Mitral regurgitation in hypertrophic obstructive cardiomyopathy: relationship to obstruction and relief with myectomy

Yu, Eric; Omran, Ahmed; Wigle, E. Douglas; Williams, William G.; Siu, Samuel C.; Rakowski, Harry

doi:10.1016/s0735-1097(00)01019-6

Cited by 190 publications

(127 citation statements)

References 41 publications

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“…Such MR, however, is usually associated with an intrinsically normal mitral valve and the severity of the MR is directly related to the LVOT gradient (1). The association of MVP, with or without chordal rupture, has been reported to complicate HCM (1)(2)(3)(4)(5).…”

Section: Discussionmentioning

confidence: 99%

“…The authors suggested that the association of MVP and HCM "may reflect the coexistence of two separate but primary disease entities." Yu et al (3), from the Toronto General Hospital (Toronto, Ontario), reviewed their operative experience with HOCM and reported that 11 of 104 patients (11%) had independent mitral valve disease. Of these, five had more than moderate MVP and one patient had ruptured chordae.…”

Section: Discussionmentioning

confidence: 99%

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Hypertrophic obstructive cardiomyopathy complicated by ruptured chordae tendinea to the posterior mitral leaflet and severe congestive heart failure

Morris

Ibrahim

2009

Canadian Journal of Cardiology

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H ypertrophic obstructive cardiomyopathy (HOCM) is frequently associated with mitral valve regurgitation (MR). In most instances, the latter is related to functional left ventricular outflow tract (LVOT) obstruction rather than intrinsic disorders of the mitral valve. The latter, however, need to be considered in presentations that are inconsistent with the rather stable natural history of HOCM. Mitral valve prolapse (MVP), with or without chordal rupture, can complicate HOCM by adding to the burden of MR and thereby aggravating and/or precipitating congestive heart failure. CASE PrESEntAtionA 63-year-old woman presented to the emergency department because of progressive, painless shortness of breath. She had suffered from fatigue for the past two weeks, shortness of breath on a home treadmill for three days, and dyspnea at rest for one day. Previous dyspnea, chest discomfort, ischemic heart disease, palpitations, presyncope or syncope were denied. She was hypertensive and had had 'asthma' for approximately 10 years. Three years before admission, a transthoracic echocardiogram revealed symmetrical left ventricular hypertrophy with hyperdynamic left ventricular systolic function and systolic anterior motion (SAM) of the mitral valve. Eccentric MR of uncertain severity was presumed to be secondary to HOCM.The patient was taking 2.5 mg of ramipril, 25 mg of hydrochlorothiazide and 240 mg of diltiazem daily.She was short of breath at rest. Her blood pressure was 162/79 mmHg and her pulse was 123 beats/min and regular. Her respiratory rate was 30 breaths/min. A grade 4/6 systolic crescendo-decrescendo murmur was noted. The jugular venous pressure was normal. The chest was clear. There was no edema.The electrocardiogram revealed sinus tachycardia at 114 beats/min, borderline left atrial abnormality and voltage criteria for left ventricular hypertrophy. The chest x-ray revealed congestive heart failure with bilateral pleural effusions. The laboratory data were unremarkable.The patient was admitted and treated with oxygen and diuretics. Her dyspnea and tachycardia persisted. Low-dose metoprolol was added but shortness of breath continued. Her clinical response was believed to be inconsistent with hypertrophic cardiomyopathy (HCM) alone. An urgent transthoracic echocardiogram revealed MR with probable prolapse of the posterior leaflet of the mitral valve. There was marked SAM of the mitral valve with a peak instantaneous LVOT gradient of 148 mmHg. A transesophageal echocardiogram examination revealed asymmetrical septal hypertrophy (septal thickness 17 mm), SAM of the mitral valve, ruptured chordae to the posterior leaflet of the mitral valve and severe MR. There was no evidence of bacterial endocarditis.The coronary angiogram was normal. Surgery revealed ruptured chordae to the P2 segment of the posterior leaflet, with mild thickening of the anterior leaflet. The mitral valve was replaced using a St Jude's prosthesis (#29; St Jude Medical Inc, USA). A septal myomectomy was not performed. The intraoperative LVOT gradient...

