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Edge-to-Edge Mitral Repair Associated With Septal Myectomy in Hypertrophic Obstructive Cardiomyopathy
Elisabetta Lapenna1, Teodora Nisi1, Stefania Ruggeri1
1Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy.
Insights
The edge-to-edge mitral procedure combined with septal myectomy effectively treats hypertrophic obstructive cardiomyopathy and mitral regurgitation, showing excellent long-term clinical and echocardiographic outcomes.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Cardiac Imaging
Background:
- Hypertrophic obstructive cardiomyopathy (HOCM) presents challenges in managing associated mitral regurgitation (MR).
- Septal myectomy is a standard treatment for HOCM, but MR may persist or require additional intervention.
- The edge-to-edge (EE) mitral procedure offers a potential adjunct for MR in HOCM.
Purpose of the Study:
- To evaluate the long-term clinical and echocardiographic results of combining the EE mitral procedure with septal myectomy in HOCM patients.
- To assess the efficacy of the EE technique in addressing MR caused by systolic anterior motion or organic valve pathology.
Main Methods:
- A single-center study included 26 HOCM patients with significant MR (≥2+/4+) and left ventricular outflow tract (LVOT) obstruction.
- Patients underwent combined EE mitral repair and ventricular septal myectomy.
- The EE procedure addressed MR due to systolic anterior motion (19 patients) or posterior leaflet prolapse/flail (7 patients).
Main Results:
- Hospital mortality was 4%, with 100% follow-up (median 6.5 years).
- Eight-year freedom from cardiac death was 88%. The cumulative incidence of reoperation was 7.7% and MR recurrence (≥3+) was 7.9%.
- At long-term follow-up, 92% of patients were in NYHA functional class I-II, and the median LVOT gradient decreased significantly to 9 mm Hg.
Conclusions:
- The EE mitral technique, when combined with septal myectomy, is a safe and effective solution for HOCM patients with MR, particularly when septal thickness limits myectomy alone.
- This combined approach effectively abolishes residual gradients and addresses MR related to systolic anterior motion and organic valve lesions.
- Satisfactory long-term clinical and echocardiographic outcomes are achievable with this combined surgical strategy.
Background:
To assess the long-term clinical and echocardiographic outcomes of the edge-to-edge mitral repair added to septal myectomy in patients with mitral regurgitation (MR) and hypertrophic obstructive cardiomyopathy.
Methods:
This is a single-center study of 26 patients with hypertrophic obstructive cardiomyopathy (septal thickness 17 ± 3 mm, resting left ventricular outflow tract gradient 63 ± 20 mm Hg, MR ≥ 2+/4+) who underwent an EE mitral procedure combined with ventricular septal myectomy. The EE procedure was used to treat MR due to systolic anterior motion in 19 patients (73%) and to posterior leaflet prolapse/flail in 7 (27%).
Results:
Hospital mortality was 4%. Follow-up was 100% complete (median 6.5 years; interquartile range, 2.7 to 9). Freedom from cardiac death was 88% ± 8.4% at 8 years. The 8-year cumulative incidence function of reoperation with death as competing risk was 7.7% ± 5.2%. At 8 years, the cumulative incidence function of recurrence of MR 3+ or greater with death as competing risk was 7.9% ± 5.3%. Residual MR at discharge (hazard ratio 8.3; 95% confidence interval, 2.1 to 32.6; P = .002) and preoperative systolic pulmonary artery pressure (hazard ratio 1.0; 95% confidence interval, 1.0 to 1.1; P = .005) were identified as predictors of MR recurrence. At the last follow-up, 92% of patients were in New York Heart Association functional class I-II, and 72% were in sinus rhythm. The last echocardiographic follow-up showed a median resting left ventricular outflow tract gradient of 9 mm Hg (interquartile range, 7 to 12; P < .001 vs preoperative).
Conclusions:
In hypertrophic obstructive cardiomyopathy patients, when septal thickness was considered inadequate to allow a safe and effective myectomy, the edge-to-edge technique provided a simple, quick, and effective solution by abolishing at the same time residual gradient and systolic anterior motion-related MR. Organic mitral valve lesions such as prolapse and flail could be addressed as well, whenever indicated. Satisfactory clinical and echocardiographic results were maintained at long-term follow-up.
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