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Surgical management of hypertrophic obstructive cardiomyopathy. Early and late results
B Heric1, B W Lytle, D P Miller
1Madigan Army Medical Center, Dept. of Thoracic Surgery, Tacoma, WA 98431-5000, USA.
Insights
Septal myectomy effectively relieves symptoms and improves long-term survival for hypertrophic obstructive cardiomyopathy patients. Combining it with coronary artery bypass grafting offers excellent outcomes, while valve procedures may impact late survival.
Area of Science:
- Cardiology
- Cardiac Surgery
- Cardiovascular Medicine
Background:
- Hypertrophic obstructive cardiomyopathy (HOCM) presents a significant challenge in cardiac surgery.
- Surgical management aims to relieve left ventricular outflow tract obstruction and improve patient outcomes.
Purpose of the Study:
- To evaluate the long-term efficacy and safety of surgical interventions for hypertrophic obstructive cardiomyopathy.
- To assess the impact of different surgical approaches, including septal myectomy and concomitant procedures, on patient survival and symptom relief.
Main Methods:
- Retrospective analysis of 178 patients who underwent surgical management for HOCM between 1975 and 1993.
- Procedures included isolated septal myectomy, septal myectomy with coronary artery bypass grafting, and septal myectomy with valve procedures.
- Transesophageal echocardiography was used for monitoring, and long-term survival data were analyzed.
Main Results:
- Septal myectomy significantly reduced left ventricular outflow tract systolic gradients from 93 mm Hg to 21 mm Hg.
- In-hospital mortality was 6% for septal myectomy and 4% for septal myectomy plus coronary artery bypass grafting.
- Long-term survival at 5 and 10 years was 86% and 70%, respectively, with a low yearly mortality of 0.6% for cardiac deaths after initial recovery.
- Concomitant valve operations, especially mitral valve replacement, were associated with reduced late survival (5-year survival 51%).
- 94% of patients reported New York Heart Association class I or II symptoms at follow-up.
Conclusions:
- Septal myectomy, alone or with coronary artery bypass grafting, is an effective treatment for HOCM, providing significant symptom relief and excellent long-term survival.
- The addition of valve procedures, particularly mitral valve replacement, may adversely affect late survival in HOCM patients.
- Surgical septal myectomy remains a cornerstone for managing symptomatic hypertrophic obstructive cardiomyopathy.
Abstract:
From 1975 through 1993, 178 patients underwent surgical management of hypertrophic obstructive cardiomyopathy. Operations included isolated septal myectomy (n = 95), septal myectomy and coronary artery bypass grafting (n = 41), septal myectomy plus a valve procedure (n = 25), septal myectomy, valve procedure, and coronary artery bypass grafting (n = 14), and mitral valve replacement without septal myectomy (n = 3). Recent myectomy results were monitored with transesophageal echocardiography. After initial myectomy, 32 patients (20%) underwent a second pump run for more extensive myectomy only (n = 22), mitral valve replacement only (n = 5), or both (n = 2). In-hospital mortality was 6% (n = 11) and 4% (n = 6) for patients undergoing septal myectomy or septal myectomy plus coronary artery bypass grafting, respectively. Heart block occurred in 17 patients (10%). Left ventricular outflow tract systolic gradients decreased from a mean of 93 mm Hg to 21 mm Hg after myectomy. Late survival was 86% and 70% at 5 and 10 postoperative years, respectively, and 93% and 79% for patients undergoing septal myectomy alone or septal myectomy plus coronary artery bypass grafting, respectively. Only 3 of 131 in-hospital survivors of septal myectomy or septal myectomy plus coronary artery bypass grafting died late cardiac deaths, for a yearly mortality of 0.6%. However, the 5-year late survival of patients undergoing valve operation plus septal myectomy was 51%, and multivariate testing confirmed the adverse influence on late survival (p = 0.008), as well as adverse influences of increasing age (p = 0.016) and return to cardiopulmonary bypass for mitral valve replacement (p = 0.038). At follow-up 136 patients (94%) had New York Heart Association class I or II symptoms. For patients with hypertrophic obstructive cardiomyopathy, septal myectomy alone or in combination with coronary artery bypass grafting produces effective symptom relief, excellent long-term survival, and a low risk of late cardiac death.