Echocardiography before and after resect-plicate-release surgical myectomy for obstructive hypertrophic
Dan G Halpern1, Daniel G Swistel2, Jose Ricardo Po1
1Hypertrophic Cardiomyopathy Program and Echocardiography Laboratory, Division of Cardiology, Mount Sinai Roosevelt and Mount Sinai St. Luke's Hospitals, New York, New York.
Insights
The resect-plicate-release operation effectively treats obstructive hypertrophic cardiomyopathy by correcting anatomical abnormalities. This surgical approach reduces mitral leaflet protrusion and improves physiological outcomes.
Area of Science:
- Cardiovascular Surgery
- Cardiac Anatomy
- Echocardiography
Background:
- Obstructive hypertrophic cardiomyopathy (oHCM) is characterized by septal hypertrophy, elongated mitral leaflets, and anteriorly displaced papillary muscles.
- The resect-plicate-release operation combines myectomy with anterior mitral leaflet (AML) plication and anterolateral papillary muscle (APM) release for selected oHCM patients.
Purpose of the Study:
- To evaluate the association between preoperative anatomical findings and surgical procedures performed.
- To assess the postoperative anatomical corrections achieved.
- To determine the consistency of physiological outcomes following the resect-plicate-release operation.
Main Methods:
- Retrospective analysis of patients with oHCM undergoing the resect-plicate-release operation between 2006 and 2012.
- Preoperative and postoperative echocardiographic data were analyzed.
- Surgical procedures included myectomy, AML plication, and APM release.
Main Results:
- Patients undergoing AML plication had longer preoperative AMLs; plication reduced AML length, residual leaflet length, and protrusion.
- Anterior extension of the APM was more frequent in patients who underwent release.
- Surgery effectively abolished systolic anterior motion, reduced resting gradients, and improved mitral regurgitation.
Conclusions:
- Echocardiographic assessment of AML length guides plication extent, decreasing protrusion and increasing leaflet stiffness.
- Anterior APM anatomy indicates the benefit of release, repositioning the mitral coaptation point posteriorly.
- Systematic surgical relief of obstructive pathophysiology yields consistent, favorable patient outcomes.
Background:
Anatomic features of obstructive hypertrophic cardiomyopathy are septal hypertrophy, elongated mitral leaflets, and anterior displacement of the papillary muscles. In addition to extended myectomy, the resect-plicate-release operation adds horizontal plication of the anterior mitral leaflet (AML) and release of the anterolateral papillary muscle (APM) in selected patients. The aim of this study was to test the hypotheses that (1) preoperative findings would be associated with procedures applied, (2) anatomic corrections would be observable postoperatively, and (3) there would be consistently good physiologic outcomes.
Methods:
A retrospective study was conducted of patients with obstructive hypertrophic cardiomyopathy who had adequate echocardiograms before and 9.5 ± 12 months after the resect-plicate-release operation was performed from 2006 to 2012.
Results:
Seventy-seven patients underwent myectomy, 50 AML plication, and 50 APM release. Patients who underwent plication had longer AMLs (32 ± 4 vs 28 ± 4 mm; P < .004). Anterior extension of the APM was more common with papillary muscle release (86% vs 62%, P < .04). Twenty-seven (35%) had septal thickness ≤ 18 mm; mitral valve-sparing operations were possible because of plication in 19 patients (70%), papillary release in 21 (78%), and one or both in 96%. Patients who underwent plication had decreased AML length by 16%, residual leaflet length by 33%, and protrusion by 24%. After APM release, there was decreased distance from mitral coaptation to the posterior wall. Surgery abolished severe systolic anterior motion and resting gradients and reduced mitral regurgitation.
Conclusions:
Echocardiographic AML length and directly observed slack provides a basis to recommend performance of plication and define its extent; plication decreases AML protrusion and stiffens the leaflet. Anterior APM recommends release, which drops the coaptation point posteriorly. Systematic relief of all aspects of obstructive pathophysiology results in consistent outcomes.
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