A contemporary European experience with surgical septal myectomy in hypertrophic cardiomyopathy

Iacovoni, Attilio; Spirito, Paolo; Simon, Caterina; Iascone, Maria; Dedda, Giovanni Di; Filippo, Paolo De; Pentiricci, Samuele; Boni, Luca; Senni, Michele; Gavazzi, Antonello; Ferrazzi, Paolo

doi:10.1093/eurheartj/ehs064

Cited by 93 publications

(68 citation statements)

References 44 publications

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“…In the Tufts experience reported here, there is little evidence to substantiate a "learning curve" in performing the myectomy operation (30). Indeed, the first 200 myectomy operations were performed without mortality or major complications, with no outstanding differences with subsequent patients regarding operative metrics, extent Data are shown as n (%) or mean ± SD.…”

Section: Discussionmentioning

confidence: 87%

Results of surgical septal myectomy for obstructive hypertrophic cardiomyopathy: the Tufts experience

Rastegar

Boll

Rowin

et al. 2017

Ann. Cardiothorac. Surg.

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Background: For over 50 years, surgical septal myectomy has been the preferred treatment for drugrefractory heart failure symptoms in patients with obstructive hypertrophic cardiomyopathy (HCM). Over this time in the United States, the majority of myectomy operations have been performed in a small number of select referral centers. Methods:We have taken the opportunity to report results from the relatively new Tufts HCM Center and surgical program, incorporated 13 years ago, during which 507 myectomies (52±14 years of age; 56% male) were performed by one cardiothoracic surgeon, Dr. Hassan Rastegar.Results: Resting left ventricular (LV) outflow gradients were reduced from 56±42 mmHg preoperatively to 1.2±6.8 mmHg on most recent echocardiogram 2.0±2.5 years after surgery, and 94% of patients showed clinical improvement to NYHA functional class I or II. The first 200 myectomies were performed without mortality or major complications. Among all patients, 30-day mortality rate was 0.8%. Over follow-up of 3.2±2.8 years, 11 patients died (four due to HCM causes) with long-term survival after myectomy of 94% at 5 years (95% CI: 89-96%) and 91% at 10 years (95% CI: 84-95%), which did not differ from the age-and gender-matched general U.S. population (log-rank P=0.9).Conclusions: This experience demonstrates that, with the appropriate support, new HCM surgical programs can provide patients successful relief of outflow obstruction, extended longevity and restored of quality of life.

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Section: Discussionmentioning

confidence: 87%

Results of surgical septal myectomy for obstructive hypertrophic cardiomyopathy: the Tufts experience

Rastegar

Boll

Rowin

et al. 2017

Ann. Cardiothorac. Surg.

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“…In addition, optimal hemodynamic results and sustained clinical improvement to New York Heart Association class I or II have been documented in >90% of patients over long-term follow-up (5,7,10). The exceedingly low operative mortality and major long-term benefits of transaortic surgical myectomy (with extended survival equivalent to patients with non-obstructive HCM and similar to the age and gender matched general population) is now well documented for high volume centers (1,5,7,10).…”

Section: Surgical Septal Myectomymentioning

confidence: 94%

“…At present, only a small number of European HCM surgical referral centers continue to perform a high volume of myectomy operations, mainly in Italy, the Netherlands and Belgium (10)(11)(12)(13). Although alcohol septal ablation was also adopted by interventional cardiologists in the United States, this procedure seems to have had the unexpected and paradoxical effect of increasing the number of surgical myectomies, possibly by enhancing awareness of the importance of LV outflow obstruction on the clinical course of HCM patients (14).…”

Section: Perspectivementioning

confidence: 99%

“…During the last 20 years, a decrease in operative mortality due to improved surgical techniques and myocardial protection has reduced the hospital mortality for isolated septal myectomy to <1% at HCM Centers of Excellence (5,7,10). In addition, optimal hemodynamic results and sustained clinical improvement to New York Heart Association class I or II have been documented in >90% of patients over long-term follow-up (5,7,10).…”

Section: Surgical Septal Myectomymentioning

confidence: 99%

“…Furthermore, major HCM centers have reported a higher rate of ventricular tachyarrhythmias, cardiac arrest, or appropriate ICD interventions after alcohol septal ablation (12,38), and some centers have prophylactically implanted ICDs for primary prevention after septal ablation (22). In contrast to these recurring concerns regarding arrhythmic risk associated with alcohol septal ablation, available data show that surgical myectomy extends survival with an exceedingly low rate of events, including ventricular tachyarrhythmias and sudden death, during long-term follow-up (5,7,10). Therefore, the issue of mid and long-term arrhythmogenic potential of septal ablation (although not definitively quantified) cannot be ignored and plays an important role in directing patient selection for ablation towards older patients, or those who for different reasons are not candidates for surgical myectomy.…”

Section: Arrhythmogenic Potential Of Alcohol Septal Ablationmentioning

confidence: 99%

See 2 more Smart Citations

Alcohol septal ablation: in which patients and why?

