Midterm Outcome of Septal Myectomy for Hypertrophic Obstructive Cardiomyopathy (HOCM): A Single-Center Observational Study
Keywords:Hypertrophic Obstructive Cardiomyopathy (HOCM), Septal Myectomy, Systolic Anterior Motion, Left Ventricular Outflow Tract Obstruction (LVOTO), Alcohol Septal Ablation (ASA)
Background: For years, septal myectomy has been considered the best available treatment for hypertrophic cardiomyopathy. In Bangladesh, however, this technique is only nascent. We present a case series of septal myectomy with outcomes after 1 to 6 years at the National Heart Foundation Hospital & Research Institute.
Methods: For this study, 21 patients who underwent septal myectomy from 2014 to 2019 were monitored retrospectively. Evidence was collected from the hospital database and followed up via telephone conversations using a structured questionnaire. Patients’ preoperative, postoperative, and follow-up clinical data were collected and analyzed.
Results: The results reveal that after septal myectomy, there were significant improvements in terms of left ventricular outflow gradient (P ≤ .01), septal thickness
(P ≤ .01), left ventricular ejection fraction (P = .001), pulmonary arterial systolic pressure (P ≤ .01), mitral regurgitation (P ≤ .01), systolic anterior motion (P ≤ .01), and New York Heart Association class (P ≤ .01).
Conclusion: This study suggests that septal myectomy be offered to symptomatic hypertrophic obstructive cardiomyopathy patients, as its survival benefits and symptoms relief are excellent. This study suggests that septal myectomy that dynamic obstruction at the left ventricular outflow tract is the major hemodynamic problem. We hope that with appropriate measures, new myectomy programs in our country can provide extended longevity and restore the quality of life.
Abozguia K, Nallur-Shivu G, Phan TT, et al. Left ventricular strain and untwist in hypertrophic cardiomyopathy: Relation to exercise capacity. Am Heart J 2010;159:825-832.
Agarwal S, Tuzcu EM, Desai MY, Smedira N, Lever HM, Lytle BW, Kapadia SR. Updated meta-analysis of septal alcohol ablation versus myectomy for hypertrophic cardiomyopathy. J Am Coll Cardiol 2010;55:823-834.
Ball W, Ivanov J, Rakowski H, et al. Long-term survival in patients with resting obstructive hypertrophic cardiomyopathy comparison of conservative versus invasive treatment. J Am Coll Cardiol 2011;58:2313-2321.
Dearani JA, Ommen SR, Gersh BJ, Schaff HV, Danielson GK. Surgery insight: Septal myectomy for obstructive hypertrophic cardiomyopathy—The Mayo Clinic experience. Nat Clin Pract Cardiovasc Med 2007; 4:503-512.
Desai MY, Bhonsale A, Smedira NG, et al. Predictors of long-term outcomes in symptomatic hypertrophic cardiomyopathy patients undergoing surgical relief of left ventricular outflow tract obstruction. Circulation 2013;128:209-216.
Firoozi S, Elliott PM, Sharma S, et al. Septal myotomy-myectomy and transcoronary septal alcohol ablation in hypertrophic obstructive cardiomyopathy: A comparison of clinical, haemodynamic and exercise outcomes. Eur Heart J 2002;20:1617-1624.
Franke A, Schöndube FA, Kühl HP, et al. Quantitative assessment of the operative results after extended myectomy and surgical reconstruction of the subvalvular mitral apparatus in hypertrophic obstructive cardiomyopathy using dynamic three-dimensional transesophageal echocardiography. J Am Coll Cardiol 1998;31:1641-1649.
Hong JH, Schaff HV, Nishimura RA, et al. Mitral regurgitation in patients with hypertrophic obstructive cardiomyopathy: Implications for concomitant valve procedures. J Am Coll Cardiol 2016;68:1497-1504.
Kim JH. Tips for successful septal myectomy in patients with hypertrophic cardiomyopathy. Kor J Thorac Cardiovasc Surg 2018;51:227-230.
Liebregts M, Vriesendorp PA, Mahmoodi BK, et al. A systematic review and meta-analysis of long-term outcomes after septal reduction therapy in patients with hypertrophic cardiomyopathy. JACC Heart Failure 2015;3:896-905.
