Surgical management of midventricular and apical hypertrophic cardiomyopathy

Area of Science:

• Cardiovascular Surgery
• Cardiology
• Medical Devices

Background:

• Hypertrophic cardiomyopathy (HCM) presents diverse phenotypes (subaortic, midventricular, apical) with unique surgical challenges.
• Transaortic septal myectomy is standard for subaortic obstruction but may lack exposure for midventricular or apical HCM.
• Limitations in traditional myectomy necessitate alternative approaches for complex HCM cases.

Purpose of the Study:

• To review the clinical indications, surgical technique, and outcomes of transapical myectomy for complex HCM.
• To highlight transapical myectomy as an adjunct or alternative to transaortic myectomy.
• To underscore the role of transapical myectomy in managing diverse HCM phenotypes.

Main Methods:

• Utilized a transapical incision for myectomy in mid and distal left ventricular portions.
• Reviewed three decades of surgical data from Mayo Clinic.
• Focused on outcomes including symptom relief, exercise capacity, and long-term survival.

Main Results:

• Transapical myectomy demonstrated safety and efficacy in treating midventricular obstruction (MVO) and apical HCM.
• The approach allows direct visualization for complete resection of hypertrophied septum and papillary muscles, relieving gradients.
• Apical myectomy improved left ventricular volumes, symptoms, and exercise capacity in apical HCM patients.
• Low procedural morbidity and mortality with durable symptomatic relief and favorable long-term survival observed.

Conclusions:

• Transapical myectomy is a safe, effective surgical strategy for complex HCM phenotypes, including MVO and apical HCM.
• This approach offers significant advantages in visualization and resection compared to transaortic myectomy for specific HCM types.
• Transapical myectomy serves as a viable alternative to heart transplantation for select patients with advanced heart failure symptoms.