Robotic Transmitral Approach for Hypertrophic Cardiomyopathy With Systolic Anterior Motion (original) (raw)
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Srpski arhiv za celokupno lekarstvo, 2004
Hypertrophie obstructive cardiomyopathy (HOCM) is an idiopathic disease frequently associated with systolic anterior motion (SAM). The anterior leaflet of mitral valve is sucked by Ventury effect into the left ventricle outflow tract making subaortic stenosis more severe and producing mitral insufficiency at the same time. Septal myectomy along with mitral valve replacement has been the treatment of choice for a long time. An understanding of pathoanatomy and hemodynamics of the disease has opened possibility for total reconstructive treatment of both subaortic stenosis and mitral insufficiency in such patients. This is a case report of 50-year-old male with severe subaortic stenosis (136/70 mmHg) due to HOCM and SAM along with grade IV mitral insufficiency. Septal myectomy was performed. Mitral insufficiency was managed by reducing the height of posterior cusp along with remodeling of mitral annulus by Carpentier-Classic ring. In that way, subaortic obstruction was reduced to 30.9/...
The American Journal of Cardiology, 2007
Relief of obstruction using ventricular septal ablation (VSA) may not eliminate systolic anterior motion (SAM) of the mitral valve and mitral regurgitation (MR) in patients with obstructive hypertrophic cardiomyopathy. The hypothesis was that persistent SAM after VSA was secondary to anterior papillary muscle displacement and malcoaptation of mitral valve leaflets and that these findings could predict persistence of SAM. Echocardiograms were examined from 37 patients with obstructive hypertrophic cardiomyopathy before and 12 ؎ 3 months after VSA. Anterior leaflet malposition (anterior-to-posterior leaflet coaptation position ratio), papillary muscle malposition (septal-to-lateral/left ventricular internal diameter ratio), and anterior position of coaptation relative to the septum (coaptation-to-septal distance) were assessed. MR proximal jet width was also measured. Of 37 patients, 30 underwent successful VSA (left ventricular outflow tract gradient reduction >50%); 22 of 30 and 7 of 7 with <50% reduction (total 29 of 37; 78%) showed persistent SAM at 12 ؎ 3 months. These patients had more anterior malposition of the mitral valve and less MR reduction than those without SAM: anterior-to-posterior leaflet coaptation position ratio 0.42 ؎ 0.06 versus 0.56 ؎ 0.09, septal-tolateral/left ventricular internal diameter ratio 0.39 ؎ 0.12 versus 0.55 ؎ 0.12, coaptation-toseptal distance 1.8 ؎ 0.42 versus 2.8 ؎ 0.30 cm, and MR reduction by 29 ؎ 22% versus 71 ؎ 12% (p <0.0001). Gradients, both at rest and provokable, were higher (27 ؎ 33 vs 4 ؎ 5 mm Hg, p ؍ 0.0004; >45 mm Hg in 9 vs 0, p ؍ 0.03, respectively) in patients with persistent SAM. Anterior malposition was present before VSA, with anterior-to-posterior leaflet coaptation position ratio <0.5 predicting SAM after VSA (p <0.0001). In conclusion, SAM and MR were often not eliminated using VSA. Mitral valve malposition was a strong predictor of SAM and MR reduction after VSA and may need to be considered in optimizing results of this procedure.
Journal of Cardiology
Background: Although transaortic septal myectomy (TASM) is recognized as a standard procedure for treating hypertrophic obstructive cardiomyopathy (HOCM), occasionally the left ventricle (LV) intracavitary gradient remains postoperatively because of this technically demanding procedure. Mitral valve replacement (MVR) is sometimes chosen as an alternative option, but data on its long-term outcomes are lacking. Methods and results: Between 1991 and 2016, 29 patients [age, 14-82 (mean 58.9 AE 15.9) years; 22 female patients (75.9%)] underwent combined mechanical MVR and transmitral myectomy. Of these, six patients had undergone MVR following a second cardiac arrest because of the residual LV outflow gradient or residual mitral regurgitation following TASM. Concomitant TASM was performed in 13 patients. The LV intracavitary gradient at rest assessed by transthoracic echocardiography significantly decreased postoperatively (16.8 AE 19.1 mmHg vs. 107.4 AE 52.5 mmHg, p < 0.0001). Actuarial freedom rates from cardiac death were 92.8%, 89.0%, and 80.1% at 5, 10, and 15 years postoperatively, respectively. Sudden death occurred in three of the four patients who died of late cardiac complications. None of these patients with sudden death had implantable cardioverter-defibrillators. Most patients had maintained their LV end-diastolic dimension at <50 mm for 10-15 years postoperatively. Actuarial freedom rates from hospitalization for heart failure were 87.7%, 82.2%, and 54.8% at 5, 10, and 15 years postoperatively, respectively. Occurrence rates of cerebral hemorrhage and infarction were 0.6% per patient-year and 1.3% per patient-year, respectively. Conclusions: Combined mechanical MVR and myectomy is an effective procedure to eliminate the LV intracavitary gradient in patients with HOCM. Although this procedure remains a viable option in certain situations, optimal medical treatment and close clinical follow-up along with the cooperation between cardiac surgeons and cardiologists are necessary to achieve favorable long-term outcomes.
