Transapical approach under 3D printing guidance for myectomy in apical hypertrophic cardiomyopathy: A case report / 中国胸心血管外科临床杂志

@#We reported a 26-year-old male who was diagnosed with apical hypertrophic cardiomyopathy with left ventricular aneurysm. The location of the hypertrophic myocardium and the extent of resection were accurately assessed preoperatively using 3D modeling and printing technology. Myectomy was performed via transapical approach, and the intraoperative exploration was consistent with the description of the preoperative 3D modeling. The patient underwent the surgery successfully without any complications during the hospitalization, and the cardiopulmonary bypass time was 117 min, the aortic cross-clamping time was 57 min, and the hospital stay time was 7 d. The postoperative echocardiography demonstrated left ventricular cavity flow patency. This case provides a reference for the management of patients with apical hypertrophic cardiomyopathy.

Totally endoscopic transmitral septal myectomy for the treatment of recurrent left ventricular outflow tract obstruction after alcohol septal ablation / 中国胸心血管外科临床杂志

@#Objective    To investigate the surgical strategies and clinical efficacy of transmitral septal myectomy in the treatment of recurrent left ventricular outflow tract obstruction (LVOTO) after alcohol septal ablation. Methods    The clinical data of patients with recurrent LVOTO after alcohol septal ablation from July 2020 to July 2021 in the Department of Cardiac Surgery, Guangdong Provincial People's Hospital were retrospectively analyzed. Patients were preoperatively evaluated by echocardiography, cardiac magnetic resonance imaging, cardiac computed tomography, 3D modeling and printing technology. A personalized surgical strategy was preoperatively developed according to multimodality imaging assessment, while visual exploration was performed on the digital model and simulated surgical resection was performed on the printed model. Results     Two female patients were enrolled, aged 62 years and 64 years, respectively. Totally endoscopic transmitral extended myectomy was successfully performed on both patients with aortic cross-clamping time of 96 min and 85 min, respectively. LVOTO was relieved immediately (subaortic peak pressure gradient decreased from 100 mm Hg to 4 mm Hg and from 84 mm Hg to 6 mm Hg, respectively) and the mitral regurgitation significantly improved after the procedure. No patient had complete atrioventricular block or required permanent pacemaker implantation. The patients were discharged uneventfully without postoperative complications. Conclusion    Personalized totally endoscopic transmitral extended myectomy combined with multimodality imaging assessment and 3D modeling and printing has an acceptable clinical effect in patients with recurrent LVOTO after alcohol septal ablation. The procedure can precisely resect the hypertrophic septal myocardium while avoiding serious complications such as septal perforation or complete atrioventricular block.

Ablação septal com cateteres e radiofrequência guiada pela ecocardiografia para tratamento de pacientes com cardiomiopatia hipertrófica obstrutiva: experiência inicial / Septal ablation with radiofrequency catheters guided by echocardiography for treatment of patients with obstructive hypertrophic cardiomyopathy: initial experience

BACKGROUND: Hypertrophic cardiomyopathy (HCM) can cause obstruction in the left ventricular outflow tract (LVOT), and be responsible for the onset of limiting symptoms, such as tiredness. When such symptoms are refractory to pharmacological treatment, interventionist alternative therapies can be useful, such as septal ablation through the infusion of alcohol in the coronary artery or through myectomy. Recently, the use of a radiofrequency (RF) catheter for endocardial septal ablation guided by electroanatomic mapping has proven to be efficient, despite the high incidence of complete atrioventricular block. An alternative would be the application of RF at the beginning point of the septal gradient guided by the transesophageal echocardiography (TEE). The echocardiography is an imaging method with high accuracy to determine septal anatomy. OBJECTIVE: To assess the long term effect of septal ablation for the relief of ventricular-arterial gradient, using TEE to help place the catheter in the area of larger septal obstruction. Besides, to assess the effects of ablation on the functional class and echocardiographic parameters. METHODS: Twelve asymptomatic patients, with LVOT obstruction, refractory to pharmacological therapy, underwent endocardial septal ablation with 8mm-tip catheters, whose placement was oriented in the region of larger obstruction, assisted by the TEE. Temperature-controlled and staggered RF applications were performed. After each application, the gradient was reassessed and a new application was performed according to the clinical criterion. The effects of RF applications were assessed both for the gradient at rest and for that provoked by the Valsalva maneuver, and considering the gradient. The differences were significant when p-value was lower than or equal to 0.05. RESULTS: It was possible to observe that the mean reduction of the maximum gradients was from 96.8±34.7 mmHg to 62.7±25.4 mmHg three months after the procedure (p=0.0036). After one year, the mean of maximum gradient was 36.1±23.8 mmHg (p=0.0001). The procedure was well tolerated, without records of complete atrioventricular block nor severe complications. CONCLUSION: The TEE-guided septal ablation was efficient and safe, and the results were maintained during the clinical follow-up period. It is a reasonable option for the interventionist treatment of LVOT obstruction in HCM.

