Transmitral Septal Myectomy and Mitral Valve Surgery via Right Mini-Thoracotomy

Abstract

Background Transmitral myectomy for symptomatic hypertrophic obstructive cardiomyopathy is possible with existence of substantial mitral valve disease. We present herein our experience of minimally invasive transmitral septal myectomy combined with mitral valve surgery through right anterior mini-thoracotomy in the past 4 years at our institution. Methods Between March 2017 and October 2020, 14 patients with hypertrophic obstructive cardiomyopathy and mitral valve disease required minimally invasive transmitral septal myectomy combined with mitral valve reconstruction or replacement at our institution. Mean age of patients was 54.2 ± 11.4 and 42.9% (n = 6) were female. Twelve patients (85.1%) were in New York Heart Association class III to IV and 6 patients (42.9%) presented with persistent atrial fibrillation. Clinical data were prospectively entered into our institutional database. Results Cardiopulmonary bypass time accounted for 140.2 ± 32.6 minutes and the myocardial ischemic time was 78.5 ± 12.4 minutes. Thirty-day mortality and overall mortality were zero. Peak ventricular outflow gradient decreased from 75.2 ± 12.7 to 9.4 ± 2.3 mm Hg (p < 0.0001). Simultaneously, mitral valve reconstruction and replacement were performed in 11 (78.6%) and 3 (21.4%) patients, respectively. No systolic anterior motion was seen in patients with mitral valve repair. No conversion to full sternotomy and/or rethoracotomy was noted. During a mean follow-up period of 24 ± 13 months, no patient required reoperation, no recurrence mitral regurgitation, and left ventricular outflow tract obstruction. Conclusion Transmitral septal myectomy combined with mitral valve surgery through right anterior mini-thoracotomy can be performed safely with excellent surgical outcomes.

Lessons learned from 10 years of experience with minimally invasive cardiac surgery

“…Considering their excellent long-term durability, simple, and efficacious MV repair is preferred over MV replacement in the treatment of degenerative MR in terms of superior early and late survival, improved reverse ventricular remodeling and ejection fraction (EF) recovery, and a better quality of life ( 15 , 16 ). MICS for MV repair provides excellent exposure of the MV and the sub-valvular apparatus, including the base of papillary muscles, allowing an optimal placement of sub-annular sutures for ring annuloplasty, leaflet resection, or augmentation, as well as uncomplicated implantation of the loops and polytetrafluorethylene neo-chords on the corresponding papillary muscle and MV leaflet when the loop technique is required ( 17 ).…”

“…Moreover, this technique allows the performance of concomitant procedures when cryomaze ablation, closure of a patent foramen oval, and/or left atrial appendage closure using AtriClip TM (AtriCure, Inc., Mason, OH, USA) are required. In this regard, concomitant trans-mitral septal myectomy and MV surgery via RAMT were enrolled in our experience in endoscopic MICS performing 14 cases safely with excellent surgical outcomes ( 17 ). Moreover, the endoscopic MICS approach for MV reoperation in selected high-risk patients seems to be safe and feasible ( 18 ).…”

Transmitral approach with endovideosurgical assistance in the surgery of obstructive hypertrophic cardiomyopathy from right-sided mini-thoracotomy

“…На сегодняшний день частота осложнений при минимально инвазивных подходах с эндовидеохирургической ассистенцией не превышает таковую для традиционной трансаортальной септальной миоэктомии [10,11].…”

Management of the mitral valve in thoracoscopic trans-mitral myectomy for hypertrophic obstructive cardiomyopathy

“… 14 , 15 With the detailed imaging evaluation of selected patients, TTM is worth promoting in centers with experience in thoracoscopic valve surgery; however, the transmitral approach has its own limitations. As in other studies of the transmitral approach, 14 , 16 here the mitral leaflet was sacrificed at the beginning of the operation, leading to a time-consuming procedure for MV after myectomy. Except in cases of MV anomalies and a large extent of hypertrophic myocardium, patients should be selected carefully to balance the prolonged surgical time and the convenience of radical myectomy.…”