Transapical Approach to Septal Myectomy for Hypertrophic Cardiomyopathy

A 63-year-old symptomatic female with apical hypertrophic cardiomyopathy and diastolic disfunction was admitted to the hospital. What is the best way to manage this patient? This study is a literature review that was performed to answer this question. The following PubMed search strategy was used: 'Hypertrophic obstructive cardiomyopathy' [All Fields] OR 'apical myectomy' [All Fields], NOT 'animal [mh]' NOT 'human [mh]' NOT 'comment [All Fields]' OR 'editorial [All Fields]' OR 'meta-analysis [All Fields]' OR 'practice-guideline [All Fields]' OR 'review [All Fields]' OR 'pediatrics [mh]'. The natural history of the disease has a benign prognosis; however, a watchful strategy was associated with the risk of adverse cardiovacular events. Contrastingly, transapical myectomy was associated with low surgical risk and acceptable outcomes. In our case, the patient underwent transapical myectomy with an unconventional post-operative period. Control echocardiography showed marked left ventricular (LV) cavity enlargement: LV end-diastolic volume, 74 mL; LV ejection fraction, 65%; and LV stroke volume index increased to 27 mL/m2. The patient was discharged 7 days after myectomy. At 6 months post-operation, the patient was NYHA Class I, with a 6 min walk test score of 420 m. Therefore, transapical myectomy may be considered as a feasible procedure in patients with apical hypertrophic cardiomyopathy and progressive heart failure.

Redo aortic root surgery post-Ross procedure

Background

Despite numerous advantages of the Ross procedure, it presents a risk of late autograft and right ventricular outflow tract conduit failure. This study aimed to analyze the outcomes of autograft dysfunction reoperations using autograft-sparing and root replacement techniques.

Methods

Between 2015 and 2023, 49 patients underwent redo root surgery in our institution. Autograft valve-sparing procedures (VSP) were performed in 20 cases and the Bentall procedure (BP) in 29 patients. The short and long-term clinical outcomes along with echocardiographic results of VSP and BP were investigated.

Results

Overall early mortality rate was 2.0% with no significant difference between the groups. Severe autograft valve insufficiency at the time of redo (OR 4.07, P = 0.03) and patient age (OR 1.07, P = 0.04) were associated with a valve replacement procedure instead of VSP. The median follow-up duration was 34 months. No late deaths occurred in either group. Freedom from VSP failure and aortic prosthesis dysfunction were 93.8% and 94.1% in the VSP and BP groups, respectively. No reoperations were necessary in either group.

Conclusion

Redo aortic root surgery can be safely performed in patients with autograft failure. Both root replacement and autograft valve-sparing procedures demonstrated acceptable results at mid-term follow-up. Early redo surgery pre-empting severe aortic insufficiency increases the likelihood of preservation of the dilated autograft valve.

Myocardial protection with phosphocreatine in high-risk cardiac surgery patients: a randomized trial

BACKGROUND

This study was conducted to test the hypothesis that phosphocreatine (PCr), administered intravenously and as cardioplegia adjuvant in patients undergoing cardiac surgery with prolonged aortic cross clamping and cardiopulmonary bypass (CPB) time, would decrease troponin I concentration after surgery.

METHODS

In this randomized, double-blind, placebo-controlled pilot study we included 120 patients undergoing double/triple valve repair/replacement under cardiopulmonary bypass in the cardiac surgery department of a tertiary hospital. The treatment group received: intravenous administration of 2 g of PCr after anesthesia induction; 2.5 g of PCr in every 1 L of cardioplegic solution (concentration = 10 mmol/L); intravenous administration of 2 g of PCr immediately after heart recovery following aorta declamping; 4 g of PCr at intensive care unit admission. The control group received an equivolume dose of normosaline.

