Mitral Valve Abnormalities in Hypertrophic Cardiomyopathy: Echocardiographic Features and Surgical Outcomes

Kaple, Ryan; Murphy, Ross T.; Dipaola, L.; Houghtaling, Penny L.; Lever, Harry M.; Lytle, Bruce W.; Blackstone, Eugene H.; Smedira, Nicholas G.

doi:10.1016/j.athoracsur.2008.01.061

Cited by 152 publications

(105 citation statements)

References 23 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…As there is a direct relation between volume of myectomies performed and surgical outcomes, optimal results cannot be expected from surgeons with a low-volume exposure to symptomatic patients with obstructive HCM (1,15,16). Therefore, the best results have been obtained by those few surgeons in the world with extensive myectomy experience and a small number of referral centers in North America and Europe (5,7,11,(17)(18)(19)(20). This represents an important obstacle to bringing septal myectomy to the HCM population.…”

Section: Surgical Septal Myectomymentioning

confidence: 99%

“…Patients with obstructive HCM often have mitral valve abnormalities, including papillary muscle displacement within the LV cavity, fibrotic and retracted secondary mitral valve chordae and markedly elongated mitral valve leaflets that can contribute to outflow obstruction (11,17,(31)(32)(33). In such patients, septal myectomy is often associated with mitral valve repair (7,11,32,34).…”

Section: Morphologic Complexity Of Hcmmentioning

confidence: 99%

See 1 more Smart Citation

Alcohol septal ablation: in which patients and why?

Spirito¹,

Rossi²,

Maron³

2017

Ann. Cardiothorac. Surg.

View full text Add to dashboard Cite

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...

show abstract

Section: Surgical Septal Myectomymentioning

confidence: 99%

Section: Morphologic Complexity Of Hcmmentioning

confidence: 99%

Alcohol septal ablation: in which patients and why?

Spirito¹,

Rossi²,

Maron³

2017

Ann. Cardiothorac. Surg.

View full text Add to dashboard Cite

show abstract

“…[1][2][3] In this case, echocardiography and direct inspection during the resumed CPB did not reveal an intrinsic abnormality or iatrogenic injury subsequent to myectomy in the MV, for which surgical intervention needed to be considered: e.g., calcification of the mitral annulus restricting leaflet motion, degenerative or myxomatous changes, prolapsed leaflet, or ruptured chordae. 8,9,12,19) The size and shape of the resected AML seemed normal and a microscopic examination revealed only mild fibroelastic changes. The shrunk posterior mitral leaflet, which can lead to decreased mobility and an interleaflet gap that promotes MR, 12) might have contributed to the pathology, but this change was only slight.…”

Section: Discussionmentioning

confidence: 96%

A Surgical Experience of Symptomatic Sigmoid Septum: Drastic Exacerbation of Mitral Regurgitation after Sufficient Ventricular Septal Myectomy

Fujita¹,

Nakashima²,

Kumakura³

et al. 2014

ATCS

View full text Add to dashboard Cite

A 74-year-old woman presented with progressive dyspnea on exertion. Transthoracic echocardiography (TTE) demonstrated significant left ventricular outflow tract (LVOT) obstruction with a pressure gradient of 100 mmHg caused by a sigmoid septum (SS). Mitral regurgitation (MR) of a mild to moderate degree occurred due to systolic anterior motion (SAM) of the anterior mitral leaflet (AML), with no intrinsic mitral valve (MV) abnormality. Myectomy of the hypertrophied septal bulge ameliorated the pressure gradient to 8 mmHg with similar MR. However, just before the sternal closure, hemodynamic status deteriorated drastically to ventricular fibrillation. MR exacerbated to a severe degree with an uncertain etiology; thus, a mechanical prosthetic valve was implanted. The postoperative course was complicated by prolonged mechanical ventilation due to massive pulmonary edema and complete atrioventricular block (CAVB) requiring permanent pacemaker implantation. One year postoperatively, the patient is asymptomatic and TTE revealed no residual pressure gradient with an iatrogenic ventricular septal defect (VSD). This case, the first published surgical experience of SS, may indicate that secondary MR, which is usually relieved by sufficient myectomy in hypertrophic cardiomyopathy (HCM), can exacerbate markedly, and that myectomy might not be advisable in SS. The therapeutic strategy must be considered carefully before embarking on surgical intervention.

show abstract

“…Recent use of three-dimensional echocardiography and magnetic resonance imaging (MRI) has identified HOCM patients with subtle findings of elongated mitral valves and displaced papillary muscles (12)(13)(14)(15)(16)(17); however, guidelines as to when to intervene on the mitral-subvalvular apparatus in conjunction with LVOT obstruction in the setting of HOCM remains unclear and largely dictated by individual center practices. Some centres advocate performing additional mitral procedures in patients with a basal septum less than 1.8 cm (4).…”

Section: Discussionmentioning

confidence: 99%

Isolated septal myectomy for hypertrophic obstructive cardiomyopathy: an update on the Toronto General Hospital experience

Vanderlaan

Woo

Ralph-Edwards

2017

Ann. Cardiothorac. Surg.

View full text Add to dashboard Cite

Background: Isolated septal myectomy is considered the gold standard for refractory left ventricular outflow tract (LVOT) obstruction at centers with dedicated hypertrophic obstructive cardiomyopathy (HOCM) surgeons. In this paper, we provide an update on the Toronto General Hospital (TGH) experience for isolated septal myectomy and comment on the safety and efficacy of myectomy in patients with thin basal septal thickness at our institution. Methods:We retrospectively reviewed all patients undergoing surgical myectomy at our institution from January 2012 to August 2016. We analyzed patient characteristics, intraoperative variables, pre-and postprocedural echocardiographic parameters, and key outcomes including post-operative stroke, renal failure, iatrogenic ventricular septal defect (VSD), post-procedure insertion of permanent pacemaker, and mortality.Results: At our institution, 150 isolated septal myectomy surgeries were performed over the study period.Preoperative echocardiography demonstrated an average basal septal thickness of 2.10±0.43 cm with a resting gradient of 67±37 mmHg and a provoked gradient of 89±40 mmHg. Fifty percent of patients had significant systolic anterior motion (SAM) of their mitral valve and 53% had associated moderate to severe mitral regurgitation (MR). Of note, 24% of patients had a thin septum of ≤1.7 cm. Discharge echocardiograms demonstrated significant septal reduction to an average basal septal thickness of 1.04±0.26 (P<0.05), with negligible resting and provokable LVOT gradients. At the time of discharge, none of the patients had significant SAM and only 5.3% of patients had residual greater than mild MR. Patients undergoing isolated myectomy with a thin basal septum had similar outcomes to those with a >1.7 cm septal thickness. In our contemporary cohort, there were no iatrogenic VSDs, 5.3% of patients required a permanent pacemaker and there was one early death.Conclusions: Our cohort demonstrates that isolated septal myectomy remains a safe and effective operation that can achieve excellent results, irrespective of basal septal thickness, when done by experienced surgeons in a dedicated hypertrophic cardiomyopathy (HCM) center.

show abstract

Mitral Valve Abnormalities in Hypertrophic Cardiomyopathy: Echocardiographic Features and Surgical Outcomes

Cited by 152 publications

References 23 publications

Alcohol septal ablation: in which patients and why?

Alcohol septal ablation: in which patients and why?

A Surgical Experience of Symptomatic Sigmoid Septum: Drastic Exacerbation of Mitral Regurgitation after Sufficient Ventricular Septal Myectomy

Isolated septal myectomy for hypertrophic obstructive cardiomyopathy: an update on the Toronto General Hospital experience

Contact Info

Product

Resources

About