1
|
Maron BJ, Dearani JA, Smedira NG, Schaff HV, Wang S, Rastegar H, Ralph-Edwards A, Ferrazzi P, Swistel D, Shemin RJ, Quintana E, Bannon PG, Shekar PS, Desai M, Roberts WC, Lever HM, Adler A, Rakowski H, Spirito P, Nishimura RA, Ommen SR, Sherrid MV, Rowin EJ, Maron MS. Ventricular Septal Myectomy for Obstructive Hypertrophic Cardiomyopathy (Analysis Spanning 60 Years Of Practice): AJC Expert Panel. Am J Cardiol 2022; 180:124-139. [PMID: 35965115 DOI: 10.1016/j.amjcard.2022.06.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 05/23/2022] [Accepted: 06/06/2022] [Indexed: 12/15/2022]
Abstract
Surgical myectomy remains the time-honored primary treatment for hypertrophic cardiomyopathy patients with drug refractory limiting symptoms due to LV outflow obstruction. Based on >50 years experience, surgery reliably reverses disabling heart failure by permanently abolishing mechanical outflow impedance and mitral regurgitation, with normalization of LV pressures and preserved systolic function. A consortium of 10 international currently active myectomy centers report about 11,000 operations, increasing significantly in number over the most recent 15 years. Performed in experienced multidisciplinary institutions, perioperative mortality for myectomy has declined to 0.6%, becoming one of the safest currently performed open-heart procedures. Extended myectomy relieves symptoms in >90% of patients by ≥ 1 NYHA functional class, returning most to normal daily activity, and also with a long-term survival benefit; concomitant Cox-Maze procedure can reduce the number of atrial fibrillation episodes. Surgery, preferably performed in high volume clinical environments, continues to flourish as a guideline-based and preferred high benefit: low treatment risk option for adults and children with drug refractory disabling symptoms from obstruction, despite prior challenges: higher operative mortality/skepticism in 1960s/1970s; dual-chamber pacing in 1990s, alcohol ablation in 2000s, and now introduction of strong negative inotropic drugs potentially useful for symptom management.
Collapse
Affiliation(s)
- Barry J Maron
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, MA.
| | | | | | | | | | | | | | | | | | | | | | | | - Prem S Shekar
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, MA
| | | | - William C Roberts
- Department of Pathology and Medicine; Baylor UniversityMedical Center, Dallas Texas
| | | | - Arnon Adler
- Toronto General Hospital, Toronto Ontario, Canada
| | | | | | | | | | | | - Ethan J Rowin
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, MA
| | - Martin S Maron
- Hypertrophic Cardiomyopathy Center, Lahey Hospital and Medical Center, Burlington, MA
| |
Collapse
|
2
|
Meier AB, Raj Murthi S, Rawat H, Toepfer CN, Santamaria G, Schmid M, Mastantuono E, Schwarzmayr T, Berutti R, Cleuziou J, Ewert P, Görlach A, Klingel K, Laugwitz KL, Seidman CE, Seidman JG, Moretti A, Wolf CM. Cell cycle defects underlie childhood-onset cardiomyopathy associated with Noonan syndrome. iScience 2022; 25:103596. [PMID: 34988410 PMCID: PMC8704485 DOI: 10.1016/j.isci.2021.103596] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/10/2021] [Accepted: 12/04/2021] [Indexed: 11/06/2022] Open
Abstract
Childhood-onset myocardial hypertrophy and cardiomyopathic changes are associated with significant morbidity and mortality in early life, particularly in patients with Noonan syndrome, a multisystemic genetic disorder caused by autosomal dominant mutations in genes of the Ras-MAPK pathway. Although the cardiomyopathy associated with Noonan syndrome (NS-CM) shares certain cardiac features with the hypertrophic cardiomyopathy caused by mutations in sarcomeric proteins (HCM), such as pathological myocardial remodeling, ventricular dysfunction, and increased risk for malignant arrhythmias, the clinical course of NS-CM significantly differs from HCM. This suggests a distinct pathophysiology that remains to be elucidated. Here, through analysis of sarcomeric myosin conformational states, histopathology, and gene expression in left ventricular myocardial tissue from NS-CM, HCM, and normal hearts complemented with disease modeling in cardiomyocytes differentiated from patient-derived PTPN11 N308S/+ induced pluripotent stem cells, we demonstrate distinct disease phenotypes between NS-CM and HCM and uncover cell cycle defects as a potential driver of NS-CM.