Spirito¹,

Rossi²,

Maron³

2017

Ann. Cardiothorac. Surg.

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At present, surgical septal myectomy is regarded as the "gold standard" treatment for most patients with obstructive hypertrophic cardiomyopathy (HCM) and drug-refractory symptoms. However, the best results are obtained by those surgeons who have extensive experience with this operation at a small number of referral centers. In the mid-1990s, percutaneous alcohol septal ablation was introduced as an alternative to myectomy to reduce LV outflow gradient and heart failure symptoms in patients with obstructive HCM. However, certain features of alcohol ablation limit its applicability to carefully selected patients.Because this procedure involves the injection of 1-4 mL of 96% ethanol into a septal perforator of the left anterior coronary artery to produce a myocardial infarction (with septal thinning, outflow tract widening and gradient reduction), alcohol ablation is limited by the size and distribution of the septal perforator branches. In addition, rich blood supply from other septal branches not occluded by the balloon and from the posterior descending coronary artery may restrict myocardial ischemia to portions of the septum that do not contribute to outflow obstruction. Septal hypertrophy may be either mild or particularly marked, and abnormalities of mitral valve apparatus may also play a major role in outflow obstruction. When such features are present, alcohol-induced septal thinning is unlikely to significantly reduce the gradient. In addition, persisting uncertainties regarding the risk for ventricular tachyarrhythmias after alcohol ablation suggest this procedure should be limited to patients of advanced age, patients at unacceptable operative risk due to comorbidities, or those with strong aversion to surgery. Further progress in the treatment for patients with obstructive HCM and severe refractory symptoms will come from assuring proper patient selection for alcohol septal ablation, as well as increasing the number of surgeons and centers experienced in performing septal myectomy. PerspectiveIn patients with hypertrophic cardiomyopathy (HCM), left ventricular (LV) outflow obstruction with a pressure gradient between the LV outflow tract and aorta is caused by systolic anterior motion of the mitral valve against the septum (1), and is identified at rest or with physiologic exercise in about 70% of patients evaluated at tertiary referral centers (2). Obstruction to LV outflow obstruction is associated with mitral valve regurgitation, disabling heart failure symptoms and increased cardiovascular mortality (3,4). For almost 50 years, transaortic septal myectomy has represented the standard surgical approach for the treatment of patients with obstructive HCM and severe symptoms refractory to medical treatment (1,5-7).In the mid-1990s, percutaneous alcohol septal ablation was introduced as an alternative to surgical myectomy to reduce the LV outflow gradient and heart failure symptoms in patients with obstructive HCM (8). This catheterbased procedure, made attractive by its less invasive nature, was rapidl...

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How Hypertrophic Cardiomyopathy Became a Contemporary Treatable Genetic Disease With Low Mortality

et al. 2016

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Hypertrophic cardiomyopathy (HCM) is a relatively common genetic heart disease encumbered throughout much of its almost 60-year history by a large measure of misunderstanding and the perception of a grim outcome without effective treatment options. However, it is now apparent that the majority of patients affected with HCM can achieve normal or near-normal life expectancy without disability, and usually do not require major treatment interventions. Nevertheless, for those patients with HCM who are at risk for (or experience) disease-related complications, a constellation of comprehensive nonpharmacologic management strategies have evolved over the last 15 years, altering the natural history and disease course for many, including implantable defibrillators, heart transplant, external defibrillation/therapeutic hypothermia, advances in surgical myectomy, and alcohol ablation. In particular, expanded contemporary risk stratification strategies have led to a more reliable selection of patients likely to achieve primary prevention of sudden death with implantable defibrillators. Most recently, large cohort studies using current management strategies and therapeutic measures have shown that it is now possible to achieve significantly improved survival with a low HCM-related mortality of 0.5% per year across all ages, and including children and young adults characteristically with the most aggressive disease course. These clinical management initiatives, instituted by the practicing cardiology community, have succeeded in preserving life and restoring an active lifestyle for thousands of patients with HCM, while providing many with a measure of reassurance and a reasonable expectation for an extended (if not normal) life span.

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A contemporary European experience with surgical septal myectomy in hypertrophic cardiomyopathy

Cited by 93 publications

References 44 publications

Results of surgical septal myectomy for obstructive hypertrophic cardiomyopathy: the Tufts experience

Results of surgical septal myectomy for obstructive hypertrophic cardiomyopathy: the Tufts experience

Alcohol septal ablation: in which patients and why?

How Hypertrophic Cardiomyopathy Became a Contemporary Treatable Genetic Disease With Low Mortality

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