FUNDAMENTOS: A cardiomiopatia hipertrófica (CMH) pode causar obstrução da via de saída do ventrículo esquerdo (VSVE) e ser responsável pelo surgimento de sintomas limitantes, como cansaço físico. Quando tais sintomas são refratários ao tratamento farmacológico, os tratamentos alternativos intervencionistas podem ser úteis, como a ablação septal por meio da infusão de álcool na artéria coronária ou por meio da miectomia cirúrgica. Recentemente, o uso de cateter de radiofrequência (RF) para ablação do septo endocárdico guiado por mapeamento eletroanatômico mostrou-se eficaz apesar da elevada incidência de bloqueio atrioventricular total. Uma alternativa seria a aplicação de radiofrequência no ponto de início do gradiente septal guiada pelo ecocardiograma transesofágico (ETE). O ecocardiograma é um método de imagem com elevada acurácia para determinação da anatomia septal. OBJETIVO: Avaliar o efeito em longo prazo da ablação septal para alívio do gradiente ventrículo-arterial, utilizando o ETE para auxiliar no posicionamento do cateter na área de maior obstrução septal. Avaliar também os efeitos da ablação na classe funcional e parâmetros ecocardiográficos. MÉTODOS: Doze pacientes sintomáticos com obstrução da VSVE, refratários à terapia farmacológica, foram submetidos à ablação endocárdica septal com cateteres com ponta de 8 mm, cujo posicionamento foi orientado na região de maior obstrução com auxílio do ETE. Foram realizadas aplicações de radiofrequência (RF) termocontrolada e escalonadas sobre a área alvo. Após cada aplicação, o gradiente era reavaliado e nova aplicação era realizada de acordo com critério clínico. Foram avaliados os efeitos das aplicações de RF tanto para o gradiente em repouso como para o provocado por meio da manobra de Valsalva, e considerado o gradiente. As diferenças foram significativas quando o valor de p foi menor ou igual a 0,05. RESULTADOS: Observou-se que a redução da média dos gradientes máximos obtidos foi de 96,8±34,7 mmHg para 62,7±25,4 mmHg ao final de três meses do procedimento (p=0,0036). Após um ano, a média dos gradientes máximos obtidos foi de 36,1±23,8 mmHg (p=0,0001). O procedimento foi bem tolerado e não houve registro de bloqueio atrioventricular total e nem complicações graves. CONCLUSÃO: A ablação septal guiada pelo ETE foi eficaz e segura, com resultados mantidos durante o período de seguimento clínico. É uma opção razoável para o tratamento intervencionista da obstrução da VSVE em CMH.

Early outcomes of combined transaortic and transapical approach to septal myectomy in patients with complex hypertrophic obstructive cardiomyopathy / 中华胸心血管外科杂志

Objective:To evaluate the early effects of combined transaortic and transapical approach to septal myectomy in patients with complex hypertrophic obstructive cardiomyopathy(HOCM).Methods:We consecutively enrolled 20 complex HOCM patients who received transaortic and transapical myectomy in fuwai hospital from January 2019 to October 2019. Echocardiography was performed to compare left atrial size, left ventricular end diastolic diameter, peak left ventricular outflow gradient, ventricular septal thickness, mitral systolic anterior motion and mitral regurgitation grade before and after operation. Furthermore, pre-operative and post-operative electrocardiogram were also analyzed to determine the incidence of bundle branch block. Functional status was evaluated by New York Heart Association functional class.Results:Of the 20 complex hypertrophic cardiomyopathy patients, 7(35%) HOCM patients with long-segment septal hypertrophy more than 7cm, 4(20%) patients had both mid-ventricular obstruction and left ventricular outflow obstruction. Apical hypertrophic cardiomyopathy with LOVT obstruction was observed in 5 patients(25%) and aneurysm was found in 4(20%) HOCM patients. Postoperative thickness of ventricular septum was significantly decreased compared with that of preoperation[(21.1±3.6)mm vs.(13.4±3.1)mm]. Peak LOVT gradient or mid-ventricular gradient also significantly reduced after operation[(77.0±21.0) mmHg vs.(9.2±3.4) mmHg] or [(71.0±23.0) mmHg vs. 0 mmHg, 1 mmHg=0.133 kPa]; After surgery, mitral systolic anterior motion disappeared, mitral regurgitation degree reduced from (1.9±1.5) to (0.2±0.4); NYHA class improved from(2.1±0.2) to(1.3±0.5). New incidence of left bundle branch block occurred in 9 patients, and 1 patient developed complete bundle branch block and implanted permanent pacemaker. The 30-day survival was 100%.Conclusion:Combined transaortic and transapical septal myectomy is an effective and reasonably safe procedure for patients with complex hypertrophic obstructive cardiomyopathy.

Hypertrophic obstructive cardiomyopathy and its outcome following surgical myectomy: a retrospective study

Background: Hypertrophic cardiomyopathy is highly heterogeneous with a diverse anatomy, pathophysiology, and clinical course. It is obstruction to left ventricular outflow that has become the major hallmark of the disease. Septal myectomy has been the gold standard treatment for the relief of left ventricular outflow tract obstruction and cardiac symptoms in both adults and children with obstructive hypertrophic cardiomyopathy. Objective of the study was to evaluate effect of Myomectomy and its impact on survival for a period of one year.Methods: The study design is a retrospective record based observational study. Data was retrieved from previous records both electronic as well as manual records of all the patients who underwent myectomy with or without concomitant procedures such as mitral valve replacement or aortic valve replacement or coronary artery bypass surgery during 2014 to 2018.Results: Majority of the patients 11 (52.4%) in fourth decade i.e. 40-59 years age group. majority were males i.e. 16 (76.2%) and remaining 5 i.e. 23.8% were females. Male to female ratio was 3.2:1. Dyspnoea was present 81% and chest pain in 76.2%. Preoperative LVOT gradient was 86.86±20.33 and post-operative gradient was 23.47±20.49.Conclusions: Operative techniques have evolved from simple myotomy to the present method of extended septal myectomy which can be done in all adult cases of hypertrophic obstructive cardiomyopathy.