The Annals of Thoracic Surgery, 2008
Background. Abnormal positioning and size of the mitral valve contribute to the systolic anterior motion and mitralseptal contact that are important components of obstructive hypertrophic cardiomyopathy (HCM). The RPR repair (resection of the septum, plication of the anterior leaflet, and release of papillary muscle attachments) addresses all aspects of this complex pathology. This study reports outcomes regarding effectiveness of the RPR repair.
Hypertrophic obstructive cardiomyopathy (HOCM) is characterized by ventricular hypertrophy, which is often asymmetric and results in severe dynamic left ventricular outflow tract (LVOT) obstruction. The mitral valve is frequently abnormal and thickened and contributes to outflow obstruction by abnormal systolic anterior motion (SAM) of the anterior or posterior mitral leaflets (1). Surgical correction of this condition has traditionally involved either septal myotomy/myomectomy (2) or mitral valve replacement (3), or both (4). Mobilization and partial excision of the papillary muscles has also been described to correct SAM as an alternative to mitral valve replacement, and with good results (5). Herein, a resectoscope was used to achieve complete myectomy without risking iatrogenic ventricular septal defect (VSD), and to repair the mitral valve in order to correct mitral regurgitation due to SAM.
Ventricular Approach for Functional Mitral Regurgitation in Cardiomyopathy
World Journal of Cardiovascular Surgery, 2013
Background: The key mechanism of functional mitral regurgitation (FMR) in cardiomyopathy is leaflet tethering caused by displacement of the papillary muscles (PM) due to left ventricular dilatation. The attendant remodeling process is characterized by intraventricular widening between both PM. Recently, surgical ventricular restoration (SVR) has been proposed as a technique to reduce leaflet tethering by improving ventricular geometry. However, it is unknown how SVR improve FMR. Methods and Results: From 2003 to 2010, we surgically treated FMR in 100 patients with idiopathic dilated cardiomyopahy (DCM) or ischemic cardiomyopathy (ICM). Of those, we performed posterior wall exclusion procedures by either resection (the Batista procedure, n = 13) or plication (n = 19) to approximate papillary muscle distance in a total of 32 patients (DCM in 17, ICM in 15), and these patients formed the cohort of this study. There were two 30-day mortalities (6.3%). There was no significant change in left ventricular ejection fraction, however, the size of the left ventricle, degree of MR, tethering height and distance of PM significantly decreased after operation and well maintained at the mean follow up of 3.3 ± 2.1 years. Conclusions: Posterior wall resection or plication with PM approximation provides excellent reduction of leaflet tethering and MR. Thus, reduction of PM distance may be helpful to treat FMR due to leaflet tethering.
Journal of the American College of Cardiology, 2000
This study examined: 1) the impact of myectomy on postoperative mitral regurgitation (MR) and 2) the association between the severity of MR and the left ventricular outflow tract (LVOT) gradient. BACKGROUND For patients with hypertrophic obstructive cardiomyopathy (HOCM) and MR, controversy exists as to whether myectomy alone is sufficient in eliminating MR. Furthermore, the relationship between the degree of MR and the LVOT peak gradient has not been well defined.
European Journal of Cardio-Thoracic Surgery, 2011
Objectives: Septal myectomy is the treatment of choice for patients with hypertrophic obstructive cardiomyopathy (HOCM) with significant left-ventricular outflow tract (LVOT) obstruction. In some HOCM patients, however, systolic anterior motion (SAM) of the anterior mitral leaflet significantly contributes to LVOT obstruction, resulting in mitral regurgitation and insufficient release of the obstruction after myectomy. We, therefore, developed a strategy of combined myectomy and anterior leaflet retention plasty (ALRP), and investigated its results in adult HOCM patients with manifest SAM. Methods: Subaortic septal myectomy and ALRP were performed in 25 adult HOCM patients with significant SAM, as assessed by echocardiography (mean age = 48.5 AE 15 years). All patients received cardiac catheterization and echocardiography evaluation prior to the operation, before discharge, and at follow-up. Follow-up ranged between 0.8 and 14 years (median = 2.5 years). Results: All patients survived the operation, and the Kaplan-Meier estimated survival was 100% at 1 year and 82 AE 6% at 5 years. Freedom from re-operation at 5 years was 83 AE 8%. The mean LVOT pressure gradient decreased from 84 AE 32 to 19 AE 11 mmHg postoperatively ( p < 0.001), and only two patients had mild residual or recurrent SAM at follow-up. Mitral regurgitation and New York Heart Association classification were also markedly improved at follow-up. Conclusions: Combined subaortic septal myectomy and ALRP is a safe and effective therapy in HOCM patients with significant SAM. ALRP can help prevent residual or recurrent LVOT obstruction and improves mitral regurgitation. #