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Published on: September 9, 2020
Hypertrophic cardiomyopathy with moderate septal thickness and mitral regurgitation: long-term surgical results
Elisabetta Lapenna1, Teodora Nisi1, Davide Carino1
1Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy.
Insights
In hypertrophic obstructive cardiomyopathy (HOCM) patients, myectomy alone may offer better outcomes than mitral valve surgery, despite a higher rate of residual mitral regurgitation. This suggests a tailored approach based on septal thickness is crucial for managing HOCM.
Area of Science:
- Cardiology
- Cardiac Surgery
- Medical Devices
Background:
- Hypertrophic obstructive cardiomyopathy (HOCM) presents challenges in managing left ventricle outflow tract (LVOT) obstruction and mitral regurgitation (MR).
- Surgical strategies aim to relieve obstruction and improve symptoms, but long-term outcomes vary.
Purpose of the Study:
- To compare the long-term outcomes of septal myectomy alone versus mitral valve (MV) surgery with or without myectomy in HOCM patients.
- To evaluate the effectiveness of different surgical interventions for moderate septal thickness and systolic anterior motion (SAM)-related MR.
Main Methods:
- A retrospective study of 76 HOCM patients with specific septal thickness and MR severity.
- Patients underwent either septal myectomy alone (54%) or MV surgery ± myectomy (46%).
- Outcomes including survival, cardiac death, and MR recurrence were assessed over a median follow-up of 8 years.
Main Results:
- No hospital deaths or ventricular septal defects occurred.
- MV surgery ± myectomy group had longer procedural times and higher low output syndrome incidence.
- Overall survival showed no significant difference, but myectomy alone trended towards lower cardiac mortality and had significantly lower MR recurrence at 9 years.
Conclusions:
- Septal myectomy alone may be associated with a better postoperative course and lower cardiac mortality in selected HOCM patients.
- While myectomy alone may lead to higher residual MR, addressing MV apparatus abnormalities might be necessary in some cases for durable relief.
- Surgical strategy should be individualized based on septal hypertrophy and MV involvement for optimal HOCM management.
Objectives:
The aim of this study was to assess the long-term outcomes of different surgical strategies in patients with hypertrophic obstructive cardiomyopathy (HOCM) with septal thickness ≤18 mm and systolic anterior motion (SAM)-related moderate-to-severe mitral regurgitation (MR).
Methods:
Seventy-six HOCM patients with septal thickness 17 [16; 18] mm, resting left ventricle outflow tract gradient 60 [41; 85] mmHg and SAM-related MR ≥2+/4+, underwent septal myectomy alone (54%) or mitral valve (MV) surgery ± myectomy (46%).
Results:
No hospital death and no ventricular septal defect occurred. Patients undergoing MV surgery ± myectomy had longer cardiopulmonary bypass and X-clamp times (77 [60-106] vs 51 [44-62] min, P < 0.001 and 56 [45-77] vs 32 [28-41] min, P < 0.001) and higher incidence of low output syndrome (11% vs 0%, P = 0.04). Follow-up was 98.6% complete, median 8 years [3-11]. There were no statistically significant differences in overall survival (P = 0.069) with survival rates at 9 years of 96 ± 4% in the myectomy alone group and 81 ± 8% in the MV surgery ± myectomy one. At 9 years, cumulative incidence function of cardiac death was 12 ± 6% in the MV surgery ± myectomy group vs 0% in the myectomy one, P = 0.06. Multivariable analysis identified age and previous septal alcoholization as predictors of cardiac death (hazard ratio (HR) = 1.1, 95% confidence interval (CI) 1.0-1.1, P = 0.004 and HR = 2.9, 95% CI 1.0-8.3, P = 0.042). The 9-year cumulative incidence function of recurrence of MR ≥2+, with death as competing risk, was 3 ± 2.8% in the MV surgery ± myectomy group vs 25 ± 6.9% in the myectomy one, P = 0.005.
Conclusions:
In HOCM patients with moderate septal thickness and SAM-related MR, as the degree of septal hypertrophy decreases, addressing the abnormalities of the MV apparatus may become necessary to provide a durable resolution of left ventricle outflow tract obstruction and SAM-related MR. However, performing myectomy alone, whenever possible, seems to be associated to a better postoperative course and a trend towards lower cardiac mortality at follow-up, despite a higher rate of residual moderate MR.
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