Collapse
Affiliation(s)
- Anna B. Meier
- First Department of Medicine, Cardiology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine and Health, Munich 81675, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich Germany
| | - Sarala Raj Murthi
- Department of Congenital Heart Defects and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, School of Medicine and Health, Munich 80636, Germany
| | - Hilansi Rawat
- First Department of Medicine, Cardiology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine and Health, Munich 81675, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich Germany
| | - Christopher N. Toepfer
- Department of Genetics, Harvard Medical School, Boston, MA 02115, USA
- Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX3 9DU, UK
- Wellcome Centre for Human Genetics, University of Oxford, Oxford OX3 7BN, UK
| | - Gianluca Santamaria
- First Department of Medicine, Cardiology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine and Health, Munich 81675, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich Germany
| | - Manuel Schmid
- Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford OX3 9DU, UK
| | - Elisa Mastantuono
- Institute of Human Genetics, Helmholtz Zentrum Munich, German Research Center for Environmental Health, Neuherberg 85764, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich Germany
| | - Thomas Schwarzmayr
- Institute of Human Genetics, Helmholtz Zentrum Munich, German Research Center for Environmental Health, Neuherberg 85764, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich Germany
| | - Riccardo Berutti
- Institute of Human Genetics, Klinikum rechts der Isar, Technical University of Munich, School of Medicine and Health, Munich 81675, Germany
- Institute of Neurogenomics, Helmholtz Zentrum Munich, German Research Center for Environmental Health, Neuherberg 85764, Germany
| | - Julie Cleuziou
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technical University of Munich, Munich 80636, Germany
- INSURE (Institute for Translational Cardiac Surgery), Department of Cardiovascular Surgery, German Heart Center Munich, Technical University of Munich, Munich 80636, Germany
| | - Peter Ewert
- Department of Congenital Heart Defects and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, School of Medicine and Health, Munich 80636, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich Germany
| | - Agnes Görlach
- Department of Congenital Heart Defects and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, School of Medicine and Health, Munich 80636, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich Germany
| | - Karin Klingel
- Institute for Pathology and Neuropathology, Department of Cardiopathology, University Hospital Tuebingen, Tuebingen 72076, Germany
| | - Karl-Ludwig Laugwitz
- First Department of Medicine, Cardiology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine and Health, Munich 81675, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich Germany
| | | | | | - Alessandra Moretti
- First Department of Medicine, Cardiology, Klinikum rechts der Isar, Technical University of Munich, School of Medicine and Health, Munich 81675, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich Germany
| | - Cordula M. Wolf
- Department of Congenital Heart Defects and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, School of Medicine and Health, Munich 80636, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich Germany
| |
Collapse
|
3
|
Hosapatna M, DSouza A, Ankolekar VH. Morphology of the papillary muscles and the chordae tendineae of the ventricles of adult human hearts. Cardiovasc Pathol 2021; 56:107383. [PMID: 34534670 DOI: 10.1016/j.carpath.2021.107383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/12/2021] [Accepted: 08/27/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The papillary muscles (PM) play a vital role in atrioventricular (AV) valve function. The PM and their chordae tendineae (CT) regulate the closure of the AV valve during systole. The present study was undertaken to categorize the PM based on their shapes and variant patterns and CT based on their types and the branching pattern. METHODS This study included formalin-fixed ten adult cadaveric heart specimens. We observed the number, shape, length, breadth, pattern, and presence of extra PM. The number of chordae attached to the tip of each PM was quantified. We classified the types and branching patterns of the chordae and their pattern of attachment to the cusps. RESULTS In the right ventricle, conical, truncated, and flat-topped PM were observed. The anterior PM had 5.3 ± 1.9, the posterior PM had 2.7 ± 2.1, and the septal PM had 3.5 ± 2.3 CT attached to it. In the left ventricle, we observed conical, truncated, flat-topped, bifurcate, and trifurcate shapes of PM. The anterior and the posterior PM had 7.7 ± 2.8 and 7.7 ± 2.7 CT attached to them, respectively. The true CT were cusp, cleft, and commissural and the false CT were pillar-wall, inter-pillar, and strut. We also found 3 branching patterns for the chordae (single, fan-shaped, and web forming). CONCLUSION The study explored the comparative morphology of PM and chordae in the right and left ventricles. The knowledge of the morphological pattern of PM and CT would contribute to the valvular function and aid in diagnosing conditions such as valve prolapse or regurgitation.
Collapse
Affiliation(s)
- Mamatha Hosapatna
- Department of Anatomy, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, India
| | - Anne DSouza
- Department of Anatomy, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, India
| | - Vrinda Hari Ankolekar
- Department of Anatomy, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, India.
| |
Collapse
|
4
|
Surgery for Anomalous Papillary Muscle Directly Into the Anterior Mitral Leaflet. Ann Thorac Surg 2021; 111:1512-1518. [DOI: 10.1016/j.athoracsur.2020.07.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/14/2020] [Accepted: 07/20/2020] [Indexed: 11/23/2022]
|
5
|
Nguyen SN, Blitzer D, Weiner S, Takayama H. Septal Myectomy: How I Teach It. Ann Thorac Surg 2020; 110:764-767. [PMID: 32522633 DOI: 10.1016/j.athoracsur.2020.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 05/13/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Stephanie N Nguyen
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, New York Presbyterian-Columbia University Irving Medical Center, New York, New York
| | - David Blitzer
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, New York Presbyterian-Columbia University Irving Medical Center, New York, New York
| | - Shepard Weiner
- Division of Cardiology, Department of Medicine, New York Presbyterian-Columbia University Irving Medical Center, New York, New York
| | - Hiroo Takayama
- Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, New York Presbyterian-Columbia University Irving Medical Center, New York, New York.
| |
Collapse
|
6
|
Jain CC, Newman DB, Geske JB. Mitral Valve Disease in Hypertrophic Cardiomyopathy:Evaluation and Management. Curr Cardiol Rep 2019; 21:136. [DOI: 10.1007/s11886-019-1231-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
|
7
|
Kaltenecker E, Schleihauf J, Meierhofer C, Shehu N, Mkrtchyan N, Hager A, Kühn A, Cleuziou J, Klingel K, Seidel H, Zenker M, Ewert P, Hessling G, Wolf CM. Long-term outcomes of childhood onset Noonan compared to sarcomere hypertrophic cardiomyopathy. Cardiovasc Diagn Ther 2019; 9:S299-S309. [PMID: 31737538 DOI: 10.21037/cdt.2019.05.01] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background To compare outcome and cardiac pathology between patients with Noonan syndrome (N-HCM) and sarcomere protein-associated (S-HCM) childhood onset hypertrophic cardiomyopathy (HCM). Methods Clinical data were recorded from medical charts. Primary endpoint was survival. Secondary endpoints were survival without hospitalization, without intervention or without arrhythmic events. Functional clinical status and results from genetic testing, imaging, electrocardiographic (ECG) studies, cardiopulmonary exercise testing (CPET) and histopathology were compared between groups. Results Childhood HCM was diagnosed in 29 N-HCM and 34 S-HCM patients. Follow-up time was greater than 10 years in more than half of all patients. Mortality was below 7% and not different between groups. Children with N-HCM presented at a younger age and there was less time of survival without hospitalization for heart failure or intervention in N-HCM compared to S-HCM patients. Clinical functional status improved over time in N-HCM patients. On long-term follow-up, left ventricular posterior wall thickness indexed to body surface area decreased in N-HCM and increased in S-HCM patients. There was a trend to lower risk for severe arrhythmic events in N-HCM patients and only S-HCM individuals received an implantable cardioverter-defibrillator. There were no differences between groups in ventricular function, ECG and CPET parameters. Myocardial fibrosis as assessed by histopathology of myocardial specimens and cardiovascular magnetic resonance with late gadolinium enhancement or T1 mapping was present in both groups. Conclusions When compared to S-HCM patients, children with N-HCM have increased morbidity during early disease course, but favorable long-term outcome with low mortality, stagnation of myocardial hypertrophy, and low risk for malignant arrhythmias.
