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Septal Myectomy With Vs Without Subvalvular Apparatus Intervention in Patients With Hypertrophic Obstructive
Alexander Bogachev-Prokophiev1, Alexander V Afanasyev1, Sergei Zheleznev1
1Heart Valve Surgery Department, Meshalkin National Medical Research Center, Novosibirsk, Russian Federation.
Insights
Adding subvalvular intervention to septal myectomy significantly reduces residual mitral regurgitation and left ventricular outflow tract obstruction in hypertrophic obstructive cardiomyopathy patients. This combined approach offers improved outcomes without immediate clinical benefit at one year.
Area of Science:
- Cardiovascular Surgery
- Cardiology
- Medical Interventions
Background:
- Hypertrophic obstructive cardiomyopathy (HOCM) is often treated with surgical septal myectomy.
- Mitral valve subvalvular abnormalities can contribute to persistent left ventricular outflow tract obstruction post-myectomy.
- The role of addressing these abnormalities concurrently requires further investigation.
Purpose of the Study:
- To compare the surgical outcomes of septal myectomy with and without concomitant subvalvular interventions in HOCM patients.
- To evaluate the effectiveness in reducing residual left ventricular outflow tract obstruction and mitral regurgitation.
- To assess clinical outcomes at 12-month follow-up.
Main Methods:
- A randomized study involving 80 HOCM patients between July 2015 and December 2016.
- Patients were assigned to undergo septal myectomy with or without subvalvular intervention.
- Outcomes measured included gradients, septum thickness, mitral regurgitation, systolic anterior motion (SAM) syndrome, and New York Heart Association (NYHA) functional class.
Main Results:
- The group with subvalvular intervention showed no residual mitral regurgitation, compared to 15% in the control group (P=0.013).
- Residual SAM syndrome was significantly lower in the intervention group (5% vs 27.5%, P=0.007).
- Postoperative gradients were significantly lower in the intervention group (median 8 mmHg vs 13 mmHg, P=0.019), with reduced residual mitral regurgitation prevalence at 1 year (10% vs 32.5%, P=0.010).
Conclusions:
- Concomitant subvalvular intervention during septal myectomy is more effective in eliminating left ventricular outflow tract obstruction.
- This approach significantly improves freedom from residual mitral regurgitation.
- While effective in reducing obstruction and regurgitation, the combined procedure did not demonstrate a significant clinical benefit in NYHA class at the 1-year follow-up.
Abstract:
Surgical septal myectomy is a standard treatment option for patients with hypertrophic obstructive cardiomyopathy. Subvalvular abnormalities of the mitral valve might play an important role in residual left ventricular outflow tract obstruction. This randomized study aimed to compare the surgical outcomes of septal myectomy with vs without subvalvular interventions. Between July 2015 and December 2016, 80 eligible patients were randomly assigned to undergo septal myectomy with vs without subvalvular intervention. The peak gradient was 92.3 ± 16.9 and 88.1 ± 15.4 mm Hg, respectively (P = 0.281). The mean septum thickness was 26.8 ± 4.5 and 26.1 ± 4.2 mm, respectively (P = 0.504). Moderate or severe systolic anterior motion syndrome-mediated mitral regurgitation was observed in all patients. There was no residual mitral regurgitation in the group with subvalvular intervention, while 15% of patients in the control group had regurgitation (P = 0.013). Residual systolic anterior motion syndrome was observed in 5% and 27.5% of patients, respectively (P = 0.007). The median postoperative gradient was 13 (interquartile range 9-16) mm Hg and 8 (interquartile range 4-12) mm Hg, respectively (P = 0. 0.019). At the 12-month follow-up, all patients were alive. There were 87.5% vs 77.5%, and 12.5% vs 22.5% of patients categorized as having New York Heart Association functional classes I and II, respectively (P = 0.378). The prevalence rate of residual mitral regurgitation was 10% and 32.5%, respectively (P = 0.010). Concomitant subvalvular intervention during septal myectomy more effectively eliminates left ventricular outflow tract obstruction, providing better freedom from residual mitral regurgitation without clinical benefit 1 year after surgery.
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