Impacto de la miectomía septal ampliada sobre los cambios ecocardiográficos en la miocardiopatía hipertrófica obstructiva / Impact of Extended Septal Miectomy on Echocardiographic Changes in Hypertophic Obstructivec Cardiomyopathy

RESUMEN Introducción: La miectomía septal ampliada (MSA) ha demostrado ser una estrategia útil para mejorar los síntomas de los pacientes con miocardiopatía hipertrófica obstructiva (MCHO). Objetivos: El objetivo de este trabajo fue analizar el impacto de la MSA en parámetros estructurales y funcionales ecocardiográficos a corto y mediano plazo, en pacientes con MCH y obstrucción dinámica del tracto de salida del ventrículo izquierdo (VI). Material y métodos: Se analizaron los ecocardiogramas en los períodos preoperatorio, postoperatorio inmediato (1 mes post cirugía) y posoperatorio alejado (2 a 3 años) de pacientes sometidos a MSA. Resultados: Se intervinieron 94 pacientes con una edad media de 57,6 ± 13,8 años. Se observó una reducción significativa del máximo espesor septal en el postoperatorio inmediato, que se mantuvo en el posoperatorio alejado, y en el tamaño auricular izquierdo en el postoperatorio inmediato que se profundizó en el alejado (p < 0,001). El gradiente intraventricular en reposo pasó de 49,2 mmHg basal a 6,4 mmHg (p < 0,001) y de allí a 4,6 mmHg (p=0,224) en los períodos inmediato y alejado, y con la maniobra de Valsalva de 93,9 mmHg a 8,7 mmHg (p < 0,001) y de allí a 7,2 mmHg (p=0,226) respectivamente. La función diastólica fue valorada como grado II en el 58,5 % de los pacientes en el preoperatorio, 51,7 % en el postoperatorio inmediato y 29 % en el postoperatorio alejado. En la misma línea se evidenció un cambio en la relación E/e´ y la presión sistólica pulmonar, grado de insuficiencia mitral y dimensiones de la aurícula izquierda. Conclusión: En esta cohorte de pacientes con MCHO, la realización de una MSA se asoció a una mejoría significativa de la función diastólica del VI, reducción de las presiones de llenado y pulmonares y grado de insuficiencia mitral, y remodelado reverso de la aurícula izquierda. Es posible que esta combinación de efectos explique los beneficios clínicos de la intervención.

ABSTRACT Background: Extended septal myectomy (ESM) has proven to be a useful strategy to improve symptoms in patients with hypertrophic obstructive cardiomyopathy (HOCM). Objectives: The aim of this study was to analyze the impact of ESM on short and mid-term structural and functional echocardiographic parameters in patients with HCM and left ventricular (LV) outflow tract dynamic obstruction. Methods: Preoperative, immediate postoperative (1 month after surgery) and late postoperative (2 to 3 years) echocardiograms of patients undergoing ESM were analyzed. Results: A total of 94 patients with mean age of 57.6 ± 13.8 years underwent surgery. A significant reduction was observed in maximum septal thickness in the immediate postoperative period, which was sustained in the late postoperative period, and in atrial size in the immediate postoperative period, which deepened in the late postoperative period (p < 0.001). Intraventricular gradient at rest dropped from 49.2 to 6.4 mmHg (p < 0.001) and then to 4.6 mmHg (p=0.224) in the immediate and late periods and with Valsalva maneuver from 93.9 to 8.7 mmHg (p < 0.001), and then to 7.2 mmHg (p=0.226), respectively. Preoperative diastolic function was assessed as grade II in 58.5% of patients, decreasing to 51.7% in the immediate postoperative period and to 29% in the late postoperative period. In agreement with these results, a change was evidenced in the E/e´ ratio and pulmonary artery systolic pressure, degree of mitral regurgitation and left atrial dimensions. Conclusion: In this cohort of patients with HOCM, ESM was associated with a significant improvement in LV diastolic function, reduction in filling and pulmonary pressures and degree of mitral regurgitation, and left atrial reverse remodeling. It is possible that this combination of effects explains the clinical benefits of the intervention.