Long-term outcome of patients with hypertrophic obstructive cardiomyopathy post percutaneous transluminal septal ablation / 中华心血管病杂志

Objective: To evaluate the long-term outcome of patients with hypertrophic obstructive cardiomyopathy(HOCM) after percutaneous transluminal septal ablation(PTSMA). Methods: HOCM patients who underwent PTSMA and surgical myectomy at the Chest Hospital of Shanghai Jiao Tong University from April 2001 to February 2019 were included in this retrospective analysis. Patients were divided into PTSMA group and surgical myectomy group. In addition, patients undergoing PTSMA were further divided into HOCM-PTSMA non-survivor group and HOCM-PTSMA survivor group. The general clinical information, procedural/surgical information and complications during hospitalization were compared between groups. Multivariate Cox regression model was used to analyze the independent risk factors for all-cause death in HOCM patients after PTSMA. Results: A total of 104 patients with HOCM who underwent PTSMA were enrolled. Mean age of the patients was (54±15) years old, including 41 females (38.7%). The follow-up time was 37.5(14.3, 76.8) months. At the last follow-up, 12 patients died (HOCM-PTSMA non-survivor group) and 92 were alive(HOCM-PTSMA survivor group). The proportion of patients with NYHA function class Ⅲ/Ⅳ was higher(P=0.036), and the posterior wall of the left ventricle was thicker(P=0.006) in the HOCM-PTSMA non-survivor group than in the HOCM-PTSMA survivor group. The immediate success rate of PTSMA in this cohort was 66%(70/104). The amount of absolute alcohol during the operation in the HOCM-PTSMA non-survivor group was (2.9±0.8) ml, which tended to be higher as compared to that in the HOCM-PTSMA survivor group((2.4±1.0)ml, P=0.056). Kaplan-Meier survival curve analysis showed that patients with HOCM who underwent PTSMA had an all-cause mortality-free survival rate of 90.1%, 78.3%, and 56.9% at 5, 10 and 15 years, and a HOCM-free survival rate of 91.3%, 79.4% and 57.7% at 5, 10 and 15 years, respectively. Multivariate Cox regression analysis showed that age≥ 65 years was an independent risk factor for all-cause death after PTSMA in patients with HOCM (HR=2.697, 95%CI 1.292-18.977, P=0.020). There were 32 patients in the surgical myectomy group. The proportion of patients with NYHA function class Ⅲ/Ⅳ was higher than that in the PTSMA group(P<0.001), while age, gender, and major comorbidities(atrial fibrillation, coronary heart disease, hypertension, and diabetes) as well as the left atrium dimension were all similar between the two groups(all P>0.05). Patients in the surgical myectomy group were followed up for 38.0(17.6, 64.2)months, and no deaths occurred during the follow-up period. Kaplan-Meier survival curve analysis showed that there were no statistically significant differences in all-cause-free and HOCM-free survival rates between patients in PTSMA group and surgical myectomy group(P=0.089 and 0.110, respectively). Conclusion: PTSMA is safe and effective for the treatment of patients with HOCM, and the long-term survival rate of patients after PTSMA is similar as patients undergoing classical surgical myectomy surgery.

Miocardiopatía hipertrófica: encare clínico y opciones de tratamiento / Hypertrophic cardiomyopathy: clinical approach and treatment options / Cardiomiopatia hipertrófica: abordagem clínica e opções de tratamento

Resumen: La miocardiopatía hipertrófica (MCH) constituye una enfermedad compleja y muy variable en cuanto a su presentación morfológica, fisiopatológica y sintomática, así como en su pronóstico. Su intrincado sustrato genético ha sido objeto de una permanente y productiva investigación en las últimas décadas. En correspondencia con esta complejidad, su manejo clínico representa un desafío, aun para los cardiólogos más experimentados. La presente controversia comienza con una valiosa actualización por parte del Dr. Walter Reyes sobre la valoración del riesgo individual de muerte súbita en el paciente portador de esta patología, sin duda el más temido evento que pueda presentarse durante su transcurso. En este abordaje se podrá apreciar la evolución de los conceptos, desde la aplicación de los clásicos factores de riesgo obtenidos de los primeros estudios en poblaciones más o menos seleccionadas, hasta las recomendaciones más recientes de la American Heart Association y la European Society of Cardiology, capitalizando la nueva información. Luego, como es habitual y dado el objetivo esencialmente práctico de esta sección, se propone una viñeta sobre un caso de MCH obstructiva en la que el autor aplica, a forma de ejercicio clínico, la información brindada en la revisión previa. A continuación se plantea la controversia propiamente dicha, donde el debate se centra en la elección de la técnica más apropiada de reducción septal en el caso propuesto, cuyas características apuntan a la necesidad de un abordaje invasivo. Dos prestigiosos invitados exponen sus argumentos en favor de cada alternativa. El Dr. Hartzell Shaff propone la miectomía septal quirúrgica como el procedimiento más adecuado, y el Dr. Pedro Trujillo plantea la ablación septal percutánea como solución de elección. El desarrollo de ambas exposiciones permitirá al lector apreciar la importancia de un enfoque individualizado, dada la riqueza de información clínica, anatomofuncional y propia de cada procedimiento que se requiere para inclinar la balanza en favor de uno u otro. Ambos autores coinciden en el beneficio de contar con un equipo especializado y experimentado para la obtención de buenos resultados con cualquiera de las técnicas.

