Septal Myectomy and Concomitant Coronary Artery Bypass Grafting for Patients With Hypertrophic Cardiomyopathy and Coronary Artery Disease

Percutaneous coronary intervention in patients with hypertrophic cardiomyopathy and coronary artery disease

BackgroundCoronary artery disease and left ventricular outflow tract obstruction may overlap in symptoms in patients with hypertrophic cardiomyopathy. It has not been clear if coronary revascularization relieves exertional symptoms in patients with hypertrophic cardiomyopathy.MethodsWe reviewed 156 patients with hypertrophic cardiomyopathy who underwent percutaneous coronary intervention at Anzhen Hospital from 2009 to 2019. Improvement in symptoms after the percutaneous coronary intervention was investigated.ResultsThe mean age was 60.8 ± 9.8 years, and 116 (74.4%) were men. The main symptoms of the patients were chest tightness in 115 (73.7%), chest pain in 88 (56.4%), dyspnea in 50 (32.1%), palpitation in 22 (14.1%), and presyncope/syncope in 12 (7.7%). At rest, the systolic anterior motion of the mitral valve was observed in only 36 patients. Among the 156 patients, 64 had single-vessel disease, 46 had two-vessel diseases, and the other 46 had three-vessel diseases. There was no early mortality in the present cohort. After the coronary intervention, there were significant improvements in symptoms including chest tightness (6.4%), chest pain (1.3%), dyspnea (2.6%), and palpitation (8.3%). In 93 patients with follow-up data, the overall survival was 77% at 10 years and the survival free from intervention was 60% at 10 years.ConclusionsIn patients with hypertrophic cardiomyopathy, coronary artery disease can be an important cause of symptoms and should be screened. Percutaneous coronary intervention is safe and effective for coronary revascularization. Cardiac symptoms can be significantly relieved and long-term outcomes are favorable.

Clinical Outcomes of Concomitant Coronary Artery Bypass Grafting During Ventricular Septal Myectomy

BACKGROUND

The clinical characteristics and survival outcomes of patients who underwent concomitant coronary artery bypass grafting during septal myectomy have not been well studied.

METHODS AND RESULTS

We reviewed patients who underwent both septal myectomy and coronary artery bypass grafting from 2009 to 2020. Causes of concomitant grafting and their impact on survival were analyzed. The median follow-up period was 5.1 years. A total of 320 patients underwent both grafting and myectomy. Of these, 69.7% and 28.1% underwent grafting attributed to atherosclerotic coronary artery disease and myocardial bridging, respectively. Patients who underwent grafting for coronary artery disease tended to be older, had a longer bypass time, and required more grafts compared with patients undergoing procedures because of myocardial bridging (all P<0.05). Postoperatively, the left ventricular outflow gradient significantly decreased from 85.4 mm Hg to 12.8 mm Hg (P<0.001) without perioperative death. The cumulative survival rates were 96.2% and 97.6% at 5 years in the coronary artery disease and myocardial bridging groups, respectively, and they were comparable to that of general myectomy cohort (hazard ratio [HR], 1.06 [95% CI, 0.47-2.36], P=0.895 and HR 0.75 [95% CI, 0.23-2.46], P=0.636, respectively). Sudden death accounted for 45.5% (5 of 11) of postoperative mortality. Analysis of composite end point events showed decreased morbidity with at least one arterial graft in the overall cohort (HR, 0.47 [95% CI, 0.23-0.94], P=0.034).

CONCLUSIONS

Concomitant grafting in septal myectomy was found to be a safe procedure. Patients who underwent such surgery experienced favorable postoperative outcomes comparable to those who underwent septal myectomy alone, with a 5-year survival rate of >95% and improved functional class of >90%.

Changes in left ventricular-aortic angulation are associated with the development of obstruction in hypertrophic cardiomyopathy

OBJECTIVE

To characterize changes in ventricular morphology in patients with hypertrophic cardiomyopathy who develop left ventricular (LV) outflow tract obstruction.

METHODS

We reviewed patients with hypertrophic cardiomyopathy with LV outflow tract obstruction who underwent septal myectomy from May 2012 to June 2023. Among 68 patients initially without obstruction documented up to 7.6 years (interquartile range, 6.3-9.4 years) before the operation, a comparison was made with 78 patients with nonobstructive hypertrophic cardiomyopathy over a similar period. Patients who did not develop obstruction were matched with those who did on sex, age, and maximum septal wall thickness during the initial echocardiography, identifying 41 matched pairs. Echocardiographic data, including 5 measures of angulation, were compared between the groups.

