Transaortic Shallow Septal Myectomy and Cutting of Secondary Fibrotic Mitral Valve Chordae-A 5-Year Single-Center Experience in the Treatment of Hypertrophic Obstructive Cardiomyopathy.

BACKGROUND: Anomalies of the mitral apparatus have been shown to contribute to left ventricular outflow obstruction in patients with hypertrophic cardiomyopathy (HCM). We report our 5-year single-center experience with a shallow myectomy procedure associated with transaortic mitral valve repair in a cohort of HCM patients. METHODS: We studied 83 consecutive patients who underwent surgical treatment of symptomatic left ventricular outflow obstruction. In all study patients, a transaortic shallow septal myectomy was performed. Fibrous or muscular structures connecting the papillary muscles to the septum or free wall were resected, and fibrotic secondary chordae of the anterior mitral valve were cut selectively. RESULTS: We report one death (1.2%) during hospitalization, no iatrogenic ventricular septal defects, and two (2.4%) mitral valve replacements. At discharge, no patients were in New York Heart Association (NYHA) Class III/IV, from 49 (59%) preoperatively. Mean maximal septal thickness decreased from 24 ± 6 to 16 ± 3 mm. Mean outflow gradient decreased from 93 ± 33 to 13 ± 11 mmHg. Grade 3 or 4 mitral regurgitation was noticed in one patient postoperatively, from 32 (39%) before surgery. CONCLUSIONS: Shallow septal myectomy associated with secondary mitral valve chordal cutting and papillary muscle mobilization provided excellent results offering adequate treatment of outflow obstruction.

Current management and surgical advances in patients with hypertrophic obstructive cardiomyopathy.

Hypertrophic cardiomyopathy (HCM) is a genetic disease and the most frequent primary cardiomyopathy, affecting 1:500 of the general population. Integrated multimodality imaging, including transthoracic echocardiography, 2- and 3­dimensional transesophageal echocardiography, stress echocardiography, and cardiac magnetic resonance, has provided answers to questions on the management of HCM, leading to standardized protocols. The late 1990s brought the news of a nonsurgical treatment of obstruction in HCM. It is now increasingly evident that septal ablation cannot address all the mechanisms of the left ventricular outflow tract (LVOT) gradient, especially mitral valve involvement. According to American and European guidelines, surgical septal myectomy is the current gold standard treatment. However, deep septal myectomy requires specific operator and institutional experience; therefore, it should not be performed in small community hospitals but only in centers of excellence for HCM treatment. The so-called Ferrazzi technique involves cutting the fibrotic secondary chordae of the mitral valve (MV) and thus helps avoid a deep myectomy by moving the anterior mitral leaflet and the coaptation point of the MV posteriorly away from the septum. This technique, together with careful mobilization of the papillary muscles, helped us achieve excellent results since November 2015, with no mortality, resolution of the LVOT gradient, and MV preservation in all 72 patients. Owing to recent advances in the surgical treatment of hypertrophic obstructive cardiomyopathy, addressing not only the septum but also the MV, the procedure of a deep myectomy has been simplified and mitral regurgitation adequately corrected.

Box Isolation of fibrotic areas: A substrate modification approach in atrial fibrillation patients.

In the last years, atrial fibrosis was shown to be an independent predictor of procedural failure in patients with paroxysmal and persistent atrial fibrillation. Ablation strategies have been developed to improve the outcome of catheter ablation by targeting detected areas of fibrosis, based either on endocardial voltage mapping or cardiac magnetic resonance. Box isolation of fibrotic areas (BIFA) is a new and promising patient-tailored ablation strategy for atrial fibrillation patients targeting substantial fibrotic areas by circumferential isolation of left atrial fibrosis.

Right bundle branch block and anterior wall ST elevation myocardial infarction.

We report the case of an acute anterior wall ST elevation myocardial infarction with new left anterior fascicular block and pre-existing right bundle branch block. Due to a wide right bundle branch block, no ST segment elevation was visible in lead V1. The left anterior fascicular block was caused by proximal occlusion of the left artery descending and disappeared after acute revascularization. However, also the R' of the right bundle branch block became significantly shorter after revascularization, dismanteling a minor ST segment elevation. The ST elevation in lead V1 in anterior wall infarction and right bundle branch block may merge with the R' and cause a further QRS widening as an "equivalent" to the ST elevation.

Global multielectrode contact mapping plus ablation with a single catheter: Preclinical and preliminary experience in humans with atrial fibrillation.

INTRODUCTION: One question for the technological advancement of catheter ablation of atrial fibrillation (AF) is whether a creative new concept can combine and even improve the diagnostic mapping options of single-tip and basket catheters with the simplicity of the use of balloon catheters for ablation. Herein, we describe the first in-human experience with a single catheter offering such a complete solution. METHODS AND RESULTS: A new catheter (Globe® ) with a distal multielectrode array consisting of 16 ribs with 122 gold-plated electrodes was used. Each electrode can ablate, pace, and can measure tissue contact, temperature, current, and intracardiac electrograms. The Globe was deployed and removed without difficulty in all 3 patients. Complete pulmonary vein isolation (PVI) was achieved in all 12 veins. In 10 veins, PVI was achieved with a single placement in front of the respective vein ("single circle isolation"). In one subject, the device was repositioned due to the esophagus location. In the other subject, a single gap was observed after circumferential ablation of the right inferior PV. After precise gap identification, the device was adjusted slightly for improved contact at that region, and reablation resulted in immediate PVI. CONCLUSIONS: PVI isolation could be performed with the new multielectrode array Globe in all 12 PVs offering the option for easy handling and fast "single-shot" PVI. Several continuously updated mapping types from 122 electrodes even in real time during ablation demonstrate the capability to go beyond PVI for voltage mapping plus substrate modification, and for rotor mapping plus rotor ablation.