Collapse
Affiliation(s)
- Emanuel Kaltenecker
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Julia Schleihauf
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Christian Meierhofer
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Nerejda Shehu
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Naira Mkrtchyan
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Alfred Hager
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Andreas Kühn
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Julie Cleuziou
- Department of Cardiovascular Surgery, German Heart Center Munich, Technical University of Munich, Munich, Germany.,(INSURE) Institute for Translational Cardiac Surgery, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Karin Klingel
- Cardiopathology, Institute for Pathology and Neuropathology, University Hospital Tübingen, Tübingen, Germany
| | - Heide Seidel
- Institute of Human Genetics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Martin Zenker
- Institute of Human Genetics, University Hospital, Otto-von-Guericke-University, Magdeburg, Germany
| | - Peter Ewert
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Gabriele Hessling
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Cordula M Wolf
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| |
Collapse
|
8
|
Rajiah P, Fulton NL, Bolen M. Magnetic resonance imaging of the papillary muscles of the left ventricle: normal anatomy, variants, and abnormalities. Insights Imaging 2019; 10:83. [PMID: 31428880 PMCID: PMC6702502 DOI: 10.1186/s13244-019-0761-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 06/18/2019] [Indexed: 02/06/2023] Open
Abstract
Left ventricular papillary muscles are small myocardial structures that play an important role in the functioning of mitral valve and left ventricle. Typically, there are two groups of papillary muscles, namely the anterolateral and the posteromedial groups. Cardiovascular magnetic resonance (CMR) is a valuable imaging modality in the evaluation of papillary muscles, providing both morphological and functional information. There is a remarkably wide variation in the morphology of papillary muscles. These variations can be asymptomatic or associated with symptoms related to LV outflow tract obstruction, often associated with hypertrophic cardiomyopathy. Abnormalities of the papillary muscles range from congenital disorders to neoplasms. Parachute mitral valve is the most common congenital abnormality of papillary muscles, in which all the chordae insert into a single papillary muscle. Papillary muscles can become dysfunctional, most commonly due to ischemia. Papillary muscle rupture is a major complication of acute myocardial infarction that results in mitral regurgitation and associated with high mortality rates. The most common papillary neoplasm is metastasis, but primary benign and malignant neoplasms can also be seen. In this article, we discuss the role of CMR in the evaluation of papillary muscle anatomy, function, and abnormalities.
Collapse
Affiliation(s)
- Prabhakar Rajiah
- Department of Radiology, Cardiothoracic Imaging, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA.
| | | | - Michael Bolen
- Imaging Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| |
Collapse
|
9
|
Costa MACD, Wippich AC. Correction of Left Ventricular Outflow Tract Obstruction Caused by Anomalous Papillary Muscle and Subaortic Membrane. Braz J Cardiovasc Surg 2019; 33:634-637. [PMID: 30652755 PMCID: PMC6326446 DOI: 10.21470/1678-9741-2017-0046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 03/09/2018] [Indexed: 11/04/2022] Open
Abstract
This paper presents a case study of a 30-year-old male patient with dyspnea on exertion had echocardiographic diagnosis of aortic subvalvar stenosis. Discrete mitral regurgitation and aortic valve dysplasia with mild to moderate insufficiency and hypertrophic cardiomyopathy were also noted. During surgery, a rare condition was identified: presence of papillary muscle anomaly associated with the subaortic membrane as a cause of obstruction of the left ventricular outflow tract. With the resection of these structures and a mitral valve annuloplasty, the patient evolved with a significant improvement of clinical condition and heart failure, with no residual mitral insufficiency.
Collapse
|
10
|
Cooper RM, Raphael CE, Liebregts M, Anavekar NS, Veselka J. New Developments in Hypertrophic Cardiomyopathy. Can J Cardiol 2017; 33:1254-1265. [DOI: 10.1016/j.cjca.2017.07.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 07/04/2017] [Accepted: 07/11/2017] [Indexed: 01/22/2023] Open
|
11
|
|
12
|
Kotkar KD, Said SM, Dearani JA, Schaff HV. Hypertrophic obstructive cardiomyopathy: the Mayo Clinic experience. Ann Cardiothorac Surg 2017; 6:329-336. [PMID: 28944173 DOI: 10.21037/acs.2017.07.03] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Hypertrophic cardiomyopathy (HCM) is a primary myocardial disease characterized by left ventricular hypertrophy in the absence of other etiologies. Clinical presentation may vary from asymptomatic to sudden cardiac death. Medical treatment is the first-line therapy for symptomatic patients. Extended left ventricular septal myectomy is the procedure of choice if medical treatment is unsuccessful or intolerable. MAYO CLINIC EXPERIENCE More than 3,000 patients have had septal myectomy for HCM at the Mayo Clinic (MN, USA) from 1993 to 2016. Risk of hospital death after isolated septal myectomy for obstructive HCM is <1% and is similar to the risk of operation for elective mitral valve repair. Complications, such as complete heart block requiring permanent pacemaker, are uncommon (2%), although partial or complete left bundle branch block is a frequent finding on the postoperative ECG. Relief of left ventricular outflow tract (LVOT) obstruction with septal myectomy dramatically improves symptoms and exercise capacity in symptomatic patients with obstructive HCM. More than 90% of severely symptomatic patients have improvement by at least two functional classes, and reduction of outflow gradients by myectomy decreases or eliminates symptoms of dyspnea, angina and/or syncope. Basal obstruction with systolic anterior motion (SAM) is treated by transaortic myectomy. The transapical approach was applied in 115 patients with obstructive midventricular and apical variants of HCM between 1993 and 2012. All patients with midventricular obstruction had gradient relief and none developed an apical aneurysm or ventricular septal defect. Recurrent obstruction after satisfactory myectomy was rare. CONCLUSIONS Septal myectomy effectively and definitively relieves LVOT obstruction and cardiac symptoms in patients with obstructive HCM. In experienced centers, early mortality for isolated septal myectomy is less than 1%, and overall results are excellent and continue to improve in the current era.