RESULTS

The median interval between echocardiographic assessments was 7.5 years (interquartile range, 6.3-8.1 years) among patients with obstruction versus 7.3 years (interquartile range, 6.2-9.0 years) in patients without nonobstruction. Patients with obstruction were more likely to have hypertension at both times. The maximum septal wall thickness increased within both groups (both P values < .001), but the magnitude of increase was not different between groups (P = .130). Patients with obstruction exhibited a greater increase in LV mass (P < .001) compared with patients without obstruction (P = .004). Aortic angulation significantly increased in 4 of the 5 measurements (all P values < .001) in patients with obstruction, whereas patients with no obstruction showed no change. Anterior and posterior mitral valve leaflet lengths and coaptation lengths remained similar in both groups over time.

CONCLUSIONS

The development of LV outflow tract obstruction in patients with hypertrophic cardiomyopathy was associated with progressive LV outflow tract angulation and increased LV hypertrophy, as reflected by LV mass. Progression to obstruction was not related to changes in the mitral valve leaflet morphology.

Transaortic Shallow Septal Myectomy and Cutting of Secondary Fibrotic Mitral Valve Chordae-A 5-Year Single-Center Experience in the Treatment of Hypertrophic Obstructive Cardiomyopathy

BACKGROUND

Anomalies of the mitral apparatus have been shown to contribute to left ventricular outflow obstruction in patients with hypertrophic cardiomyopathy (HCM). We report our 5-year single-center experience with a shallow myectomy procedure associated with transaortic mitral valve repair in a cohort of HCM patients.

METHODS

We studied 83 consecutive patients who underwent surgical treatment of symptomatic left ventricular outflow obstruction. In all study patients, a transaortic shallow septal myectomy was performed. Fibrous or muscular structures connecting the papillary muscles to the septum or free wall were resected, and fibrotic secondary chordae of the anterior mitral valve were cut selectively.

RESULTS

We report one death (1.2%) during hospitalization, no iatrogenic ventricular septal defects, and two (2.4%) mitral valve replacements. At discharge, no patients were in New York Heart Association (NYHA) Class III/IV, from 49 (59%) preoperatively. Mean maximal septal thickness decreased from 24 ± 6 to 16 ± 3 mm. Mean outflow gradient decreased from 93 ± 33 to 13 ± 11 mmHg. Grade 3 or 4 mitral regurgitation was noticed in one patient postoperatively, from 32 (39%) before surgery.

CONCLUSIONS

Shallow septal myectomy associated with secondary mitral valve chordal cutting and papillary muscle mobilization provided excellent results offering adequate treatment of outflow obstruction.

The preoperative glomerular filtration rate predicts new-onset postoperative atrial fibrillation in patients with hypertrophic obstructive cardiomyopathy who undergo isolated septal myectomy

Background

Few studies have focused on new-onset postoperative atrial fibrillation in patients with hypertrophic obstructive cardiomyopathy who have undergone septal myectomy. Therefore, we investigated the incidence and prognosis effects of postoperative atrial fibrillation following septal myectomy in patients with hypertensive obstructive cardiomyopathy. Additionally, we investigated the relationship of estimated glomerular filtration rate and postoperative atrial fibrillation.

Methods

Data from 300 patients with hypertrophic obstructive cardiomyopathy who underwent isolated surgical septal myectomy were collected from January 2012 to March 2018.

Results

The overall incidence of postoperative atrial fibrillation during hospitalization was 22.67% (68 of 300 patients). Patients with postoperative atrial fibrillation were older (P<0.001), had lower preoperative estimated glomerular filtration rate (P<0.001), and a larger preoperative left atrial diameter (P=0.038) compared to patients without. The preoperative estimated glomerular filtration rate predicted postoperative atrial fibrillation with sensitivity and specificity of 0.824 and 0.578 (P<0.001), respectively. Multivariate regression analyses showed that age [odds ratio (OR) =1.090, 95% confidence interval (CI): 1.034-1.110], an New York Heart Association functional class ≥ III (OR =2.985, 95% CI: 1.349-6.604), hypertension (OR =2.212, 95% CI: 1.062-4.608), a history of syncope (OR =3.890, 95% CI: 1.741-8.692), and the preoperative estimated glomerular filtration rate (OR =0.981, 95% CI: 0.965-0.996) were independent risk factors associated in the development of postoperative atrial fibrillation. Survival analysis showed that the incidence of long-term cardiovascular events was higher in the patients with postoperative atrial fibrillation than that in the patients without the condition (P<0.001).

Conclusions

The preoperative estimated glomerular filtration rate was a moderate predictor of postoperative atrial fibrillation after septal myectomy. Postoperative atrial fibrillation affected the early recovery and the long-term prognoses of patients with hypertrophic obstructive cardiomyopathy who underwent septal myectomy.