Three infants (aged 3, 4, and 10 months) with HOCM (left ventricular aortic gradients of 75, 95, and 110 mmHg), associated concentric left ventricular hypertrophy, and valvar aortic stenosis (n = 1) or combined valvar aortic stenosis and regurgitation (n = 2) underwent extensive resection of fibroelastosis and subendocardial myocardium of the left ventricular septum and free wall in combination with a Ross-Konno operation. All three patients had marked systolic anterior motion of the mitral valve. The length of the incision into the ventricular septum was 1.8, 2.0, and 2.3 cm. In all three patients this procedure resulted in a marked reduction of width of the left ventricular septum (median 9 mm vs 14 mm preoperatively) and the left ventricular posterior free wall (median 8 mm vs 12 mm preoperatively) and an almost twofold increase of the left ventricular end-diastolic volume (median 13.5 cm3 vs 7.0 cm3 preoperatively). The neo-aortic valve functioned normally. Systolic anterior motion of the anterior leaflet of the mitral valve had completely resolved in two patients and had markedly regressed in the remaining patient. At follow-up of 15, 17, and 26 months, two patients had absence of a left ventricular outflow tract gradient and the third patient had a residual sub-valvar gradient of 15 mmHg. The reported procedure may be a valuable technique in severe forms of hypertrophic cardiomyopathy associated with aortic valve disease. The operation results in enlargement of the left ventricular stroke volume and improvement of the left ventricular diastolic function, restores aortic valve anatomy and function, and abolishes or decreases systolic anterior motion of the mitral valve.

Ross-Konno Operation With Resection of Endocardial Fibroelastosis for Critical Aortic Stenosis With Borderline-Sized Left Ventricle in Neonates

Background. Critical aortic stenosis with severe concentric left ventricular hypertrophy and endocardial fibroelastosis has a substantial mortality rate when the conventional therapeutic strategy, ie, open surgical or balloon valvuloplasty, is applied. During the last decade, univentricular repair (Norwood operation) and heart transplantation have evolved as the only viable therapeutic options. An alternative in patients with borderline hypoplastic left heart syndrome consists of performance of a Ross-Konno operation with surgical enlargement of the left ventricular cavity, a procedure that has the advantage of achieving a two-ventricle repair. Methods. Two neonates and 2 young infants with critical aortic stenosis, concentric left ventricular hypertrophy, and severe endocardial fibroelastosis, with echocardiographically documented antegrade flow in the ascending aorta, underwent a Ross-Konno operation combined with extensive endocardial and myocardial resection of the left ventricular septum and free wall. The incision in the ventricular septum was closed with a wide cuff of infundibular muscle that was harvested in continuity with the pulmonary autograft. Results. In all 4 patients, the operation resulted in normal aortic valve function, marked reductions of width of the left ventricular septum (median, 6.5 mm, versus 11 mm preoperatively) and the left ventricular posterior free wall (median, 8.5 mm, versus 15.5 mm preoperatively), and enlargement of the left ventricular end-diastolic volume (median, 12.5 cm 3, versus 6.5 cm 3 preoperatively). Three patients had an uneventful recovery, with gradual improvement of left ventricular diastolic and systolic function during the first postoperative week; 1 neonate with associated mitral regurgitation died of left ventricular failure. Conclusions. The Ross-Konno procedure with resection of endocardial fibroelastosis may be a valuable adjunct for achieving a two-ventricle repair in borderline hypoplastic left heart syndrome. The operation results in enlargement of the left ventricular stroke volume and improvement of left ventricular diastolic function; in addition, resection of endocardial fibroelastosis relieves the mechanical impairment of myocardial function and therefore may promote the potential for left ventricular growth. (Ann Thorac Surg 1997;63:112–6)

Changes in myocardial echo amplitude during reversible ischaemia in humans.

This study investigated the changes in regional myocardial ultrasonic backscatter, measured as myocardial echo amplitude, that occur during reversible myocardial ischaemia in humans. Left anterior descending coronary angioplasty was used to produce reversible myocardial ischaemia in human subjects. Regional myocardial echo amplitude was studied in the interventricular septum and left ventricular posterior free wall before, during, and after coronary occlusion with the angioplasty balloon. Wall motion analysis of the left ventricle was performed from simultaneous cross sectional echocardiographic imaging. Patients were studied prospectively. Six patients (mean age 56 (SD 11), range 46 to 69 years) with single vessel, left anterior descending coronary artery stenoses, were investigated during elective coronary angioplasty. A total of 11 balloon inflations were studied. All patient studies were performed at Harefield Hospital. Echo amplitude analysis was performed at the Royal Brompton Hospital. Angioplasty was performed by the usual procedure at Harefield Hospital for elective coronary angioplasty. All routine medication including beta blockers and calcium antagonists were continued. Inflation pressures were up to 12 atm (1212 kPa) and mean inflation time ranged from 30 to 120 (86 (31)) s. In four studies the first inflation was examined, in three the second, in two the third, and in one each the fourth and fifth inflations. Echo amplitude and cross sectional echo-cardiographic studies were recorded with a 3.5 MHz Advanced Technology Laboratories (ATL) (720A/8736 series) mechanical sector scanner and an ATL Mark III (860-1 series) echocardiograph system with 45 dB logarithmic grey scale compression. Regional echo amplitude was examined in four regions of the left ventricle--namely, the basal and mid-septum, and basal and mid-posterior wall. Consecutive end diastolic and end systolic frames were analysed and cyclic variation was determined as the difference between the level of echo amplitude at end diastole and at end systole. Measurements were made before balloon inflation, at peak inflation, and after balloon deflation. Regional wall motion and systolic wall thickening were analysed qualitatively. Before balloon inflation, cyclic variation in echo amplitude was noted in all regions (basal septum, 2.4 (SD 1.1) dB; mid-septum, 2.5 (1.1) dB; basal posterior wall, 3.3 (2.1) dB; mid-posterior wall, 3.9 (1.6) dB). During balloon inflation there was a significant fall in cyclic variation to 0.4 (0.9) dB (p < 0.0002) in the mid-septum. This was predominantly owing to an increase in end systolic echo amplitude from 5.4 (2.0) dB to 9.3 (1.9) dB (p < or = 0.01). This was associated with the development of severe hypokinesis or akinesis in the mid-septum. No significant changes in echo amplitude occurred in the three other regions examined. Changes were completely reversed after balloon deflation. These results suggest a causal relation between occlusion of the supplying coronary artery and blunting of myocardial echo amplitude cyclic variation. It is suggested that balloon occlusion produced myocardial ischaemia. The resultant impairment of myocardial contraction then caused a blunting of cyclic variation in echo amplitude. The results of this study provide further data about the ability of quantitative studies of ultrasonic backscatter to identify alterations in the myocardium during injury.