Collapse
Affiliation(s)
- Kunal D Kotkar
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Sameh M Said
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
13
|
Anomalous Papillary Muscle Insertion Causing Dynamic Left Ventricular Outflow Tract Obstruction without Hypertrophic Obstructive Cardiomyopathy. Case Rep Cardiol 2017; 2017:9878049. [PMID: 28589043 PMCID: PMC5447279 DOI: 10.1155/2017/9878049] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Accepted: 04/09/2017] [Indexed: 11/18/2022] Open
Abstract
Anomalous papillary muscle insertion directly into the surface of the mitral valve leaflet is rare, especially in a subject without apparent evidence of hypertrophic cardiomyopathy. We present a case of this isolated congenital malformation producing two hemodynamic sequelae of dynamic left ventricular outflow tract obstruction and severe mitral regurgitation.
Collapse
|
14
|
Wang Y, Ye L, Yin L, Zeng J. Hypertrophic angulation deformity of the basal interventricular septum combined with abnormality of the papillary muscle and chordae tendineae. Cardiovasc J Afr 2017; 28:e1-e3. [PMID: 28262912 PMCID: PMC5423432 DOI: 10.5830/cvja-2016-050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 04/06/2016] [Indexed: 11/22/2022] Open
Abstract
A Chinese woman was admitted to our hospital because of syncope. Transthoracic echocardiography revealed a hypertrophic basal interventricular septum of 15 mm with a sharp angle protruding into the left ventricular outflow tract. Moreover, an anomalous anterolateral papillary muscle (maximum width of 11 mm) was inserted into the left ventricular outflow tract, with short chordae tendineae connecting both basal interventricular septum and anterior leaflet of the mitral valve. All of these abnormalities resulted in a left ventricular outflow gradient of 136 mmHg. Surgical septal myectomy of the sharp angle combined with partial papillary muscle resection and removal of the abnormal chordae tendineae was selected to relieve the left ventricular outflow obstruction. This was a rare combination of deformity of the angulation of the focal basal interventricular septum and abnormalities of the papillary muscle and chordae tendineae, which led to left ventricular outflow obstruction.
Collapse
Affiliation(s)
- Yi Wang
- Institute of Ultrasound Medicine, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu 610072, China
| | - Luwei Ye
- Institute of Ultrasound Medicine, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu 610072, China
| | - Lixue Yin
- Institute of Ultrasound Medicine, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu 610072, China
| | - Jie Zeng
- Department of Cardiology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu 610072, China. ;
| |
Collapse
|
15
|
Silbiger JJ. Abnormalities of the Mitral Apparatus in Hypertrophic Cardiomyopathy: Echocardiographic, Pathophysiologic, and Surgical Insights. J Am Soc Echocardiogr 2016; 29:622-39. [DOI: 10.1016/j.echo.2016.03.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Indexed: 12/30/2022]
|
16
|
Conservative approach to mitral valve replacement in hypertrophic cardiomyopathy with systolic anterior motion - a case report. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2016; 12:345-7. [PMID: 26855652 PMCID: PMC4735537 DOI: 10.5114/kitp.2015.56786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Accepted: 12/27/2013] [Indexed: 11/17/2022]
Abstract
The authors report the case of a 60-year-old patient with hypertrophic cardiomyopathy (HCM), systolic anterior motion (SAM), and high gradient in the left ventricular outflow tract (LVOT) who underwent surgical treatment. During the surgery, myomectomy of the septum was performed using the Morrow method: despite the persisting SAM and increased LVOT gradients, the mitral valve was not replaced. The case study presents a conservative approach to mitral valve replacement during HCM surgery.
Collapse
|
17
|
Halpern DG, Swistel DG, Po JR, Joshi R, Winson G, Arabadjian M, Lopresto C, Kushner J, Kim B, Balaram SK, Sherrid MV. Echocardiography before and after Resect-Plicate-Release Surgical Myectomy for Obstructive Hypertrophic Cardiomyopathy. J Am Soc Echocardiogr 2015; 28:1318-28. [DOI: 10.1016/j.echo.2015.07.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Indexed: 11/26/2022]
|
18
|
Cooper RM, Shahzad A, Stables RH. Intervention in HCM: patient selection, procedural approach and emerging techniques in alcohol septal ablation. Echo Res Pract 2015; 2:R25-35. [PMID: 26693329 PMCID: PMC4676471 DOI: 10.1530/erp-14-0058] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 10/30/2014] [Indexed: 11/08/2022] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is a highly heterogeneous disease with varied patterns of hypertrophy. Basal septal hypertrophy and systolic anterior motion (SAM) of the mitral valve (MV) are the key pathophysiological components to left ventricular outflow tract (LVOT) obstruction in HCM. LVOT is associated with higher morbidity and mortality in patients with HCM. Percutaneous septal reduction therapy with alcohol septal ablation (ASA) can lead to a significant improvement in left ventricle haemodynamics, patient symptoms and perhaps prognosis. ASA delivers pure alcohol to an area of myocardium via septal coronary arteries; this creates damage to tissue akin to a myocardial infarction. The basal septal myocardium involved in SAM-septal contact is the target for this iatrogenic infarct. Appropriate patient selection and accurate delivery of alcohol are critical to safe and effective ASA. Securing the correct diagnosis and ensuring suitable cardiac anatomy are essential before considering ASA. Pre-procedural planning and intra-procedural imaging guidance are important to delivering precise damage to the desired area. The procedure is performed worldwide and is generally safe; the need for a pacemaker is the most prominent complication. It is successful in the majority of patients but room for improvement exists. New techniques have been proposed to perform percutaneous septal reduction. We present a review of the relevant pathophysiology, current methods and a summary of available evidence for ASA. We also provide a glimpse into emerging techniques to deliver percutaneous septal reduction therapy.
