DOI: http://dx.doi.org/10.18203/2349-2902.isj20201060

Outcomes following transaortic septal myectomy in hypertrophic cardiomyopathy

Madhusudan Kummari, Amaresh Rao Malempati, Surya S. Gopal Palanki, Kaladhar Bomma

Abstract


Background: The objective of the study was to evaluate effect of myectomy and its impact on survival for a period of one year and to identify the co-morbid conditions that would increase the risk of surgery.

Methods: The study was conducted on the patients admitted in a single unit of department of cardiothoracic surgery, NIMS, Hyderabad during the period of 2014 to 2018. The study was a retrospective observational study. 21 patients were enrolled in the study after approval from institute ethics committee. All the patients between 7 to 70 years who underwent septal myectomy were included in the study.

Results: Out of the 21 patients underwent modified Morrows myectomy 16 (76.2%) were male and 5 (23.8%) were female. The most common presenting symptom was dyspnea (81%), followed chest pain (76%), palpitations (62%) and syncope (38%). 5 (24%) patients had a family history of sudden cardiac death. Preoperative beta blockers were used by 15 (72%) patients. 11 patients had severe mitral regurgitation, out of which 8 patients underwent valve replacement and 3 underwent mitral valve repair. The mean preoperative left ventricular outflow tract obstruction gradient was 86.86 and the mean postoperative gradient was 23.47. 3 patients had implantable cardioverter defibrillator insertions. All patients had symptom relief.

Conclusions: Surgical treatment of hypertrophic cardiomyopathy through transaortic septal myectomy is safe and effective method to relieve left ventricular outflow tract obstruction. Mitral valve replacement can be done for cases with structural defect of mitral valve. Early detection and intervention in patients with family history of sudden cardiac death would reduce the risk of death and ensure long term survival.


Keywords


Hypertrophic cardiomyopathy, Morrows procedure, Sudden cardiac death

Full Text:

PDF

References


Maron BJ, Maron MS. Hypertrophic cardiomyopathy. Lancet. 2013;381:242-55.

Elliott PM, Anastasakis A, Borger MA, Borggrefe M, Cecchi F, Charron P, et al. 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). Europ Heart J. 2014;35:2733-79.

Teare D. Asymmetrical hypertrophy of the heart in young adults. Br Heart J. 1958;20:1–8.

Maron BJ, Casey SA, Poliac LC, Gohman TE, Almquist AK, Aeppli DM. Clinical course of hypertrophic cardiomyopathy in a regional United States cohort. JAMA. 1999;281:650-5.

Cecchi F, Olivotto I, Gistri R, Lorenzoni R, Chiriatti G, Camici PG. Coronary microvascular dysfunction and prognosis in hypertrophic cardiomyopathy. N Engl J Med. 2003;349:1027-35.

Morrow AG. Hypertrophic subaortic stenosis: operative methods utilized to relieve left ventricular out-flow obstruction. J Thorac Cardiovasc Surg. 1978;76:423-30.

Maron BJ, Kalra A. Hypertrophic cardiomyopathy in the developing world: Focus on India. Europ Heart J. 2014;35(36):2492-95.

Maron BJ, Gardin JM, Flack JM, Gidding SS, Kurosaki TT, Bild DE. Prevalence of hypertrophic cardiomyopathy in a general population of young adults: Echocardiographic analysis of 4111 subjects in the CARDIA study. Circulation. 1995;85:686-96.

Karam R, Lever HM, Healy BP. Hypertensive hypertrophic cardiomyopathy or hypertrophic cardiomyopathy with hypertension. A study of 78 patients. J Am Coll Cardiol. 1989;37:1256-58.

Topol EJ, Trail TA, Fortuin NJ. Hypertensive hypertrophic cardiomyopathy of the elderly. N Engl J Med. 1985;312:277-83.

Feiner E, Arabadjian M, Winson G, Kim B, Chaudhry F, Sherrid MV. Post-prandial upright exercise echocardiography in hypertrophic cardiomyopathy. J Am Coll Cardiol. 2013;61:2487-8.

Paz R, Jortner R, Tunick PA, Sclarovsky S, Eilat B, Perez JL, et al. The effect of the ingestion of ethanol on obstruction of the left ventricula routflow tract in hypertrophic cardiomyopathy. N Engl J Med. 1996;335:938-41.

Sorajja P, Ommen SR, Nishimura RA, Gersh BJ, Berger PB, Tajik AJ. Adverse prognosis of patients with hypertrophic cardiomyopathy who have epicardial coronary artery disease. Circulation. 2003;108:2342-8.

Elliott P, McKenna WJ. Hypertrophic cardiomyopathy. Lancet. 2004;363:1881-91.

Villa BR, Inda CR, Fernandez X, Ortiz MF, Alvarez PL, Rodriguez GI, Prieto HM, et al. Severe cardiac conduction disturbances and pacemaker implantation in patients with hypertrophic cardiomyopathy. Rev Esp Cardiol. 2010;63:985-8.

Cully RB, Nishimura RA, Tajik AJ, Schaff HV, Danielson GK. Extent of clinical improvement after surgical treatment of hypertrophic obstructive cardiomyopathy. Circulation. 1996;94:467-71.

Counihan PJ, Frenneaux MP, Webb DJ, McKenna WJ. Abnormal vascular responses to supine exercise in hypertrophic cardiomyopathy. Circulation. 1991;84:686-96.