Operative Treatment of Hypertrophic Obstructive Cardiomyopathy and Aortic Valve Disease in Infants

Abstract Background: The indications for operative intervention for symptomatic hypertrophic obstructive cardiomyopathy (HOCM) in infancy and childhood are not well defined because of the rarity of the lesion. The traditional surgical procedure consists of septal myectomy. In an attempt to further improve the outcome of HOCM associated with concentric left ventricular hypertrophy and aortic valve disease in infancy, we have combined resection of the left ventricular septum and free wall with a Ross‐Konno procedure. Methods: Three infants (aged 3, 4, and 10 months) with HOCM (left ventricular aortic gradients of 75, 95, and 110 mmHg), associated concentric left ventricular hypertrophy, and valvar aortic stenosis (n = 1) or combined valvar aortic stenosis and regurgitation (n = 2) underwent extensive resection of fibroelastosis and subendocardial myocardium of the left ventricular septum and free wall in combination with a Ross‐Konno operation. All three patients had marked systolic anterior motion of the mitral valve. The length of the incision into the ventricular septum was 1.8, 2.0, and 2.3 cm. Results: In all three patients this procedure resulted in a marked reduction of width of the left ventricular septum (median 9 mm vs 14 mm preoperatively) and the left ventricular posterior free wall (median 8 mm vs 12 mm preoperatively) and an almost twofold increase of the left ventricular end‐diastolic volume (median 13.5 cm3 vs 7.0 cm3 preoperatively). The neo‐aortic valve functioned normally. Systolic anterior motion of the anterior leaflet of the mitral valve had completely resolved in two patients and had markedly regressed in the remaining patient. At follow‐up of 15, 17, and 26 months, two patients had absence of a left ventricular outflow tract gradient and the third patient had a residual sub‐valvar gradient of 15 mmHg. Conclusions: The reported procedure may be a valuable technique in severe forms of hypertrophic cardiomyopathy associated with aortic valve disease. The operation results in enlargement of the left ventricular stroke volume and improvement of the left ventricular diastolic function, restores aortic valve anatomy and function, and abolishes or decreases systolic anterior motion of the mitral valve. (J Card Surg 1999:14:273–278)

Serial two-dimensional echocardiography in Duchenne muscular dystrophy.

Patients with Duchenne muscular dystrophy (DMD) are known to have progressive epicardial fibrosis of the free wall of the left ventricle, but standard noninvasive M-mode echocardiographic tests of left ventricular function are relatively insensitive detectors of this cardiomyopathy. We therefore used two-dimensional echocardiography to record three short axis levels of the left ventricle in 13 Duchenne patients. Serial studies were separated by 2 years for most patients. The two-dimensional echocardiographic technique allows qualitative evaluation of segmental contraction of the left ventricle. Four general principles were found during this study: (1) Obvious contraction abnormalities of the left ventricle were present in most patients with DMD. (2) In most patients, the contraction deficit was first noted in the left ventricular posterior free wall behind the mitral valve. (3) Once a contraction deficit was observed, the area of abnormal contraction progressed inferiorly to include additional areas of the left ventricular posterior free wall. (4) Standard M-mode left ventricular function techniques were unreliable for detecting individuals with segmental contraction abnormalities.

Atrial septal defect--echocardiographic assessment before and after surgical repair.

Twenty-two patients with atrial septal defect (ostium secundum type and sinus venosus) were studied by echocardiography before and after surgery. The sizes of the various heart chambers - right and left ventricles, left atrium and aortic root - and the interventricular septum and the left ventricular posterior free wall (motion and thickness) were analysed and compared in the pre and postoperative period. A significant reduction in size of the right ventricle and a normalization of the left ventricular dimension in the early postoperative evaluation was found. The paradoxical motion of the interventricular septum seen in the preoperative period showed an early trend toward normalization. The changes before and after surgery are discussed, particularly for the interventricular septum.