Summary: Hypertrophic cardiomyopathy is a complex and highly variable disease in terms of morphological, pathophysiological and symptomatic presentation, as well as in its prognosis. Its intricate genetic substrate has been subject of permanent research in recent decades. Corresponding to this complexity, its clinical management represents a challenge, even for the most experienced cardiologists. The present controversy begins with a valuable update by Dr. Walter Reyes about assessment of individual risk of sudden death in the patient with this disease, without doubt the most feared event that may occur during its course. In this approach, evolution of concepts can be appreciated, from the application of the classic risk factors obtained from the first studies, to the most recent recommendations of the American Heart Association and the European Society of Cardiology. Since the practical objective of this section, a clinical case is proposed on an obstructive hypertrophic cardiomyopathy in which the author applies, as a clinical exercise, the information provided in the previous review. Next, the controversy itself arises, where the debate focuses on the choice of the most appropriate septal reduction technique. Two prestigious guests present their arguments in favour of each alternative. Prof. Hartzell Shaff proposes surgical septal myectomy as the most appropriate procedure, and Dr. Pedro Trujillo proposes percutaneous septal ablation as the solution of choice. The exposures will allow the reader to appreciate the importance of an individualized approach, given the amount of clinical, anatomic, functional and specific information of each procedure that is required to tip the balance in favour of one or the other. Both authors agree on the benefit of having a specialized and experienced team to obtain good results with any of the techniques.

Resumo: A cardiomiopatia hipertrófica é uma doença complexa e altamente variável em termos de apresentação morfológica, fisiopatológica e sintomática, bem como em seu prognóstico. Seu intrincado substrato genético tem sido objeto de pesquisa permanente nas últimas décadas. Correspondendo a essa complexidade, seu manejo clínico representa um desafio, mesmo para os cardiologistas mais experientes. A presente controvérsia começa com uma atualização valiosa do Dr. Walter Reyes sobre a avaliação do risco individual de morte súbita no paciente com esta doença, sem dúvida o evento mais temido que pode ocorrer durante seu curso. Nessa abordagem, a evolução dos conceitos pode ser apreciada, desde a aplicação dos fatores de risco clássicos obtidos nos primeiros estudos, até as recomendações mais recentes da American Heart Association e da European Society of Cardiology. Como o objetivo prático desta seção, é proposto um caso clínico em uma cardiomiopatia hipertrófica obstrutiva, no qual o autor aplica, como exercício clínico, as informações fornecidas na revisão anterior. Em seguida, surge a própria controvérsia, onde o debate se concentra na escolha da técnica de redução septal mais apropriada. Dois convidados de prestígio apresentam seus argumentos em favor de cada alternativa. O professor Hartzell Shaff propõe a miectomia septal cirúrgica como o procedimento mais apropriado e o Dr. Pedro Trujillo propõe a ablação septal percutânea como a solução de escolha. As exposições permitirão ao leitor apreciar a importância de uma abordagem individualizada, dada a quantidade de informações clínicas, anatômicas, funcionais e específicas de cada procedimento, necessárias para inclinar a balança em favor de uma ou de outra. Ambos os autores concordam com o benefício de ter uma equipe especializada e experiente para obter bons resultados com qualquer uma das técnicas.

Image-Based Simulative Training for Myectomy in Hypertrophic Cardiomyopathy: An Emerging Necessity

Surgical myectomy was initially advocated only for patients with symptoms refractory to maximal tolerated medical therapy. These were mainly symptoms of cardiac failure. In recent times, there has been a call for revision of guidelines to include patients earlier. As the disease progression cannot be reversed by most currently used drugs which become ineffective with time, this need for earlier myectomy seems mandatory. Presently, surgical expertise in myectomy is limited to specialized centers. The complexity of surgical myectomy is enhanced by the complex and variable anatomic substrate. With the need for earlier myectomy, a vast population of patients with hypertrophic cardiomyopathy will need surgery, predicating a requirement for more skilled cardiac surgeons. Mentoring programs in specialized centers may not be the solution, as is training surgeons using image-guided simulation techniques. Here, we discuss the existing simulative techniques and novel image-based preoperative planning techniques which may help guide myectomy.