Exploring the hemodynamic changes of the ascending aorta before and after interventricular septal myocardial resection in obstructive hypertrophic cardiomyopathy by CMR 4D Flow technology / 中国医师杂志

Objective:To investigate the hemodynamic changes in the ascending aorta (AAo) before and after interventricular septal myocardial resection in obstructive hypertrophic cardiomyopathy (HOCM) using cardiac magnetic resonance four-dimensional blood flow (CMR 4D Flow) technology.Methods:HOCM patients who underwent interventricular septal myocardial resection at Guangdong Provincial People′s Hospital from May 2021 to September 2022 were prospectively included. Age and gender matched healthy volunteers (control group) were included during the same period. Both the control group and HOCM patients underwent CMR examination (including cine sequence and 4D Flow sequence) before and 6 months after surgery. CMR 4D flow technology was used to evaluate changes in AAo preoperative and postoperative blood flow patterns (eddy currents, spiral flow), maximum energy loss (EL max), and average energy loss (EL avg). HOCM patients underwent laboratory tests, including N-terminal pro-brain natriuretic peptide (N-pro BNP) and high-sensitivity troponin T (hsTnT). At the same time, the correlation between postoperative energy loss in HOCM patients and the degree of improvement in laboratory biomarkers was explored. Results:A total of 15 HOCM patients and 15 healthy volunteers were included. (1) In terms of blood flow patterns, the preoperative spiral flow degree of HOCM patients was significantly higher than that of the control group ( P=0.001), but the postoperative difference was not statistically significant ( P=0.059). The degree of eddy currents in HOCM patients before and after surgery was higher than that in the control group (all P<0.05). (2) In terms of energy loss, the preoperative EL max [21.17(14.30-28.10)mW vs 10.17(7.66-13.07)mW, P<0.001] and EL avg [4.87(3.46-5.77)mW vs 2.27(2.19-2.27)mW, P=0.023] of HOCM patients were higher than those of the control group, but there was no statistically significant difference between the postoperative and control groups (all P>0.05). Compared with preoperative, the postoperative EL max [12.33(8.70-17.41)mW] and EL avg [3.10(2.25-4.40)mW] of AAo in HOCM patients were significantly reduced (mean P=0.001). (3) Correlation analysis showed that there was a positive correlation ( r=0.587, P=0.021) between the EL max of AAo and the degree of improvement in hsTNT after interventricular septum myocardial resection, but no significant correlation ( r=0.229, P=0.413) with the degree of improvement in NT-pro BNP. Conclusions:The degree of postoperative AAo blood flow disorder in HOCM patients is reduced, and EL max and EL avg are significantly reduced. The EL max of postoperative AAo is positively correlated with the degree of improvement in hsTNT, suggesting that EL max may be applicable for prognostic evaluation of patients.

Transapical beating interventricular septal resection under the navigation of three-dimensional transesophageal echocardiography for the treatment of hypertrophic obstructive cardiomyopathy / 中华超声影像学杂志

Objective:To evaluate the efficacy and safety of immediate intraoperative transapical beating-heart septal myectomy (TA-BSM) in patients with hypertrophic obstructive cardiomyopathy (HOCM) and explored the clinical value of three-dimensional transesophageal echocardiography (3D-TEE) during the procedure of TA-BSM.Methods:One hundred and thirty-seven HOCM patients who underwent TA-BSM surgery in Tongji Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology from April 2022 to March 2023 were selected.During the operation, 3D-TEE was used to locate the position of the myocardial circumcision system and navigate the range of myocardial circumcision. The interventricular septal thickness( IVST) and peak pressure gradient of the left ventricular outflow tract (LVOT-PG) were measured, and the degree of mitral systolic anterior motion (SAM) and mitral regurgitation (MR) were evaluated in HOCM patients before and after the operation. The range of the incisal margin was measured, and the number of resection knives and the weight of the removed myocardium were recorded.Results:TA-BSM under 3D-TEE navigation was successfully performed in 137 HOCM patients. The number of resection was 7(5, 9), and the weight of the removed myocardium was 5.6(3.4, 8.9)g. During the operation, there were no adverse events such as death, aortic valve injury, and iatrogenic interventricular septal perforation. Compared with those before the operation, the wall thickness of basal and middle segments of the anterior and posterior interventricular septum decreased significantly (all P<0.001), and LVOT-PG decreased significantly ( P<0.001). After TA-BSM, the number of patients with SAM≥3 decreased from 94 cases (68.6%) to 2 cases (1.5%), and the number of patients with MR≥3+ decreased from 86 cases (62.8%) to 9 cases (6.6%)(all P<0.001). For the patients with different degrees of ventricular septal hypertrophy (mild, moderate, and severe), the postoperative IVST and LVOT-PG were significantly lower than the preoperative values, and the degree of MR and SAM signs was relieved considerably. The length of the incisal margin, the weight of excised myocardium, and the number of resection in the group with extensive septal hypertrophy in all three regions were significantly higher than those in the group with localized interventricular septal hypertrophy in single or two areas (all P<0.05). Conclusions:3D-TEE can guide and monitor the process of TA-BSM myocardial resection in real-time. By accurately evaluating the IVST and the range and hemodynamic characteristics of HOCM patients, it can effectively relieve LVOTO and significantly reduce MR to ensure the safety and effectiveness of TA-BSM in HOCM patients with different degrees and ranges of hypertrophy.