RESULTS

The primary endpoint was peak concentration of troponin I after surgery. Secondary endpoints included peak concentration of serum creatinine, need for, and dosage of inotropic support, number of defibrillations after aortic declamping, incidence of arrhythmias, duration of Intensive Care Unit (ICU) stay, length of hospitalization. There was no difference in peak troponin I concentration after surgery (PCr, 10,508 pg/ml [IQR 6,838-19,034]; placebo, 11,328 pg/ml [IQR 7.660-22.894]; p = 0.24). There were also no differences in median peak serum creatinine (PCr, 100 µmol/L [IQR 85.0-117.0]; placebo, 99.5 µmol/L [IQR 90.0-117.0]; p = 0.87), the number of patients on vasopressor/inotropic agents (PCr, 49 [88%]; placebo, 57 [91%]; p = 0.60), the inotropic score on postoperative day 1 (PCr, 4.0 (0-7); placebo, 4.0 (0-10); p = 0.47), mean SOFA score on postoperative day 1 (PCr, 5.25 ± 2.33; placebo, 5,45 ± 2,65; p = 0.83), need for defibrillation after declamping of aorta (PCr, 22 [39%]; placebo, 25 [40%]; p = 0.9),, duration of ICU stay and length of hospitalization as well as 30-day mortality (PCr, 0 (0%); placebo,1 (4.3%); p = 0.4).

CONCLUSION

PCr administration to patients undergoing double/triple valve surgery under cardiopulmonary bypass is safe but is not associated with a decrease in troponin I concentration. Phosphocreatine had no beneficial effect on clinical outcomes after surgery.

TRIAL REGISTRATION

The study is registered at ClinicalTrials.gov with the Identifier: NCT02757443. First posted (published): 02/05/2016.

The David procedure through a right anterior minithoracotomy

A right anterior minithoracotomy is the least-frequently utilized approach in minimally invasive aortic valve surgery; moreover, this access is rarely used for aortic root procedures. With careful patient selection, some technical considerations, e.g. institution of peripheral cardiopulmonary bypass, and a sufficient learning curve, the right anterior minithoracotomy can become a convenient access for surgical interventions on the aortic root. We present the case of a 31-year-old female patient with Marfan syndrome and severe aortic regurgitation due to an aortic root aneurysm. We demonstrate a step-by-step guide through the David procedure via a right anterior minithoracotomy.

P3678Pulmonary artery ablation during open mitral valve surgery for pulmonary artery hypertension: a prospective randomized study

Purpose

Recent investigations of pulmonary artery (PA) ablation into the treatment of idiopathic pulmonary artery hypertension (PAH) have suggested improvement of functional capacity, and hemodynamics. We investigated the impact of PA ablation in patients with PAH due to left heart disease (Dana Point, 2008) scheduled for open-heart mitral valve surgery.

Methods

Fifty patients aged 52±10 with mitral valve disease complicated severe PAH (mean PAP >40mm Hg) were randomly assigned to mitral valve surgery with or without PA ablation procedure. Eligible criteria: positive reactive test with nitric oxide inhalation (decrease of mean PAP more than 10 mm Hg without decrease of cardiac output). There were no between group differences in preoperative characteristics.

Surgical procedure

After bypass is establishedthe fibrous fold of pericardiumand the ligamentum arteriosum are dissected out, and the branches of the right and left pulmonary artery are mobilized well out into the hilum of the lungs bilaterally. PA ablation was performed epicardially at the bifurcation of the main PA, and 10 mm distal to the right and left PA's using AtriCure Isolator®multifunctional pen.

Serial assessment of echocardiography, right heart catheterization (catheter Swan-Ganz), and 6-min walk test (6MWT) were performed during hospital stay. The primary endpoints were the change of meanpulmonary artery pressure (PAP)and 6MWT. The secondary endpoints were hospital mortality, freedom from PADN-related complication: PA perforation, PA dissection, and PA thrombosis (MDCT assessment).

Results

There were no early deaths. No procedure-related complications were observed.

On first day after surgery patients from ablation group showed significant reduction of mean PAP (from 50.6±5.3to 34.6±9.9 mm Hg, p<0.001), and significant improvement of 6MWT at discharge (from 229±34 m to 475±21 m, p<0.001). On first day after surgery patients from control group also showed significant reduction of mean PAP (from 51.3±6.3to 47.2±8.5 mm Hg, p=0.011), and significant improvement of 6MWT at discharge (from 249±32 m to 335±18 m, p<0.001). Nevertheless, there was significant between group difference in mean PAP on first day after surgery (34.6±9.9 mm Hg, vs 47.2±8.5 mm Hg, p=0.005). Moreover there was significant differences in 6MWT at discharge (475±21 m vs 335±18 m, p=0.002) with benefit to ablation group.

Epicardial pulmonary artery ablation

Conclusions

We report for the first time the effect and superiority of PA ablation on functional capacity and hemodynamics in patients with mitral valve disease complicated PAH. Epicardial PA ablation for the treatment PAH can be effectively and safely performed during open heart surgery.

Acknowledgement/Funding

None