Surgical treatment of severe aortic stenosis with septal hypertrophy / 中华胸心血管外科杂志

Objective To summarize the experience of surgical treatment of 18 cases of severe aortic stenosis with ventricular septum hypertrophy.Methods Clinical data of 18 patients with severe aortic stenosis admitted to the first affiliated hospital of zhengzhou university from January 2013 to December 2016 were collected.There were 7 males and 11 females.The mean age was (50.4 ±4.2) years old.All patients were diagnosed with severe stenosis of main artery valve by echocardiography before surgery,with mean aortic valve orifice area (0.57 ±0.11) cm2,cardiac function (NYHA classification) grade Ⅱ in 4 patients,grade Ⅲ in 9 patients,and grade ⅣV in 5 patients.There were 8 patients with mild aortic valve insufficiency,4 patients with mild to moderate mitral valve insufficiency,2 patients with moderate to severe aortic valve insufficiency,3 patients with ascending aorta dilatation (ascending aorta inner diameter ＞ 4.5 cm),and 1 patient with atrial fibrillation.Interventricular septum thickness (15.82 ± 2.04) mm,left ventricular posterior wall thickness (14.04 ± 1.28) mm,ratio of interventricular septum thickness to left ventricular posterior wall thickness (IVS/LVPW) 1.12 ±0.91,inner diameter of left ventricular outflow tract (19.01 ± 1.74) mm,cross-lobe differential pressure (102 ± 8.40) mmHg (1 mmHg =0.133 kPa),left ventricular ejection fraction (LVEF) mean 0.49 ± 0.05.Left ventricular end-diastolic diameter (LVEDD) (53.33 ± 4.00)mm,left ventricular end-systolic diameter (LVESD) (27.11 ± 1.99) mm,and left ventricular mass index (277.1 ± 37.3) g/m2.All patients underwent aortic valve replacement (AVR) and partial interventricular septum resection under general anesthesia and conventional extracorporeal circulation,2 patients underwent mitral valve formation (artificial valve ring),2 patients underwent ascending aorta formation,and 1 patient underwent ascending aorta wrapping.During the operation,the time of extracorporeal circulation,aortic occlusion,number of defibrillation during the operation,type of valve implantation and postoperative complications were recorded.Regular follow-up was conducted to analyze the changes of various indexes at different preoperative and postoperative time.Results There was no death in the whole group.2 patients were treated with temporary pacemakers.After drug treatment,sinus rhythm was restored on the 3rd and 6th day after surgery,and temporary pacemakers were removed.Echocardiography reexamination 1 week after the operation showed that all patients had a good artificial valve function and 2 patients had minor regurgitation of mitral valve.The difference in pressure across the valve,inner diameter of the left ventricular outflow tract,cardiac function classification,ventricular septum thickness,valve orifice area,and left ventricular mass index were significantly improved compared with the preoperative level (P ＜ 0.05).LVEF,LVEDD,and LVESD were compared with the preoperative level (P ＜ 0.05).After 6 months of follow-up,the difference in LVEF and LVEDD was statistically significant compared with the preoperative level (P ＜ 0.05).Conclusion Severe aortic stenosis combined with ventricular septum hypertrophy and partial ventricular septal muscle resection is a simple additional procedure in the AVR process,which does not increase the surgical risk and has a significant effect,and is conducive to postoperative left ventricular function recovery.

A single-center comparative study of alcohol septal ablation(SA) and surgery myectomy(SM) for refractory hyper-trophic obstructive cardiomyopathy( HOCM) / 中华胸心血管外科杂志

Objective Septal reduction therapies were recommended for drug-refractory patients with hypertrophic ob-structive cardiomyopathy(HOCM).To explore and compare the effectiveness and safety in patients with hypertrophic obstruc-tive cardiomyopathy(HOCM) treated with surgery myectomy(SM) and alcohol septal ablation(SA).Methods The clinical data of 260 patients performed SA(n=184) or SM(n=76)between September 2002 and September 2014 in our institute were retrospectively reviewed.The t-test, rank sum test and chi-square test were used to compare the differences between the two groups, and the Cox regression model was used for multivariate survival analysis.All-cause mortality, cardiac cause death(peri-operative death were included ) , heart function improvement , procedure-related complications and permanent pacemaker de-pendence( PPM) constituted the main contents of this study .Results Compared with patients treated with SM , patients un-dergone SA were poor heart function status(2.97 ±0.29 vs 2.50 ±0.56, P =0.01), more prevalence of atrial fibrillation( 15.14％ vs 6.80％, P=0.046) and longer follow-up period[(5.4 ±3.8) years vs(2.5 ±2.2) years, P =0.01)].All-cause mortality for SA and SM were 3.3％ and 14.5％ respectively(P=0.001).The fatal cardiac events of SA and SM were 1.63％ and 13.16％ respectively(P<0.001).Sudden cardiac arrest were the main cardiac cause death for both patients trea-ted with SA and SM.The cardiac death of left ventricular systolic dysfunction was main found in patients treated with SM . Heart function improvement(NYHA) after SA and SM were 1.23 ±0.61 and 0.88 ±0.64 respectively(all P <0.01).And SA had a lower procedure-related PPM implantation(1.63％ vs 4.20％, P<0.05).Conclusion Our results shown that SA have survival advantage, lower PPM and similar heart function improvement compared with SM for refractory patients with HOCM.

