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Published on: August 8, 2022
Surgical management of left ventricular outflow tract obstruction in a specialized hypertrophic obstructive
Kevin Hodges1, Carlos Godoy Rivas2, José Aguilera3
1Departments of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
Insights
Septal myectomy is a safe and effective procedure for left ventricular outflow tract obstruction, especially when performed by experienced surgeons at specialized centers. Mitral valve intervention can be a valuable addition for patients with moderate hypertrophy.
Area of Science:
- Cardiovascular Surgery
- Hypertrophic Cardiomyopathy Management
- Surgical Outcomes Research
Background:
- Left ventricular outflow tract obstruction (LVOTO) is a significant complication of hypertrophic cardiomyopathy (HCM).
- Surgical management, particularly septal myectomy, aims to relieve obstruction and improve patient outcomes.
- Optimizing surgical techniques and understanding adjunct procedures are crucial for successful HCM treatment.
Purpose of the Study:
- To evaluate the operative approaches and surgical outcomes for left ventricular outflow tract obstruction (LVOTO).
- To assess the safety and efficacy of septal myectomy and concomitant mitral valve interventions.
- To analyze results from a single surgeon at a high-volume, specialized hypertrophic cardiomyopathy center.
Main Methods:
- Retrospective review of 1559 consecutive operations for LVOTO between 2005 and 2015.
- Analysis of demographic profiles, echocardiogram data, operative details, and in-hospital outcomes.
- Categorization of procedures into isolated septal myectomies, myectomies with mitral valve intervention, and other concomitant procedures.
Main Results:
- Operative mortality was low at 0.38% with rare complications like ventricular septal defects (0.13%).
- Septal myectomy with mitral valve intervention was associated with thinner septums and less myocardium removed compared to myectomy alone.
- Permanent pacemaker insertion for complete heart block occurred in 4.2% of patients.
Conclusions:
- Septal myectomy is a safe procedure with excellent outcomes when performed by experienced surgeons in specialized centers.
- Mitral valve intervention serves as a beneficial adjunct for patients with moderate hypertrophy causing LVOTO.
- This study highlights the importance of specialized care and experienced surgical teams in managing complex HCM cases.
Objectives:
This study evaluates operative approach and contemporary surgical outcomes in the management of left ventricular outflow tract obstruction by a single surgeon at a high-volume, specialized hypertrophic cardiomyopathy center.
Methods:
This is a retrospective review of 1559 consecutive operations for left ventricular outflow tract obstruction from 2005 to 2015. Demographic profiles, echocardiogram-derived ventricular morphology and hemodynamics, operative data, and in-hospital outcomes were analyzed.
Results:
Of the 1559 operations, 586 were isolated septal myectomies, 522 were myectomies with mitral valve or subvalvular apparatus intervention, 422 were myectomies with another concomitant procedure, and 29 were isolated mitral valve interventions without myectomy. Common mitral valve interventions included anterior leaflet shortening (16%), chordae tendineae resection (9.8%), papillary muscle resection (7.2%), and papillary muscle reorientation (7.5%). Ninety-two patients underwent mitral valve replacement, 42 for left ventricular outflow tract obstruction and 50 for intrinsic mitral valve pathology. Patients undergoing mitral interventions had thinner septums (18 ± 0.4 mm vs 22 ± 0.5 mm, P < .001) and less myocardium removed (6.2 ± 3.5 g vs 8.8 ± 3.8 g, P < .001) than patients without a mitral intervention. Prevalence of in-hospital permanent pacemaker insertion was 4.2% (n = 1334) for complete heart block and 1.1% (n = 464) for isolated septal myectomy with normal preoperative conduction. Overall, there were 2 postoperative ventricular septal defects (0.13%) and none for isolated myectomies. Operative mortality was 0.38%.
Conclusions:
Septal myectomy can be performed safely with excellent outcomes when the procedure is performed by a highly experienced surgeon in a high-volume, specialized center. A mitral valve intervention is a useful adjunct in patients with moderate hypertrophy.
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