Collapse
Affiliation(s)
- Robert M Cooper
- Institute of Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital , Thomas Drive, Liverpool, L14 3PE , UK
| | - Adeel Shahzad
- Institute of Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital , Thomas Drive, Liverpool, L14 3PE , UK
| | - Rodney H Stables
- Institute of Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital , Thomas Drive, Liverpool, L14 3PE , UK
| |
Collapse
|
19
|
Hensley N, Dietrich J, Nyhan D, Mitter N, Yee MS, Brady M. Hypertrophic Cardiomyopathy. Anesth Analg 2015; 120:554-569. [DOI: 10.1213/ane.0000000000000538] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
|
20
|
Hinojar R, Moya Mur JL, Fernández-Golfín C, Zamorano JL. Clinical Implications from Three-dimensional Echocardiographic Analysis in Hypertrophic Cardiomyopathy. CURRENT CARDIOVASCULAR IMAGING REPORTS 2014. [DOI: 10.1007/s12410-014-9294-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
21
|
Elliott PM, Anastasakis A, Borger MA, Borggrefe M, Cecchi F, Charron P, Hagege AA, Lafont A, Limongelli G, Mahrholdt H, McKenna WJ, Mogensen J, Nihoyannopoulos P, Nistri S, Pieper PG, Pieske B, Rapezzi C, Rutten FH, Tillmanns C, Watkins H. 2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy: the Task Force for the Diagnosis and Management of Hypertrophic Cardiomyopathy of the European Society of Cardiology (ESC). Eur Heart J 2014; 35:2733-79. [PMID: 25173338 DOI: 10.1093/eurheartj/ehu284] [Citation(s) in RCA: 2823] [Impact Index Per Article: 282.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
MESH Headings
- Ablation Techniques/methods
- Adult
- Angina Pectoris/etiology
- Arrhythmias, Cardiac/etiology
- Cardiac Imaging Techniques/methods
- Cardiac Pacing, Artificial/methods
- Cardiomyopathy, Hypertrophic/diagnosis
- Cardiomyopathy, Hypertrophic/etiology
- Cardiomyopathy, Hypertrophic/therapy
- Child
- Clinical Laboratory Techniques/methods
- Death, Sudden, Cardiac/prevention & control
- Delivery of Health Care
- Diagnosis, Differential
- Electrocardiography/methods
- Female
- Genetic Counseling/methods
- Genetic Testing/methods
- Heart Failure/etiology
- Heart Valve Diseases/diagnosis
- Heart Valve Diseases/therapy
- Humans
- Medical History Taking/methods
- Pedigree
- Physical Examination/methods
- Preconception Care/methods
- Pregnancy
- Pregnancy Complications, Cardiovascular/diagnosis
- Pregnancy Complications, Cardiovascular/therapy
- Prenatal Care/methods
- Risk Factors
- Sports Medicine
- Syncope/etiology
- Thoracic Surgical Procedures/methods
- Ventricular Outflow Obstruction/etiology
Collapse
|
22
|
Modified surgical approach to symptomatic hypertrophic cardiomyopathy with abnormal papillary muscle morphology: Septal myectomy plus papillary muscle repositioning. J Thorac Cardiovasc Surg 2014; 147:1709-11. [DOI: 10.1016/j.jtcvs.2013.10.085] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 09/27/2013] [Accepted: 10/06/2013] [Indexed: 11/22/2022]
|
23
|
Geske JB, Klarich KW, Ommen SR, Schaff HV, Nishimura RA. Septal reduction therapies in hypertrophic cardiomyopathy: comparison of surgical septal myectomy and alcohol septal ablation. Interv Cardiol 2014. [DOI: 10.2217/ica.14.8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
24
|
Said SM, Dearani JA, Ommen SR, Schaff HV. Surgical treatment of hypertrophic cardiomyopathy. Expert Rev Cardiovasc Ther 2014; 11:617-27. [DOI: 10.1586/erc.13.46] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
25
|
Maron BJ, Rastegar H, Udelson JE, Dearani JA, Maron MS. Contemporary surgical management of hypertrophic cardiomyopathy, the need for more myectomy surgeons and disease-specific centers, and the Tufts initiative. Am J Cardiol 2013; 112:1512-5. [PMID: 24012037 DOI: 10.1016/j.amjcard.2013.06.040] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 06/17/2013] [Accepted: 06/18/2013] [Indexed: 11/18/2022]
Affiliation(s)
- Barry J Maron
- Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | | | | | | | | |
Collapse
|
26
|
Kumar P, Blackshear JL, Ibrahim ESH, Mergo P, Parikh P, Batton K, Shapiro B. Advances of cardiovascular MRI in hypertrophic cardiomyopathy. Future Cardiol 2013; 9:697-709. [PMID: 24020671 DOI: 10.2217/fca.13.58] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is a genetic disease characterized by abnormal myocardial hypertrophy, which can lead to a wide clinical spectrum, including sudden cardiac death and heart failure. Cardiac MRI has a significant role in establishing the diagnosis of HCM. In the three principal management issues related to HCM; testing of family members of affected individuals; assessing the risk of sudden cardiac death from lethal ventricular arrhythmias; and selection of appropriate treatments for left ventricular outflow obstruction, cardiac MRI has established or emerging roles.
Collapse
Affiliation(s)
- Preetham Kumar
- Division of Cardiovascular Diseases, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
| | | | | | | | | | | | | |
Collapse
|
27
|
Cooper RM, Shahzad A, Stables RH. Current status of nonsurgical septal reduction therapy in hypertrophic obstructive cardiomyopathy. Interv Cardiol 2013. [DOI: 10.2217/ica.13.33] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
28
|
Gibelli G, Biasi S, Buonamici V. Severe Midventricular Hypertrophic Obstructive Cardiomyopathy and Apical Aneurysm. J Cardiovasc Echogr 2013; 23:81-83. [PMID: 28465890 PMCID: PMC5353388 DOI: 10.4103/2211-4122.123954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
A 40-year-old man was found to have hypertrophic cardiomyopathy (HCM) with severe mid ventricular obstruction. The obstruction produced two distinct left ventricular chambers with an estimated 60 mmHg continuous wave (CW) Doppler intraventricular gradient. Pulsed wave (PW) Doppler showed high velocity systodiastolic flow from apex to base and flow from base to apex confined mostly to the second half of diastole. Cardiac magnetic resonance (CMR) showed midventricular obstruction, due to septal, parietal, and to an hypertrophic, double posteromedial papillary muscle; an apical aneurysm was detected. Aneurysm is underdiagnosed by echocardiography in HCM and an accurate anatomic definition is needed if surgery is planned; thus, a CMR should always be obtained in these patients.