Surgical treatment of severe aortic stenosis with septal hypertrophy / 中华胸心血管外科杂志

Objective@#To summarize the experience of surgical treatment of 18 cases of severe aortic stenosis with ventricular septum hypertrophy.@*Methods@#Clinical data of 18 patients with severe aortic stenosis admitted to the first affiliated hospital of zhengzhou university from January 2013 to December 2016 were collected. There were 7 males and 11 females. The mean age was (50.4±4.2) years old. All patients were diagnosed with severe stenosis of main artery valve by echocardiography before surgery, with mean aortic valve orifice area (0.57±0.11) cm2, cardiac function (NYHA classification) grade Ⅱ in 4 patients, grade Ⅲ in 9 patients, and grade Ⅳ in 5 patients. There were 8 patients with mild aortic valve insufficiency, 4 patients with mild to moderate mitral valve insufficiency, 2 patients with moderate to severe aortic valve insufficiency, 3 patients with ascending aorta dilatation (ascending aorta inner diameter>4.5 cm), and 1 patient with atrial fibrillation. Interventricular septum thickness (15.82±2.04)mm, left ventricular posterior wall thickness (14.04±1.28)mm, ratio of interventricular septum thickness to left ventricular posterior wall thickness (IVS/LVPW) 1.12±0.91, inner diameter of left ventricular outflow tract (19.01±1.74)mm, cross-lobe differential pressure (102±8.40) mmHg (1 mmHg=0.133 kPa), left ventricular ejection fraction (LVEF) mean 0.49±0.05. Left ventricular end-diastolic diameter (LVEDD) (53.33±4.00) mm, left ventricular end-systolic diameter (LVESD) (27.11±1.99) mm, and left ventricular mass index (277.1±37.3) g/m2. All patients underwent aortic valve replacement (AVR) and partial interventricular septum resection under general anesthesia and conventional extracorporeal circulation, 2 patients underwent mitral valve formation (artificial valve ring), 2 patients underwent ascending aorta formation, and 1 patient underwent ascending aorta wrapping. During the operation, the time of extracorporeal circulation, aortic occlusion, number of defibrillation during the operation, type of valve implantation and postoperative complications were recorded. Regular follow-up was conducted to analyze the changes of various indexes at different preoperative and postoperative time.@*Results@#There was no death in the whole group. 2 patients were treated with temporary pacemakers. After drug treatment, sinus rhythm was restored on the 3rd and 6th day after surgery, and temporary pacemakers were removed. Echocardiography reexamination 1 week after the operation showed that all patients had a good artificial valve function and 2 patients had minor regurgitation of mitral valve. The difference in pressure across the valve, inner diameter of the left ventricular outflow tract, cardiac function classification, ventricular septum thickness, valve orifice area, and left ventricular mass index were significantly improved compared with the preoperative level (P<0.05). LVEF, LVEDD, and LVESD were compared with the preoperative level (P<0.05). After 6 months of follow-up, the difference in LVEF and LVEDD was statistically significant compared with the preoperative level (P<0.05).@*Conclusion@#Severe aortic stenosis combined with ventricular septum hypertrophy and partial ventricular septal muscle resection is a simple additional procedure in the AVR process, which does not increase the surgical risk and has a significant effect, and is conducive to postoperative left ventricular function recovery.

Efficacy of Extended Myectomy on Reducing Mitral Regurgitation in Patients With Hypertrophic Obstructive Cardiomyopathy / 中国循环杂志

Objectives:To analyze the impact of extended myectomy on reducing mitral regurgitation in patients with hypertrophic obstructive cardiomyopathy (HOCM). Methods:We retrospectively analyzed 480 consecutive HOCM patients who underwent surgical treatment by the same surgeon in our institution from October 2002 to July 2017. The efficacy of extended myectomy for reducing mitral regurgitation and left ventricular outflow tract (LVOT) obstruction were evaluated by echocardiography after surgery. Results:Among the 480 patients, 22 (4.6%) received concomitant mitral repair or replacement because of their intrinsic mitral diseases. In the remaining 458 (95.4%) patients without concomitant mitral valve surgery, 1 (0.2%) died at the 5th day after surgery because of infective shock, and another 4 (0.9%) lost to follow-up, a total of 453 (98.9%) patients underwent echocardiographic follow-up (median follow-up time:6 months [3, 12]). During follow-up, left ventricular out flow tract gradient was significantly decreased from (89.1±30.6) to (12.8±11.6) mmHg (P＜0.001); the number of patients with systolic anterior motion (SAM) of mitral leaflets decreased from 451(98.5%) to 42 (9.3%) (P＜0.001); 297 (64.8%) patients presented with moderate or severe mitral regurgitation before surgery, which decreased to 14 (3.1%) at follow-up (P＜0.001); the multivariate regression analysis showed that patients with residual SAM were significantly associated with a higher incidence of moderate to severe mitral regurgitation during follow-up (odds ratio 30.334, 95% confidence interval:5.619-163.739, P＜0.001). Conclusions:Extended myectomy, combined with dividing the anomalous links between mitral apparatus and septum, and trimming papillary muscles, yields satisfactory outcomes of relieving LVOT obstruction and reducing mitral regurgitation in most of patients with HOCM. Concomitant mitral valve surgery is rarely required unless the patient have intrinsic mitral valve disease.