Prasad K, Williams L, Campbell R, Elliott PM, Kenna WJ, Frenneaux M. Episodic syncope in hypertrophic cardiomyopathy: Evidence for inappropriate vasodilation. Heart. 2008;94:1312-7.

Moya A, Sutton R, Ammirati F, Blanc JJ, Brignole M, Dahm JB, et al. Guidelines for the diagnosis and management of syncope: The Task Force for the Diagnosis and management of Syncope of the European Society of Cardiology (ESC). Eur Heart J. 2009;30:2631-71.

Brignole M, Vardas P, Hoffman E, Huikuri H, Moya A, Ricci R, et al. Indications for the use of diagnostic implantable and external ECG loop recorders. Europace. 2009;11:671-87.

Thaman R, Gimeno JR, Murphy RT, Kubo T, Sachdev B, Mogensen J, et al. Prevalence and clinical significance of systolic impairment in hypertrophic cardiomyopathy. Heart. 2005;91:920-5.

Ciro E, Maron BJ, Bonow RO, Cannon RO, Epstein SE. Relation between marked changes in left ventricular outflow tract gradient and disease progression in hypertrophic cardiomyopathy. Am J Cardiol. 1984;53:1103-9.

Guttmann OP, Rahman MS, Mahony C, Anastasakis A, Elliott PM. Atrial fibrillation and thromboembolism in patients with hypertrophic cardiomyopathy: systematic review. Heart. 2013;100(6):465-72.

Mahony C, Jichi F, Pavlou M, Monserrat L, Anastasakis A, Rapezzi C, et al. A novel clinical risk prediction model for sudden cardiac death in hypertrophic cardiomyopathy (HCM Risk-SCD). Eur Heart J. 2014;35:2010-20.

Klues HG, Schiffers A, Maron BJ. Phenotypic spectrum and patterns of left ventricular hypertrophy in hypertrophic cardiomyopathy: Morphologic observations and significance as assessed by two-dimensional echocardiography in 600 patients. J Am Coll Cardiol. 1995;26:1699-708.

Maron MS, Olivotto I, Zenovich AG. Hypertrophic cardiomyopathy is predominantly a disease of left ventricular outflow tract obstruction. Circulation. 2006;114:2232-9.

Yu EH, Omran AS, Wigle ED, Williams WG, Siu SC, Rakowski H. Mitral regurgitation in hypertrophic obstructive cardiomyopathy: relationship to obstruction and relief with myectomy. J Am Coll Cardiol. 2000; 36:2219-25.

Oki T, Fukuda N, Iuchi A, Tabata T, Tanimoto M, Manabe K, et al. Transesophageal echocardiographic evaluation of mitral regurgitation in hypertrophic cardiomyopathy: Contributions of eccentric left ventricular hypertrophy and related abnormalities of the mitral complex. J Am Soc Echocardiogr. 1995;8:503-10.

Grigg LE, Wigle ED, Williams WG, Daniel LB, Rakowski H. Transesophageal Doppler echocardiography in obstructive hypertrophic cardiomyopathy: Clarification of pathophysiology and importance in intraoperative decision making. J Am Coll Cardiol. 1992;20:42-52.

Marwick TH, Stewart WJ, Lever HM, Lytle BW, Rosenkranz ER, Duffy CI, et al. Benefits of intraoperative echocardiography in the surgical management of hypertrophic cardiomyopathy. J Am Coll Cardiol. 1992; 20:1066-72.

Flachskampf FA, Badano L, Daniel WG, Feneck RO, Fox KF, Fraser AG, et al. Recommendations for transoesophageal echocardiography: update 2010. Eur J Echocardiog. 2010;11:557-76.

Morrow AG, Brockenbrough EC. Surgical treatment of idiopathic hypertrophic subaortic stenosis: Technique and hemodynamic results of subaortic ventriculomyotomy. Ann Surg. 1961;154:181-9.

Kirklin JW, Ellis FH. Surgical relief of diffuse sub-valvular aortic stenosis. Circulation. 1961;24:739-42.

Wigle ED, Trimble AS, Adelman AG. Surgery in muscular subaortic stenosis. Prog Cardiovasc Dis. 1968; 11:83-112.

Lillehei CW, Levy MJ. Transatrial exposure for correction of subaortic stenosis. J Am Med Assoc. 1963; 1686:8-13.

Sherrid MV. Obstructive hypertrophic cardiomyopathy: Echocardiography, pathophysiology, and the continuing evolution of surgery for obstruction. Ann Thorac Surg. 2003;75:620-32.

Sherrid MV. An echocardiographic study of the fluid mechanics of obstruction in hypertrophic cardiomyopathy. J Am Coll Cardiol.1993;22:816-24.

Yu EH. Mitral regurgitation in hypertrophic obstructive cardiomyopathy: relationship to obstruction and relief with myectomy. J Am Coll Cardiol. 2000;36:2219-25.

Maron BJ, Spirito P, Shen WK, Haas TS, Formisano F, Link MS et al. Implantable cardioverter-defibrillators and prevention of sudden cardiac death in hypertrophic cardiomyopathy. JAMA. 2007;298:405-12.

Wan CKN, Dearani JA, Sundt TM, Ommen SR, Schaff HV. What Is the Best Surgical Treatment for Obstructive Hypertrophic Cardiomyopathy and Degenerative Mitral Regurgitation. Ann Thorac Surg. 2009;88:727-32.