Collapse
Affiliation(s)
- Giuseppe Gibelli
- Department of Cardiology, S Carlo Clinic, Paderno Dugnano, Milan, Italy
| | - Salvatore Biasi
- Department of Cardiology, S Carlo Clinic, Paderno Dugnano, Milan, Italy
| | - Valeria Buonamici
- Department of Cardiology, S Carlo Clinic, Paderno Dugnano, Milan, Italy
| |
Collapse
|
29
|
Rowin EJ, Maron BJ, Lesser JR, Rastegar H, Maron MS. Papillary muscle insertion directly into the anterior mitral leaflet in hypertrophic cardiomyopathy, its identification and cause of outflow obstruction by cardiac magnetic resonance imaging, and its surgical management. Am J Cardiol 2013; 111:1677-9. [PMID: 23499271 DOI: 10.1016/j.amjcard.2013.01.340] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Revised: 01/24/2013] [Accepted: 01/24/2013] [Indexed: 11/19/2022]
Abstract
This case presents an uncommon but important mechanism of muscular left ventricular outflow obstruction in hypertrophic cardiomyopathy due to anomalous and direct papillary muscle insertion into the anterior mitral leaflet, a finding reliably identified clinically by cardiac magnetic resonance imaging. The identification of this left ventricular outflow tract morphology is important before invasive ventricular septal reduction therapy because it dictates a specific surgical strategy. These findings further support the role of cardiac magnetic resonance imaging in the early evaluation of hypertrophic cardiomyopathy patients.
Collapse
Affiliation(s)
- Ethan J Rowin
- Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, Massachusetts, USA
| | | | | | | | | |
Collapse
|
30
|
Furukawa K, Hayase T, Yano M. Mitral valve replacement and septal myectomy for hypertrophic obstructive cardiomyopathy. Gen Thorac Cardiovasc Surg 2013; 62:181-3. [DOI: 10.1007/s11748-013-0245-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 03/24/2013] [Indexed: 10/27/2022]
|
31
|
Strajina V, Živković V, Nikolić S. Anomalous Anterior Papillary Muscle as an Autopsy Finding in Two Cases. J Forensic Sci 2013; 58:544-7. [DOI: 10.1111/1556-4029.12064] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Revised: 10/10/2011] [Accepted: 10/23/2011] [Indexed: 11/27/2022]
Affiliation(s)
- Veljko Strajina
- Institute of Forensic Medicine; University of Belgrade- School of Medicine; 11000; Belgrade; Serbia
| | - Vladimir Živković
- Institute of Forensic Medicine; University of Belgrade- School of Medicine; 11000; Belgrade; Serbia
| | - Slobodan Nikolić
- Institute of Forensic Medicine; University of Belgrade- School of Medicine; 11000; Belgrade; Serbia
| |
Collapse
|
32
|
SA G, RN W, MS F. Morphological variations of papillary muscles in the mitral valve complex in human cadaveric hearts. Singapore Med J 2013; 54:44-8. [DOI: 10.11622/smedj.2013011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
33
|
Abstract
Treatments for hypertrophic cardiomyopathy are largely selected based on patient symptoms and echocardiographic findings. Moreover, all the advanced treatments for heart failure symptoms depend on such imaging for planning and monitoring response to therapy. Risk of sudden death correlates with maximum left ventricular (LV) wall thickness. Massive LV thickening of 30 mm or more is an indication for primary prevention of sudden death with an implanted defibrillator. In this review, we will underscore potential pitfalls in echocardiographic diagnosis. Also we will review, a newly appreciated pathophysiologic mechanism in obstruction dynamic systolic dysfunction due to gradient.
Collapse
Affiliation(s)
- Mark V Sherrid
- Division of Cardiology, St Luke's-Roosevelt Hospital Center, Columbia University, College of Physicians and Surgeons, 1000 10th Ave, New York City, NY 10019, USA.
| | | |
Collapse
|
34
|
Lee SP, Park K, Kim HK, Kim YJ, Sohn DW. Apically displaced papillary muscles mimicking apical hypertrophic cardiomyopathy. Eur Heart J Cardiovasc Imaging 2012; 14:128-34. [PMID: 22715501 DOI: 10.1093/ehjci/jes113] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIMS Apical hypertrophic cardiomyopathy (ApHCM) is a subtype of hypertrophic cardiomyopathy, which is clinically suspected by a characteristic giant negative T (GNT) wave on electrocardiogram (ECG) and diagnosed by demonstrating apical hypertrophy on ECG. However, GNT may not always be specific for ApHCM as in this report of apically displaced papillary muscle (ADPM). METHODS AND RESULTS By retrospectively collecting 12-lead ECGs with a GNT wave and apical hypertrophy on 2D-ECG from 2008 to 2010, we identified 55 patients with both of these findings. ADPM was defined to be present when the base of the papillary muscle originated from the apical one-third of the left ventricle. A diagnosis of ApHCM in patients with apical hypertrophy but without evidence of ADPM was given otherwise. Careful evaluations of 2D-ECGs suggested that 20% (11/55) of all patients had an ADPM mimicking ApHCM. Baseline clinical and echocardiography data were not different between the two except for the maximal T wave on 12-lead ECG and apicoseptal hypertrophy, suggesting that the differentiation of these two groups may be subtle and difficult. In addition, patients with ADPM frequently showed abnormal insertion of papillary muscle into the left ventricular outflow tract or into the base of mitral valve leaflet. CONCLUSION These findings suggest that ADPM may also be present with GNT on 12-lead ECG and emphasizes the careful evaluation of the left ventricular apex for proper diagnosis and discrimination of ApHCM.
