Surgical Myectomy Remains the Primary Treatment Option for Severely Symptomatic Patients With Obstructive Hypertrophic Cardiomyopathy

Maron, Barry J.

doi:10.1161/circulationaha.107.691378

Cited by 157 publications

(124 citation statements)

References 96 publications

(61 reference statements)

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“…This procedure has been performed for about 50 years and continues to provide long-lasting and dramatic symptomatic improvement (2)(3)(4). For a heart surgeon practicing across the spectrum of surgical heart diseases, isolated septal myectomy may constitute the operation that offers the most rewarding change in quality of life and potentially restoring normal life span.…”

Section: Introductionmentioning

confidence: 99%

“…In the 5 to 7 years preceding 2007, there had been more ASA procedures (estimated >5,000) performed than myectomies in over 45 years (2). However, this incremental switch in practice has not been accompanied by the expected solid and long-term follow-up literature that one would expect in a procedure that started in 1995 (6).…”

Section: Introductionmentioning

confidence: 99%

“…It is important to acknowledge that ASA has been adopted regardless of the evidence that early outcomes are inferior to those of septal myectomy in an equally experienced operator's hands. In fact, it has been described that periprocedural mortality and morbidity are higher with ASA (2,4,(7)(8)(9).…”

Section: Introductionmentioning

confidence: 99%

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Septal myectomy after failed septal alcohol ablation

Bajona

Arguís

Prat‐González

2017

Ann. Cardiothorac. Surg.

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Despite septal myectomy remaining the gold standard septal reduction therapy for hypertrophic obstructive cardiomyopathy (HOCM), there has been a disproportionate use of alcohol septal ablation (ASA) worldwide.Absolute resolution of left ventricular outflow tract (LVOT) obstruction with ASA is not achieved in a substantial proportion of patients. The mechanisms of failure from ASA are partially understood and described. Residual obstruction in hypertrophic cardiomyopathy is associated with worse clinical outcomes and mortality. There is a growing number of patients who present with significant residual gradients after ASA and require a rescue septal myectomy operation, which then carries an increased risk of perioperative complications and life-long sequelae. This contrasts with the excellent outcomes achieved by septal myectomy without previous percutaneous intervention. Despite complete resolution of obstruction in rescue myectomy, the outcomes remain compromised by the prior ASA.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Septal myectomy after failed septal alcohol ablation

Bajona

Arguís

Prat‐González

2017

Ann. Cardiothorac. Surg.

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“…After this period, the patients showed good survival (87.9%) and with excellent quality of life with improvement of the functional class (from 3.1 to 1.4) and myocardial remodeling represented by the further reduction of the gradient in the left ventricular outflow tract (19.2 mmHg) lately evaluated in relation to the reduction initially assessed (27.8 mmHg). Groups with extensive experience in surgical treatment of HOCM also mention excellent survival rate (95% in 10 years), suggesting that myectomy may offer the opportunity for a normal life, being equivalent to the general population and higher than the population with hypertrophic obstructive cardiomyopathy not operated on [12,13,23,24].…”

Section: Discussionmentioning

confidence: 97%

“…The difficulty to visualize the anatomy below the aortic valve can lead to injuries in the aortic valve itself, in the mitral valve, perforation of the left ventricular free wall, interventricular communication, complete atrioventricular block, or septal myocardial insufficient resection compromising both the initial and long-term results [22]. More recently, following the example of most experienced groups [12,13,[23][24][25][26], we have gone ahead with myectomy up to the base of the papillary muscles (extended myectomy), and we have used as a routine, the intraoperative transesophageal echocardiography [15]. It is recommended that the return to cardiopulmonary bypass for expansion of septal myectomy should always be performed when the intraoperative residual gradient of the left ventricular outflow tract exceeds 20 mm Hg [22,23].…”

Section: Discussionmentioning

confidence: 99%

Resultados a longo prazo da miectomia septal no tratamento da cardiomiopatia hipertrófica

Lisboa¹,

Dallan²,

Pomerantzeff³

et al. 2011

Rev Bras Cir Cardiovasc

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Hypertrophic Cardiomyopathy—One Case per Year?

Ommen

Nishimura

2016

JAMA Cardiol

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Hypertrophic cardiomyopathy (HCM) has fascinated (and scared) cardiologists for years owing, in part, to the relatively few cases most physicians will see in their practice, coupled with increased risk for sudden death, complex yet incomplete genetic understanding, and enigmatic hemodynamics. The management of symptomatic patients with HCM evolved over the past (nearly) 6 decades owing to focused efforts to understand the pathophysiology and perfect the necessary skills to delivery exemplary outcomes. 1 We have learned that it is entirely possible for patients with HCM to have excellent quality of life and normal lifespans, that most patients can be treated with pharmacologic therapy, and that for most patients who remain symptomatic, there are procedures that can deliver excellent benefit with low risk.The article by Kim et al 2 using a national discharge database sampling method examines observed event rates among patients undergoing surgical septal myectomy or percutaneous septal ablation. Some of the findings are not surprising: there is a clear association between procedural volume and complications and there are differences in baseline characteristics between patients undergoing the 2 procedures. There are some shocking results: the median number of myectomy cases or ablation cases in this database is less than or equal to 1 case per year. Seriously, only 1 case per year? Why would we subject our patients to this?There is some critical information missing as an artifact of the study design: specifically, there are no effectiveness data and thus, a comparison cannot be made between the results of surgical septal myectomy vs septal ablation. More importantly, there is no description of what can be expected if the procedures were performed not just at higher volume centers, but at Centers of Excellence.The study of Kim et al 2 in this issue of JAMA Cardiology does go a long way to making an excellent case for having a few highly focused centers that specialize in the care of patients with HCM. The results achievable at major HCM centers are remarkable. In expert hands, surgical myectomy has a greater than 95% efficacy, with mortality rates that are approaching 0% (ie, thousands of cases performed without an operative death), normalization of long-term survival following the procedure, and a reduction in sudden cardiac death. [3][4][5] Similarly, among those patients who respond to septal ablation, the symptomatic improvement can mirror that of myectomy, with a procedural mortality rate that is only about 1%. 6 Given that there are recognizable differences in complication rates and controversy regarding the association between septal ablation and subsequent sudden cardiac death/ Editor's Note page 334

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Surgical Myectomy Remains the Primary Treatment Option for Severely Symptomatic Patients With Obstructive Hypertrophic Cardiomyopathy

Cited by 157 publications

References 96 publications

Septal myectomy after failed septal alcohol ablation

Septal myectomy after failed septal alcohol ablation

Resultados a longo prazo da miectomia septal no tratamento da cardiomiopatia hipertrófica

Hypertrophic Cardiomyopathy—One Case per Year?

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