Surgical Treatment for Hypertrophic Obstructive Cardiomyopathy with Concomitant Mitral Valve Abnormalities: A Cohort of 26 Cases
DOI:
https://doi.org/10.1532/hsf.2013Abstract
Background: We sought to analyze the pathological characteristics of hypertrophic obstructive cardiomyopathy (HOCM) with concomitant mitral valve abnormalities and to discuss the surgical treatment strategies.
Methods: The clinical data of 26 HOCM patients treated from January 2014 to March 2016 were retrospectively analyzed. There were 19 males and 7 females with a mean age of 47 ± 16 years (range, 10-70 years). Echocardiography showed HOCM, systolic anterior motion of the mitral apparatus, and concomitant mitral regurgitation. Modified Morrow procedure with expanded resection area was performed in 21 patients. Concomitant mitral valvuloplasty was performed in 4 patients, coronary artery bypass grafting was performed in one patient, and aortic valve replacement was performed in one patient. Echocardiography was performed intraoperatively at postoperative 1 week and at postoperative 1 year to evaluate the left ventricular obstruction and the mitral regurgitation.
Results: The left ventricular outflow tract gradient, left ventricular outflow tract velocity, septal thickness, and mitral regurgitation area decreased significantly at postoperative 1 week and 1 year in comparison with the baseline (all P < .001). The postoperative mitral regurgitation and systolic anterior motion of the mitral apparatus were completely abolished or significantly relieved. Only one patient had moderate mitral regurgitation of 7 cm2 after the surgery. At postoperative 1 year, all patients were asymptomatic, and the quality of life was significantly improved. The New York Heart Association (NYHA) class was I-II. Echocardiography showed good anatomy and function of the mitral valve.
Conclusions: Concomitant mitral valve abnormality is not uncommon in HOCM. Septal myectomy can adequately expand the left ventricular outflow tract and abolish mitral regurgitation and systolic anterior motion of the mitral apparatus. Concomitant mitral valvuloplasty is indicated for severe congenital abnormalities or secondary lesions of the mitral valve, and the outcomes are satisfactory.
References
Elliott P, McKenna WJ. 2004. Hypertrophic cardiomyopathy, Lancet 363(9424):1881-91.
Gersh BJ, Maron BJ, Bonow RO, et al. 2011. 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 Thorac Cardiovasc Surg 142(6):1303-38.
Jiang L, Levine RA, King ME, Weyman AE. 1987. An integrated mechanism for systolic anterior motion of the mitral valve in hypertrophic cardiomyopathy based on echocardiographic observations. Am Heart J 113(3):633-44.
Klues HG, Maron BJ, Dollar AL, Roberts WC. 1992. Diversity of structural mitral valve alterations in hypertrophic cardiomyopathy. Circulation 85(5):1651-60.
Kofflard MJ, van Herwerden LA, Waldstein DJ, et al. 1996. Initial results of combined anterior mitral leaflet extension and myectomy in patients with obstructive hypertrophic cardiomyopathy. J Am Coll Cardiol 28(1):197-202.
Maron BJ. 2002. Hypertrophic cardiomyopathy: a systematic review. JAMA 287(10):1308-20.
Maron BJ. 2007. Surgical myectomy remains the primary treatment option for severely symptomatic patients with obstructive hypertrophic cardiomyopathy. Circulation 116(2):196-206.
Maron MS, Olivotto I, Betocchi S, et al. 2003. Effect of left ventricular outflow tract obstruction on clinical outcome in hypertrophic cardiomyopathy. N Engl J Med 348(4):295-303.
McIntosh CL, Maron BJ, Cannon RO 3rd, Klues HG. 1992. Initial results of combined anterior mitral leaflet plication and ventricular septal myotomy-myectomy for relief of left ventricular outflow tract obstruction in patients with hypertrophic cardiomyopathy. Circulation 86(5 suppl):II60-7.
Minakata K, Dearani JA, Nishimura RA, Maron BJ, Danielson GK. 2004. Extended septal myectomy for hypertrophic obstructive cardiomyopathy with anomalous mitral papillary muscles or chordae. J Thorac Cardiovasc Surg 127(2):481-9.
Minakata K, Dearani JA, Schaff HV, O’Leary PW, Ommen SR, Danielson GK. 2005. Mechanisms for recurrent left ventricular outflow tract obstruction after septal myectomy for obstructive hypertrophic cardiomyopathy. Ann Thorac Surg 80(3):851-6.
Schwammenthal E, Nakatani S, He S, Hopmeyer J, et al. 1998. Mechanism of mitral regurgitation in hypertrophic cardiomyopathy: mismatch of posterior to anterior leaflet length and mobility. Circulation 98(9):856-65.
Song B, Ran D. 2016. Comparison of modified with classic Morrow septal myectomy in treating hypertrophic obstructive cardiomyopathy. Medicine (Baltimore) Jan;95(2):e2326.
Yu EH, Omran AS, Wigle ED, Williams WG, Siu SC, Rakowski H. 2000. Mitral regurgitation in hypertrophic obstructive cardiomyopathy: relationship to obstruction and relief with myectomy. J Am Coll Cardiol 36(7):2219-25.
Zhu WX, Oh JK, Kopecky SL, Schaff HV, Tajik AJ. 1992. Mitral regurgitation due to ruptured chordae tendineae in patients with hypertrophic obstructive cardiomyopathy. J Am Coll Cardiol 20(1):242-7.