Collapse
Affiliation(s)
- Seung-Pyo Lee
- Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | | | | | | | | |
Collapse
|
35
|
|
36
|
Iacovoni A, Spirito P, Simon C, Iascone M, Di Dedda G, De Filippo P, Pentiricci S, Boni L, Senni M, Gavazzi A, Ferrazzi P. A contemporary European experience with surgical septal myectomy in hypertrophic cardiomyopathy. Eur Heart J 2012; 33:2080-7. [PMID: 22522842 PMCID: PMC3418509 DOI: 10.1093/eurheartj/ehs064] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Aims The recent American College of Cardiology and American Heart Association Guidelines on hypertrophic cardiomyopathy (HCM) have confirmed surgical myectomy as the gold standard for non-pharmacological treatment of obstructive HCM. However, during the last 15 years, an extensive use of alcohol septal ablation has led to the virtual extinction of myectomy programmes in several European countries. Therefore, many HCM candidates for myectomy in Europe cannot be offered the option of this procedure. The purpose of our study is to report the difficulties and results in developing a myectomy programme for HCM in a centre without previous experience with this procedure. Methods and results The clinical course is reported of 124 consecutive patients with obstructive HCM and heart failure symptoms who underwent myectomy at a single European centre between 1996 and 2010. The median follow-up was 20.3 months (inter-quartile range: 3.9–40.6 months). No patients were lost to follow-up. A cumulative incidence of HCM-related death after myectomy was 0.8, 3.3, and 11.2% at 1, 5, and 10 years, respectively, including one operative death (procedural mortality 0.8%). The left ventricular (LV) outflow gradient decreased from 95 ± 36 mmHg before surgery to 12 ± 6 mmHg at most recent evaluation (P < 0.001), with none of the patients having a significant residual LV outflow gradient. Of the 97 patients in New York Heart Association functional class III–IV before surgery, 93 (96%) were in class I–II at most recent evaluation (P < 0.001). Conclusion Our results show that the development of a myectomy programme at a centre without previous experience with this procedure is feasible and can lead to highly favourable clinical results.
Collapse
Affiliation(s)
- Attilio Iacovoni
- Dipartimento Cardiovascolare, Ospedali Riuniti, Bergamo 24128, Italy
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Abstract
Hypertrophic cardiomyopathy is a fascinating disease of marked heterogeneity. Hypertrophic cardiomyopathy was originally characterized by massive myocardial hypertrophy in the absence of known etiology, a dynamic left ventricular outflow obstruction, and increased risk of sudden death. It is now well accepted that multiple mutations in genes encoding for the cardiac sarcomere are responsible for the disease. Complex morphologic and pathophysiologic differences, disparate natural history studies, and novel treatment strategies underscore the challenge to the practicing cardiologist when faced with the management of the hypertrophic cardiomyopathy patient.
Collapse
|
38
|
Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW, Jacobs AK, Smith SC, Anderson JL, Albert NM, Buller CE, Creager MA, Ettinger SM, Guyton RA, Halperin JL, Hochman JS, Krumholz HM, Kushner FG, Nishimura RA, Ohman EM, Page RL, Stevenson WG, Tarkington LG, Yancy CW. 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy. J Thorac Cardiovasc Surg 2011; 142:e153-203. [DOI: 10.1016/j.jtcvs.2011.10.020] [Citation(s) in RCA: 223] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
|
39
|
Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW, Jacobs AK, Smith SC, Anderson JL, Albert NM, Buller CE, Creager MA, Ettinger SM, Guyton RA, Halperin JL, Hochman JS, Krumholz HM, Kushner FG, Nishimura RA, Ohman EM, Page RL, Stevenson WG, Tarkington LG, Yancy CW. 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy: Executive summary. J Thorac Cardiovasc Surg 2011; 142:1303-38. [DOI: 10.1016/j.jtcvs.2011.10.019] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
|
40
|
Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW. 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2011; 58:2703-38. [PMID: 22075468 DOI: 10.1016/j.jacc.2011.10.825] [Citation(s) in RCA: 196] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
41
|
2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2011; 58:e212-60. [PMID: 22075469 DOI: 10.1016/j.jacc.2011.06.011] [Citation(s) in RCA: 823] [Impact Index Per Article: 63.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
|
42
|
Abstract
Hypertrophic cardiomyopathy (HCM) is the most common inherited cardiac disorder. This autosomal dominant condition is defined by left ventricular hypertrophy and associated with functional limitation and premature death. In fact, many individuals are asymptomatic and the annual mortality in most modern series is 1% or less. However, severe symptoms may develop at any age, and the risk of premature death from arrhythmia, stroke, and progressive systolic impairment may complicate asymptomatic disease. The clinical management of patients with HCM therefore encompasses (1) genetic counseling including discussion of indications for genetic testing and cascade family screening, (2) assessment of prognostic risk from ventricular arrhythmia, stroke, and heart failure, and (3) symptom management. This article describes the interventional treatments in the management of severe symptoms associated with left ventricular outflow tract obstruction (LVOTO).
Collapse
Affiliation(s)
- Saidi A Mohiddin
- The Heart Muscle Disease Clinic, London Chest Hospital, Barts and The London NHS Trust, London, UK.
| | | |
Collapse
|
43
|
Prinz C, Farr M, Hering D, Horstkotte D, Faber L. The diagnosis and treatment of hypertrophic cardiomyopathy. DEUTSCHES ARZTEBLATT INTERNATIONAL 2011; 108:209-15. [PMID: 21505608 DOI: 10.3238/arztebl.2011.0209] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2009] [Accepted: 03/11/2010] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hypertrophic cardiomyopathy (HCM) is the most common hereditary disease of the heart. METHODS In this article, we summarize the current state of the diagnosis and treatment of HCM on the basis of a selective review of recent publications with relevance to clinical practice. RESULTS Several hundred mutations in more than 27 genes, most of which encode sarcomeric structures, are associated with the HCM phenotype. Thus, HCM can be thought of as a sarcomeric disease, with myocardial fiber disarray as its histological hallmark. There are two types of HCM, a more common, obstructive type (HOCM, 70%) and a less common, non-obstructive type (HNCM; in all cases of HCM, testing should be performed to detect outflow obstruction at rest and/or on provocation, and to thereby determine whether HOCM or HNCM is present. The symptoms of HCM include dyspnea, angina pectoris, palpitations, dizziness, and occasionally syncope. Because sudden cardiac death is the most serious complication of HCM, particularly in young and asymptomatic patients, it follows that correct diagnosis, followed by risk stratification of patients with regard to the need for prophylactic implantation of an implantable cardiac defibrillator (ICD), can be of life-saving importance. The pharmacotherapy of symptomatic HNCM consists of the treatment of heart failure with a normal ejection fraction (HFNEF). In HOCM, the patient's symptoms and the obstructive gradient are the guide to treatment with beta-blockers or verapamil. For patients with drug-resistant disease, surgical myectomy and percutaneous septal ablation are now standard treatments. CONCLUSION A near-normal life expectancy and a highly satisfactory quality of life are now realistic treatment goals for patients with HCM.
