Live/Real Time Three‐Dimensional Transesophageal Echocardiographic Assessment of Ventricular Septal Volume and Mass before and after Myectomy in Hypertrophic Cardiomyopathy

Abstract

Hypertrophic cardiomyopathy (HCM) is the most common genetically transmitted cardiomyopathy. In patients resistant to medical management, myectomy is the surgical procedure of choice to reduce the symptoms of left ventricular outflow obstruction. Two-dimensional transesophageal echocardiography (2DTEE) has become part of the operative procedure by decreasing the incidence of postoperative complications. However, because of the three-dimensional geometry of left ventricular outflow tract, it is unable to comprehensively assess the location and severity of the obstruction and to provide accurate guidance during myectomy. In this study, 10 patients with HCM underwent live/real time three-dimensional transesophageal echocardiography (3DTEE) intra-operatively to measure the volume of the resected septum. This volume correlated well with the volume of the resected septal muscle directly obtained using a graduating cylinder containing water (r = 0.9, P < 0.000). 3DTEE may be potentially used as an adjunct to guide the surgeon in performing an adequate myectomy with a lower incidence of residual obstruction and complications such as an iatrogenic ventricular septal defect.

Use of Theranostic Strategies in Myocardial Cavitation-Enabled Therapy

“…The strategy has been called “theranostic” ultrasound (Martin and Dayton, 2013), and represents a promising means of creating cavitation enabled therapies suitable for clinical application. The desired treatment volume for hypertrophic cardiomyopathy already can be identified and mapped for surgery using three dimensional ultrasound (Sadat et al 2013). The prospective theranostic method for MCET would simply add a high-power scan region set in the image to include the volume targeted for tissue reduction.…”

Echocardiographic advances in hypertrophic cardiomyopathy: Three‐dimensional and strain imaging echocardiography

“…Finally, 3D transesophageal echocardiography provides a useful aid to guide surgeons to determine septum geometry giving a useful support to identify site, extent, and depth for myectomy, during the procedure. 3DE can quantify the mass of resected septal optimizing the surgical results, and it is helpful in the postresection evaluation of LVOT patency …”

“…3DE can quantify the mass of resected septal optimizing the surgical results, and it is helpful in the postresection evaluation of LVOT patency. 20,21 An alternative to surgery is represented by alcohol septal ablation (ASA). In this context, real time 3D contrast echocardiography has emerged to guide ablation and increase the safety of the procedure.…”

Hypertrophic cardiomyopathy part II - Anesthetic and surgical considerations

“…The three-dimensional geometry of the LVOT can be comprehensively assessed for the location and severity of obstruction and can accurately guide myectomy. [51] Real-time 3D TEE shows excellent correlation with cardiac MRI for measurement of LV wall thickness, volume, and mass and ejection fraction and was found superior to 2D TEE. [52] Three-dimensional TEE is especially helpful in assessing the contribution of SAM and intrinsic mitral valve pathology in the genesis of LVOTO.…”

“…[53] Post repair 3D TEE is helpful in assessing the adequacy of mitral valve repair and relief of LVOTO. [51] SURGICAL PROCEDURES Septal myectomy (Morrow's procedure) [3] The resection is begun by making two parallel longitudinal incisions in the septum, the first beneath the nadir of the right coronary cusp and the second beneath the commissure between the right and the left coronary cusps. These incisions are connected superiorly with a third incision 1.0 cm below the aortic Mitral infl ow shows a restrictive infl ow pattern (E velocity, 140 cm/s).…”