Role of mitral valve plication in the surgical management of hypertrophic cardiomyopathy.

BACKGROUND: We have previously reported our 3-step repair for obstructive hypertrophic cardiomyopathy (HCM) consisting of resection of the septum, horizontal plication of the anterior mitral leaflet (AML), and release of abnormal papillary muscle attachments. This article reviews our complete experience with surgical management of HCM to better understand the role and relevance of mitral plication. METHODS: From 1997 to 2011, 132 patients with HCM underwent surgical treatment at our institution. Eighty-two patients (62%) received AML plication based on selection criteria and were classified as group A; patients in group B did not receive plication. All patients underwent preoperative and postoperative echocardiography. Long-term clinical follow-up was obtained by review of scheduled echocardiograms and direct patient interview. RESULTS: The average age of all patients was 55.5 years. Operative mortality was 0%. The mean left ventricular outflow tract (LVOT) gradient decreased from 118±41 mm Hg to 6±13 mm Hg (p<0.0001). Mean mitral regurgitation improved from 2.4±1.0 to 0.5±0.7 (p<0.0001). Postoperatively, 96.2% of patients had no residual systolic anterior motion (SAM). Significant improvements in heart failure classification and quality of life scores were noted for all patients. Comparison of groups A and B showed no statistically significant differences in outcomes, complications, or survival. Survival at 1, 5, and 10 years was 98%, 98%, and 92%, respectively. CONCLUSIONS: The heterogeneity of the pathologic process in HCM supports detailed analysis of the septum, mitral leaflets, and subvalvular apparatus. Surgical management of HCM that includes horizontal plication of a lax and elongated AML is safe and results in durable clinical and echocardiographic improvement.

Anesthesia management of patients with hypertrophic obstructive cardiomyopathy.

Hypertrophic obstructive cardiomyopathy presents a challenge to the anesthesiologist. Because the condition is relatively prevalent, it is important for anesthesiologist to be aware of the pathophysiology. In this review, we draw upon case reports and studies of the anesthesia management of patients with hypertrophic obstructive cardiomyopathy to enhance medical decision making. The scope of this article ranges from the preoperative period, when the severity of the obstruction needs to be assessed; the intraoperative period, with monitoring, as well as general management guidelines; and finally, the postoperative period, when it is important to minimize the sympathetic response. Furthermore, we address the management of the obstetric patient, with particular focus on neuraxial anesthesia, and extrapolate how this type of anesthesia may be applied to the management of patients undergoing nonlaboring, noncardiac surgery.

Lack of effectiveness of the pulmonary artery catheter in cardiac surgery.

BACKGROUND: The pulmonary artery catheter (PAC) continues to be used for monitoring of hemodynamics in patients undergoing coronary artery bypass graft (CABG) surgery despite concerns raised in other settings regarding both effectiveness and safety. Given the relative paucity of data regarding its use in CABG patients, and given entrenched practice patterns, we assessed the impact of PAC use on fatal and nonfatal CABG outcomes as practiced at a diverse set of medical centers. METHODS: Using a formal prospective observational study design, 5065 CABG patients from 70 centers were enrolled between November 1996 and June 2000 using a systemic sampling protocol. Propensity score matched-pair analysis was used to adjust for differences in likelihood of PAC insertion. The predefined composite endpoint was the occurrence of any of the following: death (any cause), cardiac dysfunction (myocardial infarction or congestive heart failure), cerebral dysfunction (stroke or encephalopathy), renal dysfunction (dysfunction or failure), or pulmonary dysfunction (acute respiratory distress syndrome). Secondary variables included treatment indices (inotrope use, fluid administration), duration of postoperative intubation, and intensive care unit length of stay. After categorization based on PAC and transesophageal echocardiography use (both, neither, PAC only, transesophageal echocardiography only), we performed the primary analysis contrasting PAC only and neither (total, 3321 patients), from which propensity paring yielded 1273 matched pairs. RESULTS: The primary endpoint occurred in 271 PAC patients versus 196 without PAC (21.3% vs.15.4%; adjusted odds ratio [AOR], 1.68; 95% confidence interval [CI], 1.24 to 2.26; P<0.001). The PAC group had an increased risk of all-cause mortality, 3.5% vs 1.7% (AOR, 2.08; 95% CI, 1.11 to 3.88; P=0.02) and an increased risk of cardiac (AOR, 1.58; 95% CI, 1.14 to 2.20; P=0.007), cerebral (AOR, 2.02; 95% CI, 1.08 to 3.77; P=0.03) and renal (AOR, 2.47; 95% CI, 1.68 to 3.62; P<0.001) morbid outcomes. PAC patients received inotropic drugs more frequently (57.8% vs 50.0%; P<0.001), had a larger positive IV fluid balance after surgery (3220 mL vs 3022 mL; P=0.003), and experienced longer time to tracheal extubation (15.40 hours [11.28/20.80] versus 13.18 hours [9.58/19.33], median plus Q1/Q3 interquartile range; P<0.0001). Use of PAC was also associated with prolonged intensive care unit stay (14.5% vs 10.1%; AOR, 1.55; 95% CI, 1.06 to 2.27; P=0.02). CONCLUSIONS: Use of a PAC during CABG surgery was associated with increased mortality and a higher risk of severe end-organ complications in this propensity-matched observational study. A randomized controlled trial with defined hemodynamic goals would be ideal to either confirm or refute our findings.