Malek M, Iqbal S, Khan Z, Haque A, Sultana S. Clinical profile of hypertrophic cardiomyopathy in a tertiary level hospital. Cardiovasc J 2014;7:31-37.
Maron BJ. Hypertrophic cardiomyopathy: A systematic review. JAMA 2002;287:1308-1320.
Maron BJ. Surgery for hypertrophic obstructive cardiomyopathy: Alive and quite well. Circulation 2005;111:2016-2018.
Maron BJ. Controversies in cardiovascular medicine. Surgical myectomy remains the primary treatment option for severely symptomatic patients with obstructive hypertrophic cardiomyopathy. Circulation 2007;116:196-206.
Maron BJ, Harding AM, Spirito P, et al. Systolic anterior motion of the posterior mitral leaflet: A previously unrecognized cause of dynamic subaortic obstruction in patients with hypertrophic cardiomyopathy. Circulation 1983;68:282-293.
Maron BJ, McKenna WJ, Danielson GK, et al. American College of Cardiology/European Society of Cardiology Clinical Expert Consensus Document on Hypertrophic Cardiomyopathy—A report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents and the European Society of Cardiology Committee for Practice Guidelines Committee to Develop an Expert Consensus Document on Hypertrophic Cardiomyopathy. J Am Coll Cardiol 2003;42:1687-1713.
Maron BJ, Dearani JA, Ommen SR, Maron MS, Schaff HV, Gersh BJ, Nishimura RA. The case for surgery in obstructive hypertrophic cardiomyopathy. J Am Coll Cardiol 2004;44:2044-2053.
Maron BJ, Yacoub M, Dearani JA. Benefits of surgery in obstructive hypertrophic cardiomyopathy: Bring septal myectomy back for European patients. Eur Heart J 2011;32:1055-1058.
Maron BJ, Dearani JA, Ommen SR, et al. Low operative mortality achieved with surgical septal myectomy: Role of dedicated hypertrophic cardiomyopathy centers in the management of dynamic subaortic obstruction. J Am Coll Cardiol 2015;66:1307-1308.
Maron MS, Olivotto I, Betocchi S, et al. Effect of left ventricular outflow tract obstruction on clinical outcome in hypertrophic cardiomyopathy. N Engl J Med 2003;348:295-303.
Maron MS, Olivotto I, Zenovich AG, et al. Hypertrophic cardiomyopathy is predominantly a disease of left ventricular outflow tract obstruction. Circulation 2006;114:2232-2239.
McCully RB, Nishimura RA, Tajik AJ, Schaff HV, Danielson GK. Extent of clinical improvement after surgical treatment of hypertrophic obstructive cardiomyopathy. Circulation 1996;94:467-471.
Merrill WH, Friesinger GC, Graham TP Jr, Byrd BF 3rd, Drinkwater DC Jr, Christian KG, Bender HW Jr. Long-lasting improvement after septal myectomy for hypertrophic obstructive cardiomyopathy. Ann Thorac Surg 2000;69:1732-1735.
Nishimura RA, Ommen SR. Septal reduction therapy for obstructive hypertrophic cardiomyopathy and sudden death. What statistics cannot tell you. Circ Cardiovasc Intervent 2010;3:91-93.
Nishimura RA, Schaff HV. Septal myectomy for patients with hypertrophic cardiomyopathy: A new paradigm. J Thorac Carciovasc Surg 2016;151:303-304.
Ommen SR, Nishimura RA, Squires RW, et al. Comparison of dual chamber pacing versus septal myectomy for the treatment of patients with hypertrophic obstructive cardiomyopathy: A comparison of objective hemodynamic and exercise and points. J Am Coll Cardiol 1999;34:191-196.
Ommen SR, Maron BJ, Olivotto I, et al. Long-term effects of surgical septal myectomy on survival in patients with obstructive hypertrophic cardiomyopathy. J Am Coll Cardiol 2005;46:470-476.
Qin JX, Shiota T, Lever HM, et al. Outcome of patients with hypertrophic obstructive cardiomyopathy after percutaneous transluminal septal myocardial ablation and septal myectomy surgery. J Am Coll Cardiol 2001;38:1994-2000.
Ralph-Edwards A, Vanderlaan RD, Bajona P. Transaortic septal myectomy: Techniques and pitfalls. Ann Cardiothorac Surg 2017;6:410-415.
