Role of Mitral Valve Plication in the Surgical Management of Hypertrophic Cardiomyopathy

Balaram, Sandhya K.; Ross, Ruth; Sherrid, Mark V.; Schwartz, Gary S.; Hillel, Zak; Winson, Glenda; Swistel, Daniel G.

doi:10.1016/j.athoracsur.2012.06.008

Cited by 105 publications

(74 citation statements)

References 20 publications

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“…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%

“…A number of novel valve repair techniques have been developed that reduce the contribution of the mitral valve apparatus to outflow obstruction. Such techniques include mobilization of the papillary muscles, secondary anterior leaflet chordal cutting, and extension or plication of the anterior mitral leaflet (11,18,19). Of note, septal myocardial infarction caused by alcohol cannot abolish the outflow gradient in HCM patients where abnormalities of the mitral valve apparatus play a major role in LV outflow obstruction and in many instances, mitral valve abnormalities would exclude alcohol ablation as a viable treatment option.…”

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.

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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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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.

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show abstract

“…Current national and international practice still commonly involves concomitant mitral valve intervention to manage MR associated with HCM (58)(59)(60)(61)(62). However, in our experience, a mitral valve procedure is generally the exception rather than the norm in HCM.…”

Section: Management Of Associated Mitral Regurgitationmentioning

confidence: 69%

Surgical treatment for hypertrophic cardiomyopathy: a historical perspective

Hang¹,

Nguyen²,

Schaff³

2017

ASVIDE

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Our understanding of hypertrophic cardiomyopathy (HCM) as a disease entity has increased dramatically over the last half century. There has been a concerted effort by several surgical groups to develop operative techniques to relieve left ventricular outflow tract (LVOT) obstruction and alleviate symptoms. This paper traces the development of transaortic septal myectomy, the current gold standard therapy for relief of LVOT obstruction, in symptomatic patients refractory to medical treatment. In addition, we introduce newer methods for myectomy that have expanded the role of surgery in patients with various forms of HCM.

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“…An additional potential advantage of the surgical myectomy approach is the opportunity to repair mitral valve abnormalities. Indeed, greatly elongated mitral leaflets are not an uncommon component of obstructive HCM morphology, [29][30][31][32][33] and there may be concern that, despite an adequate myectomy, the enlarged mitral valve may create septal contact. Differences of opinion are evident among operating surgeons about the potential importance of the mitral valve in residual LV outflow tract obstruction.…”

Section: 2327mentioning

confidence: 99%