Top

Journal of Cardiothoracic Surgery

Published in:

Open Access 01-12-2021 | Transesophageal Echocardiography | Research article

Mini-invasive surgical instruments in transaortic myectomy for hypertrophic obstructive cardiomyopathy: a single-center experience with 168 cases

Authors: Qiang Ji, Yu Lin Wang, Ye Yang, Hao Lai, Wen Jun Ding, Li Min Xia, Chun Sheng Wang

Published in: Journal of Cardiothoracic Surgery | Issue 1/2021

Abstract

Background

Although septal myectomy is a standard strategy for managing patients with hypertrophic obstructive cardiomyopathy (HOCM) and drug-refractory symptoms, so far, only a few experienced myectomy centers exist globally. Mainly, this can be explained by the many technical challenges presented by myectomy. From our clinical experience, applying the mini-invasive surgical instruments during myectomy potentially reduces the technical difficulty. This study reports the preliminary experience regarding transaortic septal myectomy using mini-invasive surgical instruments for managing patients with HOCM and drug-refractory symptoms; also, we evaluate the early results following myectomy.

Methods

Between March 2016 and March 2019, consecutive HOCM patients who underwent isolated transaortic septal myectomy using the mini-invasive surgical instruments were enrolled in this analysis. Intraoperative, in-hospital and follow-up results were analyzed.

Results

We included 168 eligible patients (83 males, mean 56.8 ± 12.3 years). The midventricular obstruction was recorded in 7 (4.2%) patients. All patients underwent transaortic septal myectomy with a mean aortic cross-clamping time of 36.0 ± 8.1 min. During myectomy, 9 (5.4%) patients received repeat aortic cross-clamping. Surgical mortality was 0.6%. Notably, 5 (3.0%) patients developed complete atrioventricular block, they needed permanent pacemaker implantation. The median follow-up time was 6 months; however, no follow-up deaths occurred with a significant improvement in New York Heart Association functional status. We reported a sharp decrease in the maximum gradients from the preoperative value (11.6 ± 7.4 mmHg vs. 94.4 ± 22.6 mmHg, p < 0.001). The median degree of mitral regurgitation fell to 1.0 (vs. 3.0 preoperatively, p < 0.001) with a significant reduction in the proportion of moderate or more regurgitation (1.2% vs. 57.7%, p < 0.001).

Conclusions

Mini-invasive surgical instruments may be beneficial in reducing the technical challenges of transaortic septal myectomy procedure. Of note, transaortic septal myectomy using the mini-invasive surgical instruments may present with favorable results.

Kim LK, Swaminathan RV, Looser P, Minutello RM, Wong SC, Bergman G, Naidu SS, Gade CLF, Charitakis K, Singh HS, Feldman DN. Hospital volume outcomes after septal myectomy and alcohol septal ablation for treatment of obstructive hypertrophic cardiomyopathy: US Nationwide inpatient database, 2003-2011. JAMA Cardiol. 2016;1(3):324–32. https://doi.org/10.1001/jamacardio.2016.0252.CrossRefPubMed

Nguyen A, Schaff HV, Hang D, Nishimura RA, Geske JB, Dearani JA, et al. Surgical myectomy versus alcohol septal ablation for obstructive hypertrophic cardiomyopathy: A propensity score-matched cohort. J Thorac Cardiovasc Surg. 2019;157:306–15. e3.CrossRefPubMed

Ommen SR, Maron BJ, Olivotto I, Maron MS, Cecchi F, Betocchi S, Gersh BJ, Ackerman MJ, McCully RB, Dearani JA, Schaff HV, Danielson GK, Tajik AJ, Nishimura RA. Long-term effects of surgical septal myectomy on survival in patients with obstructive hypertrophic cardiomyopathy. J Am Coll Cardiol. 2005;46(3):470–6. https://doi.org/10.1016/j.jacc.2005.02.090.CrossRefPubMed

Woo A, Williams WG, Choi R, Wigle ED, Rozenblyum E, Fedwick K, Siu S, Ralph-Edwards A, Rakowski H. Clinical and echocardiographic determinants of long-term survival after surgical myectomy in obstructive hypertrophic cardiomyopathy. Circulation. 2005;111(16):2033–41. https://doi.org/10.1161/01.CIR.0000162460.36735.71.CrossRefPubMed