Comparison of Clinical Effects between Percutaneous Transluminal Septal Myocardial Ablation and Modified Morrow Septal Myectomy on Patients with Hypertrophic Cardiomyopathy / 中华医学杂志(英文版)

<p><b>Background</b>Percutaneous transluminal septal myocardial ablation (PTSMA) and modified Morrow septal myectomy (MMSM) are two invasive strategies used to relieve obstruction in patients with hypertrophic cardiomyopathy (HCM). This study aimed to determine the clinical outcome of these two strategies.</p><p><b>Methods</b>From January 2011 to January 2015, 226 patients with HCM were treated, 68 by PTSMA and 158 by MMSM. Both ultrasonic cardiograms and heart functional class were recorded before, after operations and in the follow-up. Categorical variables were compared using Chi-square or Fisher's exact tests. Quantitative variables were compared using the paired samples t-test.</p><p><b>Results</b>Interventricular septal thickness was significantly reduced in both groups (21.27 ± 4.43 mm vs. 18.72 ± 4.13 mm for PTSMA, t = 3.469, P < 0.001, and 21.83 ± 5.03 mm vs. 16.57 ± 3.95 mm for MMSM, t = 10.349, P < 0.001, respectively). The left ventricular outflow tract (LVOT) pressure gradient (PG) significantly decreased after the operations in two groups (70.30 ± 44.79 mmHg vs. 39.78 ± 22.07 mmHg for PTSMA, t = 5.041, P < 0.001, and 74.58 ± 45.52 mmHg vs. 13.95 ± 9.94 mmHg for MMSM, t = 16.357, P < 0.001, respectively). Seven patients (10.29%) in the PTSMA group required a repeat operation in the follow-up. Eight (11.76%) patients were evaluated for New York Heart Association (NYHA) III/IV in the PTSMA group, which was significantly more than the five (3.16%) in the same NYHA classes for the MMSM group at follow-up. Less than 15% of patients in the PTSMA group and none of the patients in the MMSM group complained of chest pain during follow-up.</p><p><b>Conclusions</b>Both strategies can not only relieve LVOT PG but also improve heart function in patients with HCM. However, MMSM might provide a more reliable reduction in gradients compared to PTSMA.</p>

Extensive Left Ventricular Myectomy Surgery for Hypertrophic Obstructive Cardiomyopathy / 日本心臓血管外科学会雑誌

<b>[Background] </b>Surgical septal myectomy is the gold-standard therapy for hypertrophic obstructive cardiomyopathy (HOCM) in Europe and America. However, few cases underwent surgical septal myectomy in Japan. We have performed the surgical transaortic extended left ventricular myectomy (LV myectomy) as a first choice in HOCM patients unresponsive to pharmacologic therapy. We report the short and medium term clinical outcomes. <b>Methods</b> : From May 2012 to September 2014, 9 patients underwent extended LV myectomy without other accompanying procedures. All cases were symptomatic and peak left ventricular outflow tract pressure gradients (LVOTG) were 50 mmHg or more. We assessed clinical and echocardiographic outcomes at the short and medium term, intra-operative findings and cardiomyocyte pathological findings. <b>Results</b> : All patients (mean age 64.3 years, 56% female) underwent transaortic LV myectomy with no obvious complications. Postoperative LVOTG were controlled within 10 mmHg or less. SAM disappeared completely in all patients and MR decreased to mild or less. LVOTG sustained good control of 10 mmHg or less under low-dose dobutamine stress echocardiography at the medium term. <b>Conclusion</b> : Our transaortic extended LV myectomy procedure is effective in decreasing LVOTG, SAM and MR with low operative morbidity and mortality.

Survival and Clinical Behavior of Hypertrophic Cardiomyopathy in a Latin American Cohort in Contrast to Cohorts from the Developed World

BACKGROUND: Hypertrophic cardiomyopathy (HCM) is the most common hereditary heart disease with diverse phenotipyc, genetic expession and clinical presentations. The evolution of patients with HCM in Latin America has not been properly described being the frequency, the long-term prognosis as well as the predominant phenotypic expression still unknown. The aim of this study was to determine the survival rate of HCM patients having different phenotypes in a Mexican cohort of patients. METHODS: Clinical and echocardiographic data obtained from 77 Mexican patients with recently diagnosed HCM were analyzed. The follow-up was of 12.5 years. RESULTS: 96.1% of patients were in functional class I/II according to the New York Heart Association, 2.6% in class III and 1.3% in class IV. Only 3.9% of them went to surgery for myectomy. During the follow-up, 17 patients (22%) died: 4/9 (44%) had apical HCM, 5/20 (25%) had obstructive septal asymmetric HCM, 6/35 (17%) had nonobstructive septal asymmetric HCM and 2/3 (15%) had concentric HCM. The survival rate was worse for patients with apical HCM, followed by those with obstructive and nonobstructive septal asymmetric HCM and patients showing concentric HCM had the best survival rates. There is significant difference in survival rates which declined in 65% in a 9 years-period. Log rank test showed significant differences (p < 0.002). CONCLUSION: The survival rate of patients with HCM was worse in those with apical variety. The majority of patients received medical treatment. The indication for myectomy was below that observed in other international centers.

Minimally Invasive Trans-Mitral Septal Myectomy to Treat Hypertrophic Obstructive Cardiomyopathy

A 43-year-old man with symptomatic hypertrophic obstructive cardiomyopathy (HOCM) was admitted to our hospital with aggravated exertional dyspnea and successfully treated with robotic transmitral septal myectomy. Minimally invasive transmitral septal myectomy may be a feasible surgical option for the treatment of HOCM in selected cases as an alternative to transaortic myectomy.