Rastegar H, Boll G, Rowin EJ, et al. Results of surgical septal myectomy for obstructive hypertrophic cardiomyopathy: The Tufts experience. Ann Cardiothorac Surg 2017;6:353-363.
Said SM, Schaff HV. Surgical treatment of hypertrophic cardiomyopathy. Semin Thorac Cardiovasc Surg 2013;25:300-309.
Schaff HV, Dearani JA, Ommen SR, Sorajja P, Nishimura RA. Expanding the indications for septal myectomy in patients with hypertrophic cardiomyopathy: Results of operation in patients with latent obstruction. J Thorac Carciovasc Surg 2012;143:303-309.
Schulte HD, Bircks WH, Loesse B, et al. Prognosis of patients with hypertrophic obstructive cardiomyopathy after transaortic myectomy. Late results up to twenty-five years. J Thorac Cardiovasc Surg 1993;106:709-717.
Sedehi D, Finocchiaro G, Tibayan Y, et al. Long-term outcomes of septal reduction for obstructive hypertrophic cardiomyopathy. J Cardiol 2015;66:57-62.
Semsarian C, Ingles J, Maron MS, and Maron BJ. New perspectives on the prevalence of hypertrophic cardiomyopathy. J Thorac Carciovasc Surg 2015;65:1249-1254.
Shah PM, Gramiak R, Adelman AG, Wigle ED. Echocardiographic assessment of the effects of surgery and propranolol on the dynamics of outflow obstruction in hypertrophic subaortic stenosis. Circulation 1972;45:516-521
Sherrid MV, Chu CK, Delia E, Mogtader A, Dwyer EM Jr. An echocardiographic study of the fluid mechanics of obstruction in hypertrophic cardiomyopathy. J Am Coll Cardiol 1993;22:816-824.
Sherrid MV, Chaudhry FA, Swistel DG. Obstructive hypertrophic cardiomyopathy: Echocardiography, pathophysiology, and the continuing evolution of surgery for obstruction. Ann Thorac Surg 2003;75:620-632.
Smedira NG, Lytle BW, Lever HM, et al. Current effectiveness and risks of isolated septal myectomy for hypertrophic cardiomyopathy. Ann Thorac Surg 2008;85:127-133.
Sorajja P, Valeti U, Nishimura R, et al. Outcome of alcohol septal ablation for obstructive hypertrophic cardiomyopathy. Circulation 2008;118:131-139.
Sorajja P, Nishimura RA, Gersh BJ, et al. Outcome of mildly symptomatic or asymptomatic obstructive hypertrophic cardiomyopathy: A long-term follow-up study. J Am Coll Cardiol 2009;54:234-241.
Spirito P et al. The management of hypertrophic cardiomyopathy. N Engl J Med 1997;336:775-785.
ten Cate F, Soliman OII, Michels M, et al. Long-term outcomes of alcohol septal ablation in patients with obstructive hypertrophic cardiomyopathy: A word of caution. Circ Heart Fail 2010;3:362-369.
Vaglio JC Jr, Ommen SR, Nishimura RA, Tajik AJ, Gersh BJ. Clinical characteristics and outcomes of patients with hypertrophic cardiomyopathy with latent obstruction. Am Heart J 2008;156:342-347.
Wang S, Cui H, Yu Q, et al. Excision of anomalous muscle bundles as an important addition to extended septal myectomy for treatment of left ventricular outflow tract obstruction. J Thorac Carciovasc Surg 2016;152:461-468.
Watson DC, Henry WL, Epstein SE, Morrow AG. Effects of operation on left atrial size and the occurrence of atrial fibrillation in patients with hypertrophic subaortic stenosis. Circulation 1977;55:178-181.
Wigle ED, Sasson Z, Henderson MA, et al. Hypertrophic cardiomyopathy: The importance of the site and the extent of hypertrophy: A review. Prog Cardiovasc Dis 1985;28:1-83.
Wigle ED, Rakowski H, Kimball BP, Williams WG. Hypertrophic cardiomyopathy: Clinical spectrum and treatment. Circulation 1995;92:1680-1692.
Woo A, Williams WG, Choi R, et al. Clinical and echocardiographic determinants of long-term survival after surgical myectomy in obstructive hypertrophic cardiomyopathy. Circulation 2005;111:2033-2041.
