Hospital Volume Outcomes After Septal Myectomy and Alcohol Septal Ablation for Treatment of Obstructive Hypertrophic Cardiomyopathy

Kim, Luke K.; Swaminathan, Rajesh V.; Looser, Patrick; Minutello, Robert M.; Wong, S. Chiu; Bergman, Geoffrey; Naidu, Srihari S.; Gade, Christina; Charitakis, Konstantinos; Singh, Harsimran; Feldman, Dmitriy N.

doi:10.1001/jamacardio.2016.0252

Cited by 240 publications

(139 citation statements)

References 37 publications

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“…Evolution of the Tufts program addresses an unmet need in the contemporary management of this disease by partially closing the disparity between the number of obstructive HCM patients deserving of myectomy and the available number of surgeons experienced with this operation. This issue has been highly visible recently, given recognition that myectomy mortality rates in the practicing community outside of HCM centers can be as high as 6% (34,35), triggering a call for more cardiac surgeons to gain experience specifically with this operation and become available to the HCM patient population in high volume settings (35).…”

Section: Discussionmentioning

confidence: 99%

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: 99%

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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“…Widening of the LVOT with these interventions reduces LVOT pressure gradients with low procedural mortality and morbidity, particularly with contemporary surgical techniques at high-volume centers [31]. Non-randomized, retrospective studies suggest that many patients have improved symptoms and functional capacity as well as a potential improvement in long-term mortality [9,32].…”

Section: Discussionmentioning

confidence: 99%

A Small Molecule Inhibitor of Sarcomere Contractility Acutely Relieves Left Ventricular Outflow Tract Obstruction in Feline Hypertrophic Cardiomyopathy

Stern¹,

Markova²,

Ueda³

et al. 2016

PLoS ONE

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Hypertrophic cardiomyopathy (HCM) is an inherited disease of the heart muscle characterized by otherwise unexplained thickening of the left ventricle. Left ventricular outflow tract (LVOT) obstruction is present in approximately two-thirds of patients and substantially increases the risk of disease complications. Invasive treatment with septal myectomy or alcohol septal ablation can improve symptoms and functional status, but currently available drugs for reducing obstruction have pleiotropic effects and variable therapeutic responses. New medical treatments with more targeted pharmacology are needed, but the lack of preclinical animal models for HCM with LVOT obstruction has limited their development. HCM is a common cause of heart failure in cats, and a subset exhibit systolic anterior motion of the mitral valve leading to LVOT obstruction. MYK-461 is a recently-described, mechanistically novel small molecule that acts at the sarcomere to specifically inhibit contractility that has been proposed as a treatment for HCM. Here, we use MYK-461 to test whether direct reduction in contractility is sufficient to relieve LVOT obstruction in feline HCM. We evaluated mixed-breed cats in a research colony derived from a Maine Coon/mixed-breed founder with naturally-occurring HCM. By echocardiography, we identified five cats that developed systolic anterior motion of the mitral valve and LVOT obstruction both at rest and under anesthesia when provoked with an adrenergic agonist. An IV MYK-461 infusion and echocardiography protocol was developed to serially assess contractility and LVOT gradient at multiple MYK-461 concentrations. Treatment with MYK-461 reduced contractility, eliminated systolic anterior motion of the mitral valve and relieved LVOT pressure gradients in an exposure-dependent manner. Our findings provide proof of principle that acute reduction in contractility with MYK-461 is sufficient to relieve LVOT obstruction. Further, these studies suggest that feline HCM will be a valuable translational model for the study of disease pathology, particularly LVOT obstruction.

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“…This could be due to the lack of familiarity and experience with the operation and the reported very high mortality of the operation reported by centers performing small numbers per year (22). The early results of the operation performed in experienced centers are excellent references.…”

Section: Surgical Resultsmentioning

confidence: 99%

Current state of the art and future of myectomy

Yacoub¹,

Afifi²,

Saad³

et al. 2017

ASVIDE

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Surgical relief of left ventricular outflow tract obstruction (LVOTO) in hypertrophic cardiomyopathy (HCM) requires more than septal myectomy. The procedure is currently the gold standard for all symptomatic HCM patients except those with comorbidities. The operation requires an individualized approach to restore the sophisticated functions of the left ventricular outflow tract (LVOT) without injury to the surrounding vital structures. The procedure should be tailored to deal with all the varied components of the obstruction including fibrous trigones, accessory tissues, and papillary muscle fusion. Preoperative multimodality imaging and numerical modeling combined with intraoperative transesophageal echocardiography (TEE) are essential to define existing anomalies as well as assess the adequacy of the repair. The mitral valve can be conserved in virtually all patients. The operation can be conducted with very low mortality and morbidity with predictable good outcomes both in the short and long term. Nevertheless, surgical relief of LVOTO is still grossly underused.

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Hospital Volume Outcomes After Septal Myectomy and Alcohol Septal Ablation for Treatment of Obstructive Hypertrophic Cardiomyopathy

Cited by 240 publications

References 37 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

A Small Molecule Inhibitor of Sarcomere Contractility Acutely Relieves Left Ventricular Outflow Tract Obstruction in Feline Hypertrophic Cardiomyopathy

Current state of the art and future of myectomy

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