Resection-plication-release for hypertrophic cardiomyopathy: clinical and echocardiographic follow-up.

BACKGROUND: Abnormal positioning and size of the mitral valve contribute to the systolic anterior motion and mitral-septal contact that are important components of obstructive hypertrophic cardiomyopathy (HCM). The RPR repair (resection of the septum, plication of the anterior leaflet, and release of papillary muscle attachments) addresses all aspects of this complex pathology. This study reports outcomes regarding effectiveness of the RPR repair. METHODS: Fifty consecutive unselected patients (average age, 55.8 years) undergoing RPR repair for obstructive HCM from 1997 to 2007 were studied. Each patient underwent preoperative and postoperative transthoracic echocardiograms to document gradient, ejection fraction, degree of mitral regurgitation, and systolic anterior motion. Intraoperative transesophageal echocardiogram was used to guide all surgical repairs. Clinical follow-up included patient interviews to determine New York Heart Association (NYHA) status. RESULTS: Concomitant operations were performed in 25 patients (50%). Postoperative mortality was 0%. Average mean left ventricular outflow tract gradients decreased from 134 +/- 40 to 2.8 +/- 8.0. Mitral regurgitation improved from a mean of 2.5 to 0.1 (p < 0.001). Average length of stay was 6.9 +/- 2.7 days. NYHA class improved from 3.0 +/- 0.6 to 1.2 +/- 0.5. Follow-up was 100%, with a mean of 2.5 +/- 1.8 years. Average mitral regurgitation at follow-up was 0.9, with no residual systolic anterior motion. CONCLUSIONS: The RPR repair is safe and effective for symptomatic obstructive HCM. Our data support repair of the mitral valve that results in good intermediate outcomes with respect to gradient, mitral regurgitation, and clinical status.

Mortality associated with aprotinin during 5 years following coronary artery bypass graft surgery.

CONTEXT: Acute safety concerns have been raised recently regarding certain hemorrhage-sparing medications commonly used in cardiac surgery. However, no comprehensive data exist regarding their associations with long-term mortality. OBJECTIVE: To contrast long-term all-cause mortality in patients undergoing coronary artery bypass graft (CABG) surgery according to use of 2 lysine analog antifibrinolytics (aminocaproic acid and tranexamic acid), the serine protease inhibitor aprotinin, or no antibleeding agent. DESIGN, SETTING, AND PARTICIPANTS: Observational study of mortality conducted between November 11, 1996, and December 7, 2006. Following index hospitalization (4374 patients; 69 medical centers), survival was prospectively assessed at 6 weeks, 6 months, and annually for 5 years after CABG surgery among 3876 patients enrolled in a 62-center international cohort study. The associations of survival with hemorrhage-sparing medications were compared using multivariable analyses including propensity adjustments. MAIN OUTCOME MEASURE: Death (all-cause) over 5 years. RESULTS: Aprotinin treatment (223 deaths among 1072 patients [20.8% 5-year mortality]) was associated with significantly increased mortality compared with control (128 deaths among 1009 patients [12.7%]; covariate adjusted hazard ratio for death, 1.48; 95% confidence interval, 1.19-1.85), whereas neither aminocaproic acid (132 deaths among 834 patients [15.8%]; adjusted hazard ratio for death, 1.03; 95% confidence interval, 0.80-1.33) nor tranexamic acid (65 deaths among 442 patients [14.7%]; adjusted hazard ratio for death, 1.07; 95% confidence interval, 0.80-1.45) was associated with increased mortality. In multivariable logistic regression, either with propensity adjustment or without, aprotinin was independently predictive of 5-year mortality (adjusted odds ratio with propensity adjustment, 1.48; 95% confidence interval, 1.13-1.93; P = .005) among patients with diverse risk profiles, as well as among those surviving their index hospitalization. Neither aminocaproic nor tranexamic acid was associated with increased risk of death. CONCLUSIONS: These findings indicate that in addition to the previously reported acute renal and vascular safety concerns, aprotinin use is associated with an increased risk of long-term mortality following CABG surgery. Use of aprotinin among patients undergoing CABG surgery does not appear prudent because safer and less expensive alternatives (ie, aminocaproic acid and tranexamic acid) are available.

