Resection, Plication, Release--the RPR procedure for obstructive hypertrophic cardiomyopathy

Area of Science:

• Cardiovascular Surgery
• Cardiac Surgery
• Cardiology

Background:

• Hypertrophic cardiomyopathy (HCM) often causes left ventricular outflow tract (LVOT) obstruction, classically managed with septal myectomy.
• Inconsistent results with traditional septal myectomy have led to the development of extended techniques, including papillary muscle release and mitral leaflet plication.
• The RPR (resection-plication-release) operation is a novel surgical approach for complex HCM pathology.

Purpose of the Study:

• To investigate the mid-term outcomes of the RPR operation for surgical management of both simple and complex HCM.
• To evaluate the efficacy of the RPR procedure in reducing LVOT obstruction and improving mitral insufficiency in HCM patients.

Main Methods:

• Forty-two patients with HCM underwent surgical procedures, including extended myectomy alone, myectomy with papillary muscle release or mitral leaflet plication, or the full RPR procedure.
• Pre- and post-operative transesophageal echocardiograms assessed LVOT gradient and mitral insufficiency.
• Trans-thoracic echocardiograms were performed at a mean follow-up of 3.4 years to evaluate long-term results.

Main Results:

• The RPR procedure was performed in 21 patients, with 13 receiving partial procedures and 7 undergoing myectomy alone.
• Preoperative LVOT obstruction (137 mm Hg) and mitral insufficiency (grade 3.1) were significantly reduced postoperatively to 10 mm Hg and grade 0.2, respectively.
• At mid-term follow-up, LVOT gradient remained low (6 mm Hg) and mitral insufficiency trivial (grade 0.4), with no hospital deaths or reoperations.

Conclusions:

• The RPR operation, tailored to individual HCM anatomy, provides durable mid-term results for LVOT obstruction and mitral valve pathology.
• Appreciating and appropriately repairing mitral valve pathology alongside adequate septal myectomy is crucial for achieving successful long-term outcomes in HCM patients.
• The RPR approach offers a safe and effective surgical solution for complex hypertrophic cardiomyopathy, addressing both obstructive and valvular components.