Totally endoscopic transmitral septal myectomy for the treatment of recurrent left ventricular outflow tract obstruction after alcohol septal ablation / 中国胸心血管外科临床杂志

@#Objective    To investigate the surgical strategies and clinical efficacy of transmitral septal myectomy in the treatment of recurrent left ventricular outflow tract obstruction (LVOTO) after alcohol septal ablation. Methods    The clinical data of patients with recurrent LVOTO after alcohol septal ablation from July 2020 to July 2021 in the Department of Cardiac Surgery, Guangdong Provincial People's Hospital were retrospectively analyzed. Patients were preoperatively evaluated by echocardiography, cardiac magnetic resonance imaging, cardiac computed tomography, 3D modeling and printing technology. A personalized surgical strategy was preoperatively developed according to multimodality imaging assessment, while visual exploration was performed on the digital model and simulated surgical resection was performed on the printed model. Results     Two female patients were enrolled, aged 62 years and 64 years, respectively. Totally endoscopic transmitral extended myectomy was successfully performed on both patients with aortic cross-clamping time of 96 min and 85 min, respectively. LVOTO was relieved immediately (subaortic peak pressure gradient decreased from 100 mm Hg to 4 mm Hg and from 84 mm Hg to 6 mm Hg, respectively) and the mitral regurgitation significantly improved after the procedure. No patient had complete atrioventricular block or required permanent pacemaker implantation. The patients were discharged uneventfully without postoperative complications. Conclusion    Personalized totally endoscopic transmitral extended myectomy combined with multimodality imaging assessment and 3D modeling and printing has an acceptable clinical effect in patients with recurrent LVOTO after alcohol septal ablation. The procedure can precisely resect the hypertrophic septal myocardium while avoiding serious complications such as septal perforation or complete atrioventricular block.

Early outcomes of combined transaortic and transapical approach to septal myectomy in patients with complex hypertrophic obstructive cardiomyopathy / 中华胸心血管外科杂志

Objective:To evaluate the early effects of combined transaortic and transapical approach to septal myectomy in patients with complex hypertrophic obstructive cardiomyopathy(HOCM).Methods:We consecutively enrolled 20 complex HOCM patients who received transaortic and transapical myectomy in fuwai hospital from January 2019 to October 2019. Echocardiography was performed to compare left atrial size, left ventricular end diastolic diameter, peak left ventricular outflow gradient, ventricular septal thickness, mitral systolic anterior motion and mitral regurgitation grade before and after operation. Furthermore, pre-operative and post-operative electrocardiogram were also analyzed to determine the incidence of bundle branch block. Functional status was evaluated by New York Heart Association functional class.Results:Of the 20 complex hypertrophic cardiomyopathy patients, 7(35%) HOCM patients with long-segment septal hypertrophy more than 7cm, 4(20%) patients had both mid-ventricular obstruction and left ventricular outflow obstruction. Apical hypertrophic cardiomyopathy with LOVT obstruction was observed in 5 patients(25%) and aneurysm was found in 4(20%) HOCM patients. Postoperative thickness of ventricular septum was significantly decreased compared with that of preoperation[(21.1±3.6)mm vs.(13.4±3.1)mm]. Peak LOVT gradient or mid-ventricular gradient also significantly reduced after operation[(77.0±21.0) mmHg vs.(9.2±3.4) mmHg] or [(71.0±23.0) mmHg vs. 0 mmHg, 1 mmHg=0.133 kPa]; After surgery, mitral systolic anterior motion disappeared, mitral regurgitation degree reduced from (1.9±1.5) to (0.2±0.4); NYHA class improved from(2.1±0.2) to(1.3±0.5). New incidence of left bundle branch block occurred in 9 patients, and 1 patient developed complete bundle branch block and implanted permanent pacemaker. The 30-day survival was 100%.Conclusion:Combined transaortic and transapical septal myectomy is an effective and reasonably safe procedure for patients with complex hypertrophic obstructive cardiomyopathy.