Beyond extended myectomy for hypertrophic cardiomyopathy: the resection-plication-release (RPR) repair.

BACKGROUND: Extended myectomy for left ventricular outflow tract obstruction (LVOTO) due to hypertrophic cardiomyopathy (HCM) has good long-term results. In addition to the midseptal resection (R) for HCM, our group has introduced a novel variation in anterior leaflet plication (P) and release (R) of papillary muscle attachments. We sought to investigate the medium-term success of this three-step repair that addresses all aspects of complex HCM pathology. METHODS: Nineteen patients underwent resection-plication-release repair for complex HCM pathology. Transesophageal echocardiography was performed on all patients preoperatively and postoperatively to assess adequacy of resection, left ventricular outflow tract gradients, and mitral valve function. All patients underwent transthoracic outpatient echocardiography at a mean follow-up of 2.4 +/- 2.1 years (range, 0.5 to 6). RESULTS: The average age of the patients was 57 +/- 14 years. The preoperative peak LVOTO was 137 +/- 45 mm Hg. The average degree of mitral regurgitation was 3.1. The average length of stay was 7.5 +/- 3.3 days. There were no readmissions or deaths in the group. Initial postoperative transesophageal echocardiography demonstrated marked reduction in LVOTO to 10 +/- 17 mm Hg (p < 0.0001) and significant improvement in mitral regurgitation to 0.2 (p < 0.0001). In follow-up, the LVOT gradient remained low at 6 +/- 14 (p > 0.0001) and mitral regurgitation remained insignificant at 0.4 (p < 0.0001). CONCLUSIONS: Anterior leaflet plication and papillary muscle release are logical adjuncts to septal resection in the treatment of the complicated pathophysiology of obstructive HCM. Durable long-term results can be achieved with an aggressive approach to mitral valve pathology in conjunction with extended myectomy.

Robotically assisted left ventricular epicardial lead implantation for biventricular pacing.

OBJECTIVES: Ventricular resynchronization might be achieved in a minimally invasive fashion using a robotically assisted, direct left ventricular (LV) epicardial approach. BACKGROUND: Approximately 10% of patients undergoing biventricular pacemaker insertion have a failure of coronary sinus (CS) cannulation. Rescue therapy for these patients currently is limited to standard open surgical techniques. METHODS: Ten patients with congestive heart failure (New York Heart Association class 3.4 +/- 0.5) and a widened QRS complex (184 +/- 31 ms) underwent robotic LV lead placement after failed CS cannulation. Mean patient age was 71 +/- 12 years, LV ejection fraction (EF) was 12 +/- 6%, and LV end-diastolic diameter was 7.1 +/- 1.3 cm. Three patients had previous cardiac surgery, and five patients had a prior device implanted. RESULTS: Nineteen epicardial leads were successfully placed on the posterobasal surface of the LV. Intraoperative lead threshold was 1.0 +/- 0.5 V at 0.5 ms, R-wave was 18.6 +/- 8.6 mV, and impedance was 1,143 +/- 261 ohms at 0.5 V. Complications included an intraoperative LV injury and a postoperative pneumonia. Improvements in exercise tolerance (8 of 10 patients), EF (19 +/- 13%, p = 0.04), and QRS duration (152 +/- 21 ms, p = 0.006) have been noted at three to six months follow-up. Lead thresholds have remained unchanged (2.1 +/- 1.4 V at 0.5 ms, p = NS), and a significant drop in impedance (310 +/- 59 ohms, p < 0.001) has been measured. CONCLUSIONS: Robotic LV lead placement is an effective and novel technique which can be used for ventricular resynchronization therapy in patients with no other minimally invasive options for biventricular pacing.