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Hypertrophic obstructive cardiomyopathy complicated by ruptured chordae tendinea to the posterior mitral leaflet and severe congestive heart failure

Morris

Ibrahim

2009

Canadian Journal of Cardiology

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“…A study showed that after septal myectomy, all of the patients experienced a significant reduction in MR degree: no MR in 80%, mild in 19%, moderate in 1%. 142 The main complications were atrioventricular nodal block, ventricular septal defect and aortic regurgitation. 137 This method is now associated with a less than 1% mortality risk 143 , including a decrease in the LVOT gradient from 78 mmHg to 11 mmHg and an improvement in 98% of the patients concerning the NYHA class (I, II).…”

Section: Septal Myectomymentioning

confidence: 99%

The mechanisms, diagnosis and management of mitral regurgitation in mitral valve prolapse and hypertrophic cardiomyopathy

Popa

Irimia

Papagheorghe

et al. 2016

Discoveries (Craiova)

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“…Left ventricular outflow tract (LVOT) obstruction is an important complication of hypertrophic cardiomyopathy, related to symptoms, functional limitations, and prognoses of the patients [1][2][3], and various types of medical and surgical interventions are performed to reduce the pressure gradient in LVOT [4][5][6][7][8][9][10][11][12][13][14][15]. The degree of dynamic obstruction seen in patients with hypertrophic obstructive cardiomyopathy (HOCM) can vary markedly by the physiological changes in preload, contractility, and afterload [16][17][18].…”

Section: Introductionmentioning

confidence: 99%

Usefulness of Left Parasternal Approach for the Continuous-Wave Doppler Measurement of Left Ventricular Outflow Tract Pressure Gradient in Patients With Hypertrophic Cardiomyopathy

et al. 2005

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Background. The apical approach (ApA) has been usually employed for the continuous-wave Doppler (CWD) measurement of pressure gradient in the left ventricular outflow tract (LVOT) in patients with hypertrophic obstructive cardiomyopathy (HOCM). This study aimed to assess the usefulness of a left parasternal approach (LPA) using the most cranial part of the echo-window for the measurement of the LVOT pressure gradient.Methods. CWD using LPA and ApA was performed in 19 patients with HOCM to measure LVOT peak pressure gradients (PGLPA and PGApA, respectively) and record a signal of mitral regurgitation (MR). The beam incident angles to LVOT flow in LPA ( LPA) and in ApA ( ApA) were measured using color Doppler flow imaging.Results. PGLPA was distinctly greater (>= 10mmHg) than PGApA in 7 patients (37%); they were similar in 6 (32%); and PGLPA was distinctly smaller (<= -10mmHg) than PGApA in 6 (32%). All patients had MR. While all the MR jets in ApA shifted away from the probe, i.e. to the same side of the LVOT flow, 18 of the 19 MR jets shifted to the opposite side of the LVOT flow, when using LPA. Cos LPA was significantly smaller and Cos ApA was significantly greater in the HOCM patients than 10 control subjects (p<0.001 for both). Both PGLPA and PGApA correlated with the invasive pressure gradient (r=0.99 and r=0.97) in 7 patients who underwent invasive study. PGLPA was closer to the invasive pressure gradient than PGApA in 6 patients.Conclusions. LPA provided a more accurate measurement of pressure gradient than ApA in about one third of HOCM patients, probably due to the altered direction of LVOT flow in HOCM. LPA is also useful in distinguishing LVOT flow from MR jet commonly seen in these patients. (J Echocardiogr 2005; 3: 140-147)

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Mitral regurgitation in hypertrophic obstructive cardiomyopathy: relationship to obstruction and relief with myectomy

Abstract: For patients with HOCM and MR not due to independent mitral valve disease, myectomy significantly reduced the degree of MR, without requirement for additional mitral valve surgery. In these patients the severity of MR was directly related to the magnitude of the LVOT gradient.

Cited by 190 publications

References 41 publications

Hypertrophic obstructive cardiomyopathy complicated by ruptured chordae tendinea to the posterior mitral leaflet and severe congestive heart failure

Hypertrophic obstructive cardiomyopathy complicated by ruptured chordae tendinea to the posterior mitral leaflet and severe congestive heart failure

The mechanisms, diagnosis and management of mitral regurgitation in mitral valve prolapse and hypertrophic cardiomyopathy

Usefulness of Left Parasternal Approach for the Continuous-Wave Doppler Measurement of Left Ventricular Outflow Tract Pressure Gradient in Patients With Hypertrophic Cardiomyopathy

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