Collapse
Affiliation(s)
- Christian Prinz
- Kardiologische Klinik, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen.
| | | | | | | | | |
Collapse
|
44
|
Maron BJ, Yacoub M, Dearani JA. Controversies in cardiovascular medicine. Benefits of surgery in obstructive hypertrophic cardiomyopathy: bring septal myectomy back for European patients. Eur Heart J 2011; 32:1055-8. [PMID: 21324934 DOI: 10.1093/eurheartj/ehr006] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Hypertrophic cardiomyopathy (HCM), a heterogeneous genetic heart disease with global distribution, is an important cause of heart failure disability at any age. For 50 years, surgical septal myectomy has been the preferred and primary treatment strategy for most HCM patients with progressive, drug refractory functional limitation due to left ventricular (LV) outflow tract obstruction. With very low surgical mortality at experienced centres, septal myectomy reliably abolishes impedance to LV outflow and heart failure-related symptoms, restores quality of life, and importantly is associated with long-term survival similar to that in the general population. Nevertheless, alternatives to surgical management are necessary for selected HCM patients. For example, after a brief flirtation with dual-chamber pacing 20 years ago, percutaneous alcohol septal ablation has garnered a large measure of enthusiasm and a dedicated following in the interventional cardiology community, achieving benefits for patients, paradoxically, by virtue of producing a transmural myocardial infarct. However, an unintended consequence has been the virtual obliteration of the surgical option for HCM patients in Europe, where several robust myectomy programmes once existed. Therefore, clear differences are now evident internationally regarding management strategies for symptomatic obstructive HCM. The surgical option is now unavailable to many patients based solely on geography, including some who would likely benefit more substantially from surgical myectomy than from catheter-based alcohol ablation. It is our aspiration that this discussion will generate reconsideration and resurgence of interest in surgical septal myectomy as a treatment option for severely symptomatic obstructive HCM patients within Europe.
Collapse
Affiliation(s)
- Barry J Maron
- Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, 920 E. 28th Street, Minneapolis, MN 55407, USA.
| | | | | |
Collapse
|
45
|
Abstract
Percutaneous septal ablation has emerged as a less invasive treatment of symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM). In the past decade, the availability of this sophisticated technique has revived the interest of cardiologists in left ventricular outflow tract obstruction, which led to the recognition that most patients with HCM have the obstructive type. Follow-up studies have already shown the safety and efficacy of the procedure, which offers symptomatic relief in most patients. Long-term survival is comparable to historical reports after surgical myectomy. Complications are rare and can be further reduced with increased experience of the operators, and the theoretical concern for possible ventricular arrhythmogenicity of the myocardial scar has not been documented by the existing data. Although there are still no randomized trials, percutaneous septal ablation is undeniably a viable alternative for patients with HOCM.
Collapse
Affiliation(s)
- Angelos G Rigopoulos
- 2nd Department of Cardiology, University of Athens Medical School, Athen, Greece
| | | |
Collapse
|
46
|
Hwang HJ, Choi EY, Kwan J, Kim SA, Shim CY, Ha JW, Rim SJ, Chung N, Kim SS. Dynamic change of mitral apparatus as potential cause of left ventricular outflow tract obstruction in hypertrophic cardiomyopathy. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2010; 12:19-25. [DOI: 10.1093/ejechocard/jeq092] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
|
47
|
Shah A, Duncan K, Winson G, Chaudhry FA, Sherrid MV. Severe symptoms in mid and apical hypertrophic cardiomyopathy. Echocardiography 2010; 26:922-33. [PMID: 19968680 DOI: 10.1111/j.1540-8175.2009.00905.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND We analyzed the clinical and quantitative echocardiographic characteristics of patients with sub-basal hypertrophic cardiomyopathy (HCM) to define the characteristics of patients (pts) with severe symptoms. METHODS Of 444 pts in a referral-based HCM program, 22 (5%) had midventricular or apical HCM. Quality of life (QoL) questionnaire was administered as an independent confirmer of symptomatic state. RESULTS Ten pts were NYHA III and IV, and 12 pts were NYHA I and II; QoL scores (41 +/- 26 vs. 10 +/- 13, P = 0.001) confirmed a priori division of two groups based on NYHA classification. Pts with more severe symptoms were more likely female (70% vs. 25%, P = 0.001) with atrial fibrillation (40% vs. 0%, P = 0.02). They more frequently had midventricular HCM 60% versus 8% (P = 0.01) (mid-LV thickness 17 +/- 6 vs. 12 +/- 2 mm, P = 0.03) and had much smaller LV diastolic volumes 68 +/- 12 versus 102 +/- 22 ml (39 +/- 4 vs. 53 +/- 12 ml/m(2), P = 0.001). Septal E/E' was higher in the severely symptomatic pts (15 +/- 5 vs. 7 +/- 3, P = 0.001) indicating higher estimated LV filling pressure. Midobstruction with apical akinetic chamber was noted in 4/10 pts who developed refractory symptoms. Cardiac mortality was higher in the severely symptomatic patients, 4/10 who had midventricular HCM as compared to 0/12 in the mildly symptomatic apical HCM group (P = 0.03). CONCLUSIONS In subbasal HCM, pts with severe symptoms have midventricular hypertrophy, with encroachment of the LV cavity and consequent very small LV volumes that may be complicated by mid-LV obstruction. Pts with mid-LV hypertrophy are more symptomatic than those with apical HCM, are often refractory to therapy, and have higher mortality.
Collapse
Affiliation(s)
- Ajay Shah
- Division of Cardiology, St. Luke's-Roosevelt Hospital Center, College of Physicians and Surgeons, Columbia University, New York City, New York, USA
| | | | | | | | | |
Collapse
|
48
|
Olivotto I, Girolami F, Nistri S, Rossi A, Rega L, Garbini F, Grifoni C, Cecchi F, Yacoub MH. The Many Faces of Hypertrophic Cardiomyopathy: From Developmental Biology to Clinical Practice. J Cardiovasc Transl Res 2009; 2:349-67. [DOI: 10.1007/s12265-009-9137-2] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2009] [Accepted: 09/28/2009] [Indexed: 11/28/2022]
|
49
|
|
50
|
|