Hypertrophic cardiomyopathy part II - Anesthetic and surgical considerations.

Hypertrophic cardiomyopathy (HCM) poses many unique challenges regarding the conduct of anesthesia and surgery. Adequate preload, control of sympathetic stimulation, heart rate, and increased afterload are required to decrease the left ventricular outfl ow tract obstruction. Comprehensive intraoperative transesophageal echocardiography (TEE) examination confi rms the diagnosis, elucidates the pathophysiology, and identifi es the various anomalies of mitral valve apparatus and allows assessment of the adequacy of surgery. In this review, we focus on the preoperative assessment, conduct of anesthesia and comprehensive TEE examination of patients presenting for surgery with HCM. The various surgical options are extended myectomy and resection, plication and release.

Application of Intro-operative Transesophageal Echocardiography for Extended Septal Myectomy in Patients With Obstructive Hypertrophic Cardiomyophathy / 中国循环杂志

Objective: To evaluate the intro-operative transesophageal echocardiography (TEE) for extended septal myectomy in patients with obstructive hypertrophic cardiomyophathy (HCM). Methods: A total of 56 obstructive HCM patients with extended septal myectomy in our hospital from 2012-01 to 2012-12 were retrospectively studied. The results of pre-operative transthoracic echocardiography, intro-operative TEE and post-operative transthoracic echocardiography were analyzed and compared. Results: There were 36 male and 20 female patients with the average age of (46.1 ± 11.3) years. The pre-operative width of inter ventricular septal was (26.1 ± 6.9) mm, left ventricular outlfow tract (LVOT) pressure gradient was (87.5 ± 12.5) mmHg. All patients received successful operation, no in-hospital death, no TEE related complication. The removed ventricular septal thickness was at (10.7 ± 2.1) mm, length at (39.1±5.5) mm. Compared with pre-operative transthoracic echocardiography, TEE indicated the immediate drop of post-operative LVOT peak velocity (4.57 ± 0.99)m/s vs (1.68±0.46)m/s and LVOT peak gradient (87.5 ± 34.4) vs (11.3 ± 7.0) mmHg, both P Conclusion: TEE is safe for extended septal myectomy in obstructive HCM patients. It may pre-operatively identify the cause and degree of MR, evaluate the post-operative improvement of LVOT obstruction and MR. Meanwhile, TEE may ifnd the surgical complication for in time correction in relevant patients.

Septal Myectomy and Mitral Valve Replacement for Hypertrophic Obstructive Cardiomyopathy Accompanied by Severe Mitral Regurgitation / 日本心臓血管外科学会雑誌

Septal myectomy and mitral valve surgery are performed for the treatment of hypertrophic obstructive cardiomyopathy (HOCM) ; however, there is a debate as to which is the better option. In this paper, we report on the eventless postoperative course of a patient who underwent septal myectomy and mitral valve replacement simultaneously to treat HOCM accompanied by severe mitral regurgitation. A 75-year-old woman was referred to our department for severe mitral regurgitation accompanied by exertional dyspnea; we observed systolic anterior motion of the anterior mitral leaflet and a left ventricular outflow tract pressure gradient of 130 mmHg that was not decreased by DDD pacing. A 15×6×15-mm rectangular parallele pipe-shaped section of the hypertrophied basal septum was resected via a transaortic approach. In addition, mitral valve replacement with a 25-mm SJM was performed during the same procedure, as lesions were observed in the mitral valve. After surgery, the left ventricular outflow tract pressure gradient decreased by 12.5 mmHg. Necessary and sufficient resection of the hypertrophied basal septum, after careful preoperative and intraoperative evaluation of the extent of myocardial resection and mitral valve lesions is important for improving left ventricular outflow tract pressure gradient in HOCM. Mitral valve replacement should also be performed, if necessary, to treat mitral valve lesions.

Mitral Valve Plasty for Mitral Regurgitation in Hypertropic Obstructive Cardiomyopathy / 日本心臓血管外科学会雑誌

Mitral valve replacement (MVR) is an effective method to treat mitral valve regurgitation (MR) associated with hypertrophic obstructive cardiomyopathy (HOCM) because of systolic anterior movement (SAM) of anterior leaflet. We retrospectively investigated results of mitral valve surgery concomitant with septal myectomy for MR with HOCM. Between August 2008 to July 2009, 7 patients underwent septal myectomy. Among them, 6 patients who had moderate or severe MR preoperatively were objects of this study. Pre and post operative clinical conditions, findings of echocardiogram, and operative techniques employed in each patient were reviewed. Four patient successfully underwent mitral valve plasty (MVP) with septal myectomy. One patient needed only septal myectomy because MR subsequently disappeared with resolution of SAM. One patient resulted in MVR after attempted mitral valve plasty (MVP). SAM disappeared in all patients who had MVP, and residual MR was mild or less. Pressure gradient of left ventricular outflow significantly decreased in all cases. All patients discharged hospital uneventfully. Plication of posterior leaflet, anterior leaflet augmentation if necessary, and prudent use of annuloplasty ring seemed to be effective for successful MVP in HOCM patients. MVP is feasible even in patients with MR derived from HOCM.