Minimally invasive septal myectomy for the treatment of hypertrophic obstructive cardiomyopathy and intrinsic mitral valve disease.

OBJECTIVE: Transaortic left ventricular septal myectomy described by Morrow is a classical procedure for the treatment of systolic anterior motion of the mitral apparatus associated with hypertrophic obstructive cardiomyopathy (HOCM). We aimed to review our results of transmitral septal myectomy and mitral valve repair/replacement in patients with intrinsic mitral valve disease associated with HOCM, operated on through a minimally invasive approach. METHODS: Between 2005 and 2014, 19 patients [7 men (37%); mean (SD) age, 69.4 (14.5) years] were treated with minimally invasive approach for degenerative mitral regurgitation and HOCM. Preoperative peak left ventricular outflow tract (LVOT) gradient was 66 (24) mm Hg. Severe mitral regurgitation was diagnosed in 16 cases (84%). New York Heart Association functional class III to IV heart failure was present in 13 patients (68%). RESULTS: Fifteen patients (79%) underwent mitral valve replacement, and four patients (21%) underwent mitral valve repair. Left ventricular outflow tract obstruction was corrected directly in all patients via the mitral valve with septal myectomy/myotomy, avoiding aortotomy in majority of the patients. No significant prolongation of extracorporeal circulation/aortic cross-clamping times was observed (P = 0.41 and P = 0.67, respectively) when compared with a similar population without HOCM. No iatrogenic ventricular septal defect developed in treated patients. No hospital mortality occurred. Resting LVOT gradient reduced at discharge to 13 (22) mm Hg (P = 0.025). CONCLUSIONS: Transmitral left ventricular septal myectomy in patients with degenerative mitral valve disease is quite a simple, feasible, and effective technique and does not require aortotomy in most cases. It can be performed with low early mortality and satisfactory resolution of LVOT obstruction in a minimally invasive setting.

Sutureless aortic valve replacement for aortic incompetence.

OBJECTIVE: Sutureless prostheses for surgical aortic valve replacement (AVR) are usually used in degenerative calcified aortic stenosis. Less is known on the application of sutureless prostheses for pure aortic incompetence. METHODS: Between 2011 and 2014, 442 patients were operated on with the Perceval aortic sutureless valve implant. We identified 11 patients (10 female, mean age 70.5) who underwent sutureless AVR for pure aortic incompetence (off-label use). Three patients had a left ventricle ejection fraction of 30% or less. Mean logistic EuroSCORE was 15.2 (range 2.2-45.2). In five patients associated mitral procedures (three [60%] repair and two [40%] replacement) were performed. Four procedures were performed through a minimally invasive approach (three right minithoracotomies and one partial sternotomy). RESULTS: Mean cardiopulmonary bypass time was 130.2 min and aortic cross clamp time was 82.2 min. Mean implanted prosthesis size was 24.5 ± 1.3 (median 25) mm (insignificant correlation with preoperative aortic valve annulus measurement by transthoracic echocardiography: 21.6 ± 1.5 [median 21] mm, Pearson's r = 0.373, p = 0.259). One patient died on 24th day after AVR associated with aortic arch replacement and hypothermic circulatory arrest (10 years after correction for type A aortic dissection). No residual para- or intravalvular leakage was present on discharge and 12-month follow-up. No migration of the prosthesis occurred. CONCLUSION: Sutureless AVR is an option in selected patients with aortic incompetence. Preoperative aortic annulus measurement by echocardiography has poor predictive value for estimation of prosthetic valve size.