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Association Between Three-Dimensional Left Ventricular Outflow Tract Area and Gradients After Myectomy in
J Moreno Garijo1, Y Amador1, C S Fan2
1Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada.
Insights
Intraoperative 3D left ventricular outflow tract area after septal myectomy correlates with pressure gradients, aiding surgical success assessment in hypertrophic cardiomyopathy. Postoperative gradients are better predicted by immediate post-procedure measurements than long-term rest values.
Area of Science:
- Cardiology
- Cardiovascular Surgery
- Medical Imaging
Background:
- Hypertrophic obstructive cardiomyopathy (HOCM) presents a significant challenge in cardiac surgery.
- Septal myectomy is a key surgical intervention for HOCM, aiming to relieve left ventricular outflow tract (LVOT) obstruction.
- Assessing surgical success and predicting residual obstruction are crucial for patient outcomes.
Purpose of the Study:
- To investigate the correlation between intraoperative three-dimensional (3D) left ventricular outflow tract (LVOT) cross-sectional area and pressure gradients post-septal myectomy.
- To determine if LVOT area is a determinant of surgical success in hypertrophic cardiomyopathy patients.
Main Methods:
- Retrospective review of perioperative data from 67 hypertrophic obstructive cardiomyopathy patients.
- Intraoperative transesophageal echocardiography (TEE) for pressure gradient and 3D LVOT area assessment.
- Transthoracic echocardiography for postoperative gradient evaluation.
Main Results:
- The LVOT area significantly increased post-myectomy (average 1.883 cm²).
- A significant inverse correlation was found between the increase in LVOT area and intraoperative transesophageal pressure gradients (r = -0.32, p = 0.01).
- Predictors of high residual gradients included preoperative transesophageal gradient, postoperative transesophageal LVOT area, and mitral regurgitation.
Conclusions:
- Intraoperative 3D LVOT area measured by TEE after septal myectomy correlates with immediate postoperative transesophageal pressure gradients.
- Patients with persistent elevated transthoracic gradients at follow-up had smaller intraoperative TEE LVOT areas and higher transesophageal gradients.
- Immediate transesophageal pressure gradients post-myectomy showed poor correlation with long-term resting transthoracic gradients.
Objective:
Determine whether the intraoperative three-dimensional left ventricular outflow tract cross-sectional area may be inversely correlated with pressure gradients as a determinant of surgical success after septal myectomy in hypertrophic cardiomyopathy patients.
Design:
Perioperative data were obtained by retrospective review.
Setting:
Toronto General Hospital, University of Toronto, Toronto, Canada, a tertiary hospital.
Participants:
The study comprised 67 patients with hypertrophic obstructive cardiomyopathy.
Interventions:
Transthoracic and intraoperative transesophageal echocardiographic assessment of pressure gradients. Transesophageal measurement of the three-dimensional left ventricular outflow tract cross-sectional area.
Measurements And Main Results:
The smallest left ventricular outflow tract area increased on average 1.883 cm2 (98.3%) after septal myectomy. There was a significant correlation between the increase in the area and the transesophageal pressure gradients (r = -0.32; p = 0.01) after myectomy, but none with postoperative transthoracic gradients at rest (r = -0.10; p = 0.42). Postoperative transesophageal and transthoracic gradients were significantly correlated (r = 0.26; p = 0.04). The best risk factors to predict high residual gradients were preoperative transesophageal gradient >97 mmHg, postoperative transesophageal area <3.16 cm2, and moderate or more residual transesophageal mitral regurgitation (specificity 89%, 81%, and 78%, respectively).
Conclusions:
Three-dimensional left ventricular outflow tract area measurements with transesophageal echocardiography after myectomy correlated fairly well with postoperative transesophageal pressure gradients. Patients with residual transthoracic elevated gradients after surgery at follow-up had a smaller transesophageal area and higher transesophageal pressure gradients immediately after the procedure. However, transesophageal pressure gradients after myectomy correlated poorly with follow-up transthoracic gradients at rest.
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