Long-term outcome of patients with hypertrophic obstructive cardiomyopathy post percutaneous transluminal septal ablation / 中华心血管病杂志

Objective: To evaluate the long-term outcome of patients with hypertrophic obstructive cardiomyopathy(HOCM) after percutaneous transluminal septal ablation(PTSMA). Methods: HOCM patients who underwent PTSMA and surgical myectomy at the Chest Hospital of Shanghai Jiao Tong University from April 2001 to February 2019 were included in this retrospective analysis. Patients were divided into PTSMA group and surgical myectomy group. In addition, patients undergoing PTSMA were further divided into HOCM-PTSMA non-survivor group and HOCM-PTSMA survivor group. The general clinical information, procedural/surgical information and complications during hospitalization were compared between groups. Multivariate Cox regression model was used to analyze the independent risk factors for all-cause death in HOCM patients after PTSMA. Results: A total of 104 patients with HOCM who underwent PTSMA were enrolled. Mean age of the patients was (54±15) years old, including 41 females (38.7%). The follow-up time was 37.5(14.3, 76.8) months. At the last follow-up, 12 patients died (HOCM-PTSMA non-survivor group) and 92 were alive(HOCM-PTSMA survivor group). The proportion of patients with NYHA function class Ⅲ/Ⅳ was higher(P=0.036), and the posterior wall of the left ventricle was thicker(P=0.006) in the HOCM-PTSMA non-survivor group than in the HOCM-PTSMA survivor group. The immediate success rate of PTSMA in this cohort was 66%(70/104). The amount of absolute alcohol during the operation in the HOCM-PTSMA non-survivor group was (2.9±0.8) ml, which tended to be higher as compared to that in the HOCM-PTSMA survivor group((2.4±1.0)ml, P=0.056). Kaplan-Meier survival curve analysis showed that patients with HOCM who underwent PTSMA had an all-cause mortality-free survival rate of 90.1%, 78.3%, and 56.9% at 5, 10 and 15 years, and a HOCM-free survival rate of 91.3%, 79.4% and 57.7% at 5, 10 and 15 years, respectively. Multivariate Cox regression analysis showed that age≥ 65 years was an independent risk factor for all-cause death after PTSMA in patients with HOCM (HR=2.697, 95%CI 1.292-18.977, P=0.020). There were 32 patients in the surgical myectomy group. The proportion of patients with NYHA function class Ⅲ/Ⅳ was higher than that in the PTSMA group(P<0.001), while age, gender, and major comorbidities(atrial fibrillation, coronary heart disease, hypertension, and diabetes) as well as the left atrium dimension were all similar between the two groups(all P>0.05). Patients in the surgical myectomy group were followed up for 38.0(17.6, 64.2)months, and no deaths occurred during the follow-up period. Kaplan-Meier survival curve analysis showed that there were no statistically significant differences in all-cause-free and HOCM-free survival rates between patients in PTSMA group and surgical myectomy group(P=0.089 and 0.110, respectively). Conclusion: PTSMA is safe and effective for the treatment of patients with HOCM, and the long-term survival rate of patients after PTSMA is similar as patients undergoing classical surgical myectomy surgery.

Miocardiopatía hipertrófica: encare clínico y opciones de tratamiento / Hypertrophic cardiomyopathy: clinical approach and treatment options / Cardiomiopatia hipertrófica: abordagem clínica e opções de tratamento