Ball W, Ivanov J, Rakowski H, Wigle E, Linghorne M, Ralph-Edwards A, et al. Long-term survival in patients with resting obstructive hypertrophic cardiomyopathy: comparison of conservative versus invasive treatment. J Am Coll Cardiol. 2011;58(22):2313–21. https://doi.org/10.1016/j.jacc.2011.08.040.CrossRefPubMed

Desai MY, Bhonsale A, Smedira NG, Naji P, Thamilarasan M, Lytle BW, Lever HM. Predictors of long-term outcomes in symptomatic hypertrophic obstructive cardiomyopathy patients undergoing surgical relief of left ventricular outflow tract obstruction. Circulation. 2013;128(3):209–1. https://doi.org/10.1161/CIRCULATIONAHA.112.000849.CrossRefPubMed

Dearani JA, Ommen SR, Gersh BJ, Schaff HV, Danielson GK. Surgery insight: Septal myectomy for obstructive hypertrophic cardiomyopathy--the Mayo Clinic experience. Nat Clin Pract Cardiovasc Med. 2007;4(9):503–12. https://doi.org/10.1038/ncpcardio0965.CrossRefPubMed

Ferrazzi P, Spirito P, Iacovoni A, Calabrese A, Igliorati K, Simon C, et al. Transaortic chordal cutting: mitral valve repair for obstructive hypertrophic cardiomyopathy with mild septal hypertrophy. J Am Coll Cardiol. 2015;66(15):1687–99. https://doi.org/10.1016/j.jacc.2015.07.069.CrossRefPubMed

Iacovoni A, Spirito P, Simon C, Iascone M, Di Dedda G, De Filippo P, et al. A contemporary European experience with surgical septal myectomy in hypertrophic cardiomyopathy. Eur Heart J. 2012;33(16):2080–7. https://doi.org/10.1093/eurheartj/ehs064.CrossRefPubMedPubMedCentral

10.

Smedira NG, Lytle BW, Lever HM, Rajeswaran J, Krishnaswamy G, Kaple RK, Dolney DOW, Blackstone EH. Current effectiveness and risks of isolated septal myectomy for hypertrophic obstructive cardiomyopathy. Ann Thorac Surg. 2008;85(1):127–33. https://doi.org/10.1016/j.athoracsur.2007.07.063.CrossRefPubMed

11.

Ommen SR, Nishimura RA. Hypertrophic cardiomyopathy – one case per year? A clarion call to do what is right. JAMA Cardiol. 2016;1(3):333–4. https://doi.org/10.1001/jamacardio.2016.0277.CrossRefPubMed

12.

Elliott PM, Anastasakis A, Borger MA, Borggrefe M, Cecchi F, Charron P, et al. 2014 ESC guidelines on diagnosis and management of hypertrophic cardiomyopathy: the task force for the diagnosis and management of hypertrophic cardiomyopathy of the European Society of Cardiology (ESC). Eur Heart J. 2014;35(39):2733–79. https://doi.org/10.1093/eurheartj/ehu284.CrossRefPubMed

13.

Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW, American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons. 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011;124(24):2761–96. https://doi.org/10.1161/CIR.0b013e318223e230.CrossRefPubMed

14.

Cho YH, Quintana E, Schaff HV, Nishimura RA, Dearani JA, Abel MD, Ommen S. Residual and recurrent gradients after septal myectomy for hypertrophic cardiomyopathy-mechanisms of obstruction and outcomes of reoperation. J Thorac Cardiovasc Surg. 2014;148(3):909–16. https://doi.org/10.1016/j.jtcvs.2014.05.028.CrossRefPubMed

15.

Maron BJ, Yacoub M, Dearani JA. Controversies in cardiovascular medicine. Benefits of surgery in obstructive hypertrophic cardiomyopathy: bring septal myectomy back for European patients. Eur Heart J. 2011;32(9):1055–8. https://doi.org/10.1093/eurheartj/ehr006.CrossRefPubMed

16.

Rosca M, Calin A, Beladan CC, Enache R, Mateescu AD, Gurzun MM, et al. Right ventricular remodeling, its correlates, and its clinical impact in hypertrophic cardiomyopathy. J Am Soc Echocardiogr. 2015;28(11):1329–38. https://doi.org/10.1016/j.echo.2015.07.015.CrossRefPubMed

17.

