Why we need more septal myectomy surgeons: An emerging recognition

Maron, Barry J.; Dearani, Joseph A.; Maron, Martin S.; Ommen, Steve R.; Rastegar, Hassan; Nishimura, Rick A.; Swistel, Daniel G.; Sherrid, Mark V.; Ralph-Edwards, Anthony; Rakowski, Harry; Smedira, Nicholas G.; Rowin, Ethan J.; Desai, Milind Y.; Lever, Harry M.; Spirito, Paolo; Ferrazzi, Paolo; Schaff, Hartzell V.

doi:10.1016/j.jtcvs.2016.12.038

Cited by 48 publications

(41 citation statements)

References 34 publications

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“…Through this initiative, the natural history of many HCM patients have benefited substantially, including the aspiration for successful relief of outflow obstruction, extended longevity and restored quality of life. This experience provides precedent for future efforts creating new HCM programs to expand the access to surgical myectomy for obstructive HCM patients in the United States and internationally (36,37).…”

Section: Limitationsmentioning

confidence: 91%

Results of surgical septal myectomy for obstructive hypertrophic cardiomyopathy: the Tufts experience

Rastegar

Boll

Rowin

et al. 2017

Ann. Cardiothorac. Surg.

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Background: For over 50 years, surgical septal myectomy has been the preferred treatment for drugrefractory heart failure symptoms in patients with obstructive hypertrophic cardiomyopathy (HCM). Over this time in the United States, the majority of myectomy operations have been performed in a small number of select referral centers. Methods:We have taken the opportunity to report results from the relatively new Tufts HCM Center and surgical program, incorporated 13 years ago, during which 507 myectomies (52±14 years of age; 56% male) were performed by one cardiothoracic surgeon, Dr. Hassan Rastegar.Results: Resting left ventricular (LV) outflow gradients were reduced from 56±42 mmHg preoperatively to 1.2±6.8 mmHg on most recent echocardiogram 2.0±2.5 years after surgery, and 94% of patients showed clinical improvement to NYHA functional class I or II. The first 200 myectomies were performed without mortality or major complications. Among all patients, 30-day mortality rate was 0.8%. Over follow-up of 3.2±2.8 years, 11 patients died (four due to HCM causes) with long-term survival after myectomy of 94% at 5 years (95% CI: 89-96%) and 91% at 10 years (95% CI: 84-95%), which did not differ from the age-and gender-matched general U.S. population (log-rank P=0.9).Conclusions: This experience demonstrates that, with the appropriate support, new HCM surgical programs can provide patients successful relief of outflow obstruction, extended longevity and restored of quality of life.

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Section: Limitationsmentioning

confidence: 91%

Results of surgical septal myectomy for obstructive hypertrophic cardiomyopathy: the Tufts experience

Rastegar

Boll

Rowin

et al. 2017

Ann. Cardiothorac. Surg.

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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%

“…This represents an important obstacle to bringing septal myectomy to the HCM population. While there is no easy solution to this problem, it is important to promote septal myectomy, encourage other cardiac surgeons to gain experience with this operation and to develop additional HCM referral centers that include surgical treatment (20). Furthermore, similar programs should be implemented in developing countries that (at present) cannot offer the option of surgical myectomy to patients with obstructive HCM.…”

Section: Surgical Septal Myectomymentioning

confidence: 99%

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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“…As a result, within a few years, most time‐honoured European surgical myectomy programmes were replaced by an extensive use of alcohol septal ablation . At present, only a few European surgical centres, mainly in Italy and the Netherlands, continue to perform high volumes of myectomy operations and are included amongst the best international referral centres for this highly specialized surgical procedure …”

mentioning

confidence: 99%

“…What can we do for those many European HCM candidates for invasive treatment of outflow obstruction who do not have access to septal myectomy? The answer can be found in a recent consensus commentary published in the Journal of Thoracic and Cardiovascular Surgery and co‐authored by seven surgeons (only one European) with extensive septal myectomy experience: ‘We need more septal myectomy surgeons.’ This, however, is not an easy objective to achieve. The learning curve for surgical myectomy can be long because the experience required for this operation is increased by the unusual surgical technique, which is based on a septal muscular resection through the limited visual field allowed by an aortotomy, and is often associated with mitral valve repair .…”

mentioning

confidence: 99%