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Mitral Regurgitation in Patients With Hypertrophic Obstructive Cardiomyopathy: Implications for Concomitant Valve
Joon Hwa Hong1, Hartzell V Schaff1, Rick A Nishimura2
1Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
Insights
Mitral regurgitation in hypertrophic obstructive cardiomyopathy (HOCM) patients often resolves with septal myectomy alone. Mitral valve surgery is typically unnecessary unless intrinsic valve disease is present; repair offers better survival than replacement.
Area of Science:
- Cardiology
- Cardiac Surgery
- Cardiovascular Imaging
Background:
- Hypertrophic obstructive cardiomyopathy (HOCM) presents unique challenges in managing mitral regurgitation (MR).
- The role and outcomes of mitral valve (MV) surgery in conjunction with extended transaortic septal myectomy for HOCM are not well-defined.
Purpose of the Study:
- To determine the indications for and optimal surgical strategy for addressing MR in HOCM patients.
- To evaluate the necessity and outcomes of concomitant MV surgery during septal myectomy.
Main Methods:
- Retrospective review of 2,004 septal myectomy operations in 1,993 adult patients (1993-2014).
- Exclusion of patients with prior MV operations or apical hypertrophic cardiomyopathy.
- Analysis of pre-operative and post-operative MR severity, intraoperative findings, and MV surgical interventions.
Main Results:
- Pre-operative MR (grade ≥3) was present in 57.5% of patients, primarily due to systolic anterior motion.
- Isolated septal myectomy effectively reduced significant MR in most cases (54.3% to 1.7%).
- Concomitant MV surgery was performed in 75 patients due to intrinsic MV disease, with repair (86.7%) preferred over replacement (13.3%); MV repair demonstrated superior late survival (80.0% at 10 years) compared to replacement (55.2%).
Conclusions:
- Septal myectomy alone adequately addresses MR caused by systolic anterior motion in most HOCM patients.
- Concomitant MV surgery is indicated only when intrinsic MV disease is identified.
- Mitral valve repair is associated with improved long-term survival compared to valve replacement in HOCM patients requiring MV intervention.
Background:
Incidence and outcome of mitral valve (MV) surgery are unknown in patients with hypertrophic obstructive cardiomyopathy (HOCM) undergoing extended transaortic septal myectomy.
Objectives:
This study sought to define indications and suitable operative strategy for mitral regurgitation (MR) in patients with HOCM.
Methods:
A total of 2,107 septal myectomy operations performed in adults from January 1993 to May 2014 at Mayo Clinic in Rochester, Minnesota, were retrospectively reviewed. Patients with prior MV operation and apical hypertrophic cardiomyopathy were excluded. Overall, 2,004 operations were performed in 1,993 patients.
Results:
Pre-operative MR was grade ≥3 (of 4) in 1,152 operations (57.5%). Systolic anterior motion of mitral leaflets caused the MR in most patients. However, intrinsic MV disease was identified pre-operatively in 99 patients, all of whom had MV surgery (with septal myectomy). In 1,905 operations, no intrinsic MV disease was identified pre-operatively; in 1,830 (96.1%), septal myectomy was performed without a direct MV procedure. For 75 patients, intrinsic MV disease discovered intraoperatively led to concomitant MV repair (86.7%) or replacement (13.3%). After isolated septal myectomy, the percentage of patients with MR grade ≥3 decreased from 54.3% to 1.7% (p = 0.001) on early post-operative echocardiography. Among 174 patients with concomitant MV surgery, late survival was superior with MV repair (n = 133 [76.4%]) versus replacement (10-year survival: 80.0% vs. 55.2%; p = 0.002).
Conclusions:
In most patients with HOCM, MR related to systolic anterior motion of the MV is relieved through adequate myectomy. Concomitant MV surgery is rarely necessary unless intrinsic MV disease is present. When MV procedures are required, repair is preferred because of improved survival compared with replacement.
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