Yu EH, Omran AS, Wigle ED, Williams WG, Siu SC, Rakowski H. Mitral regurgitation in hypertrophic obstructive cardiomyopathy: Relationship to obstruction and relief with myectomy. J Am Coll Cardiol 2000;36:2219-2225.
How to Cite
Author Disclosure & Copyright Transfer Agreement
In order to publish the original work of another person(s), The Heart Surgery Forum® must receive an acknowledgment of the Author Agreement and Copyright Transfer Statement transferring to Forum Multimedia Publishing, L.L.C., a subsidiary of Carden Jennings Publishing Co., Ltd. the exclusive rights to print and distribute the author(s) work in all media forms. Failure to check Copyright Transfer agreement box below will delay publication of the manuscript.
A current form follows:
The author(s) hereby transfer(s), assign(s), or otherwise convey(s) all copyright ownership of the manuscript submitted to Forum Multimedia Publishing, LLC (Publisher). The copyright transfer covers the exclusive rights to reproduce and distribute the article and the material contained therein throughout the world in all languages and in all media of expression now known or later developed, including but not limited to reprints, photographic reproduction, microfilm, electronic data processing (including programming, storage, and transmission to other electronic data record(s), or any other reproductions of similar nature), and translations.
However, Publisher grants back to the author(s) the following:
- The right to make and distribute copies of all or part of this work for use of the author(s) in teaching;
- The right to use, after publication in The Heart Surgery Forum, all or part of the material from this work in a book by the author(s), or in a collection of work by the author(s);
- The royalty-free right to make copies of this work for internal distribution within the institution/company that employs the author(s) subject to the provisions below for a work-made-for-hire;
- The right to use figures and tables from this work, and up to 250 words of text, for any purpose;
- The right to make oral presentations of material from this work.
Publisher reserves the right to grant or refuse permission to third parties to republish all or part of the article or translations thereof. To republish, such third parties must obtain written permission from the Publisher. (This is in accordance with the Copyright Statute, United States Code, Title 17. Exception: If all authors were bona fide officers or employees of the U.S. Government at the time the paper was prepared, the work is a “work of the US Government” (prepared by an officer or employee of the US Government as part of official duties), and therefore is not subject to US copyright; such exception should be indicated on signature lines. If this work was prepared under US Government contract or grant, the US Government may reproduce, royalty-free, all or portions of this work and may authorize others to do so, for official US Government purposes only, if the US Government contract or grant so requires.
I have participated in the conception and design of this work and in the writing of the manuscript and take public responsibility for it. Neither this manuscript nor one with substantially similar content under my authorship has been published, has been submitted for publication elsewhere, or will be submitted for publication elsewhere while under consideration by The Heart Surgery Forum, except as described in an attachment. I have reviewed this manuscript (original version) and approve its submission. If I am listed above as corresponding author, I will provide all authors with information regarding this manuscript and will obtain their approval before submitting any revision. I attest to the validity, accuracy, and legitimacy of the content of the manuscript and understand that Publisher assumes no responsibility for the validity, accuracy, and legitimacy of its content. I warrant that this manuscript is original with me and that I have full power to make this Agreement. I warrant that it contains no matter that is libelous or otherwise unlawful or that invades individual privacy or infringes any copyright or other proprietary right. I agree to indemnify and hold Publisher harmless of and from any claim made against Publisher that relates to or arises out of the publication of the manuscript and agree that this indemnification shall include payment of all costs and expenses relating to the defense of any such claim, including all reasonable attorney’s fees.
I warrant that I have no financial interest in the drugs, devices, or procedures described in the manuscript (except as disclosed in the attached statement).
I state that the institutional Human Subjects Committee and/or the Ethics Committee approved the clinical protocol reported in this manuscript for the use of experimental techniques, drugs, or devices in human subjects and appropriate informed consent documents were utilized.
Furthermore, I state that any and all animals used for experimental purposes received humane care in USDA registered facilities in compliance with the “Principles of Laboratory Animal Care” formulated by the National Society for Medical Research and the “Guide for the Care and Use of Laboratory Animals” prepared by the Institute of Laboratory Animal Resources and published by the National Institutes of Health (NIH Publication No. 85-23, revised 1985).