Spirito P, Binaco I, Poggio D, Zyrianov A, Grillo M, Pezzoli L, Rossi J, Malanin D, Vaccari G, Dorobantu L, Iascone M, Mortara A, Khouri T, Bruzzi P, Ferrazzi P. Role of preoperative cardiovascular magnetic resonance in planning ventricular septum myectomy in patients with obstructive hypertrophic cardiomyopathy. Am J Cardiol. 2019;123(9):1517–26. https://doi.org/10.1016/j.amjcard.2019.01.041.CrossRefPubMed

18.

Yang DH, Kang JW, Kim N, Song JK, Lee JW, Lim TH. Myocardial 3-dimensional printing for septal myectomy guidance in a patient with obstructive hypertrophic cardiomyopathy. Circulation. 2015;132(4):300–1. https://doi.org/10.1161/CIRCULATIONAHA.115.015842.CrossRefPubMed

19.

Dorobantu L, Ticulescu R, Greavu M, Dermengiu A, Alexandrescu M, Trofin M. Current management and surgical advances in patients with hypertrophic obstructive cardiomyopathy. Kardiol Pol. 2019;77(9):829–36. https://doi.org/10.33963/KP.14965.CrossRefPubMed

20.

Rodriguez F, Langer F, Harrington KB, Tibayan FA, Zasio MK, Cheng A, Liang D, Daughters GT, Covell JW, Criscione JC, Ingels NB, Miller DC. Importance of mitral valve second-order chordae for left ventricular geometry, wall thickening mechanics, and global systolic function. Circulation. 2004;110(11 Suppl 1):II115–22. https://doi.org/10.1161/01.CIR.0000138580.57971.b4.CrossRefPubMed

21.

Wang S, Cui H, Yu Q, Chen H, Zhu C, Wang J, Xiao M, Zhang Y, Wu R, Hu S. Excision of anomalous muscle bundles as an important addition to extended septal myectomy for treatment of left ventricular outflow tract obstruction. J Thorcac Cardiovasc Surg. 2016;152(2):461–8. https://doi.org/10.1016/j.jtcvs.2016.01.051.CrossRef

22.

Patel P, Dhillon A, Popovic ZB, Smedira NG, Rizzo J, Thamilarasan M, et al. Left ventricular outflow tract obstruction in hypertrophic cardiomyopathy patients without severe septal hypertrophy: implications of mitral valve and papillary muscle abnormalities assessed using cardiac magnetic resonance and echocardiography. Circ Cardiovasc Imaging. 2015;8:e003132.PubMed

23.

Hodges K, Rivas CG, Aguilera J, Borden R, Alashi A, Blackstone EH, Desai MY, Smedira NG. Surgical management of left ventricular outflow tract obstruction in a specialized hypertrophic obstructive cardiomyopathy center. J Thorac Cardiovasc Surg. 2019;157(6):2289–99. https://doi.org/10.1016/j.jtcvs.2018.11.148.CrossRefPubMed

Title: Mini-invasive surgical instruments in transaortic myectomy for hypertrophic obstructive cardiomyopathy: a single-center experience with 168 cases
Authors: Qiang Ji
Yu Lin Wang
Ye Yang
Hao Lai
Wen Jun Ding
Li Min Xia
Chun Sheng Wang
Publication date: 01-12-2021
Publisher: BioMed Central
Keywords: Transesophageal Echocardiography
Cardiomyopathy
Atrioventricular Block
Published in: Journal of Cardiothoracic Surgery / Issue 1/2021
Electronic ISSN: 1749-8090
DOI: https://doi.org/10.1186/s13019-021-01403-3

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Mini-invasive surgical instruments in transaortic myectomy for hypertrophic obstructive cardiomyopathy: a single-center experience with 168 cases

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 1/2021

Prognostic factors of esophageal perforation and rupture leading to mortality: a retrospective study

Effect of ventilation strategy during cardiopulmonary bypass on postoperative pulmonary complications after cardiac surgery: a randomized clinical trial

Analysis of bronchial and vascular patterns in left upper lobes to explore the genesis of mediastinal lingular artery and its influence on pulmonary anatomical variation

Hemoglobin A1c and preoperative glycemia as a decision tool to help minimise sternal wound complications: a retrospective study in OPCAB patients

Fifteen-year experience with pericardiectomy at a tertiary referral center

Conservative treatment of left ventricular pseudoaneurysm after mitral valve replacement due to early left ventricular rupture: a case report