Resumen: La miocardiopatía hipertrófica (MCH) constituye una enfermedad compleja y muy variable en cuanto a su presentación morfológica, fisiopatológica y sintomática, así como en su pronóstico. Su intrincado sustrato genético ha sido objeto de una permanente y productiva investigación en las últimas décadas. En correspondencia con esta complejidad, su manejo clínico representa un desafío, aun para los cardiólogos más experimentados. La presente controversia comienza con una valiosa actualización por parte del Dr. Walter Reyes sobre la valoración del riesgo individual de muerte súbita en el paciente portador de esta patología, sin duda el más temido evento que pueda presentarse durante su transcurso. En este abordaje se podrá apreciar la evolución de los conceptos, desde la aplicación de los clásicos factores de riesgo obtenidos de los primeros estudios en poblaciones más o menos seleccionadas, hasta las recomendaciones más recientes de la American Heart Association y la European Society of Cardiology, capitalizando la nueva información. Luego, como es habitual y dado el objetivo esencialmente práctico de esta sección, se propone una viñeta sobre un caso de MCH obstructiva en la que el autor aplica, a forma de ejercicio clínico, la información brindada en la revisión previa. A continuación se plantea la controversia propiamente dicha, donde el debate se centra en la elección de la técnica más apropiada de reducción septal en el caso propuesto, cuyas características apuntan a la necesidad de un abordaje invasivo. Dos prestigiosos invitados exponen sus argumentos en favor de cada alternativa. El Dr. Hartzell Shaff propone la miectomía septal quirúrgica como el procedimiento más adecuado, y el Dr. Pedro Trujillo plantea la ablación septal percutánea como solución de elección. El desarrollo de ambas exposiciones permitirá al lector apreciar la importancia de un enfoque individualizado, dada la riqueza de información clínica, anatomofuncional y propia de cada procedimiento que se requiere para inclinar la balanza en favor de uno u otro. Ambos autores coinciden en el beneficio de contar con un equipo especializado y experimentado para la obtención de buenos resultados con cualquiera de las técnicas.

Summary: Hypertrophic cardiomyopathy is a complex and highly variable disease in terms of morphological, pathophysiological and symptomatic presentation, as well as in its prognosis. Its intricate genetic substrate has been subject of permanent research in recent decades. Corresponding to this complexity, its clinical management represents a challenge, even for the most experienced cardiologists. The present controversy begins with a valuable update by Dr. Walter Reyes about assessment of individual risk of sudden death in the patient with this disease, without doubt the most feared event that may occur during its course. In this approach, evolution of concepts can be appreciated, from the application of the classic risk factors obtained from the first studies, to the most recent recommendations of the American Heart Association and the European Society of Cardiology. Since the practical objective of this section, a clinical case is proposed on an obstructive hypertrophic cardiomyopathy in which the author applies, as a clinical exercise, the information provided in the previous review. Next, the controversy itself arises, where the debate focuses on the choice of the most appropriate septal reduction technique. Two prestigious guests present their arguments in favour of each alternative. Prof. Hartzell Shaff proposes surgical septal myectomy as the most appropriate procedure, and Dr. Pedro Trujillo proposes percutaneous septal ablation as the solution of choice. The exposures will allow the reader to appreciate the importance of an individualized approach, given the amount of clinical, anatomic, functional and specific information of each procedure that is required to tip the balance in favour of one or the other. Both authors agree on the benefit of having a specialized and experienced team to obtain good results with any of the techniques.

Resumo: A cardiomiopatia hipertrófica é uma doença complexa e altamente variável em termos de apresentação morfológica, fisiopatológica e sintomática, bem como em seu prognóstico. Seu intrincado substrato genético tem sido objeto de pesquisa permanente nas últimas décadas. Correspondendo a essa complexidade, seu manejo clínico representa um desafio, mesmo para os cardiologistas mais experientes. A presente controvérsia começa com uma atualização valiosa do Dr. Walter Reyes sobre a avaliação do risco individual de morte súbita no paciente com esta doença, sem dúvida o evento mais temido que pode ocorrer durante seu curso. Nessa abordagem, a evolução dos conceitos pode ser apreciada, desde a aplicação dos fatores de risco clássicos obtidos nos primeiros estudos, até as recomendações mais recentes da American Heart Association e da European Society of Cardiology. Como o objetivo prático desta seção, é proposto um caso clínico em uma cardiomiopatia hipertrófica obstrutiva, no qual o autor aplica, como exercício clínico, as informações fornecidas na revisão anterior. Em seguida, surge a própria controvérsia, onde o debate se concentra na escolha da técnica de redução septal mais apropriada. Dois convidados de prestígio apresentam seus argumentos em favor de cada alternativa. O professor Hartzell Shaff propõe a miectomia septal cirúrgica como o procedimento mais apropriado e o Dr. Pedro Trujillo propõe a ablação septal percutânea como a solução de escolha. As exposições permitirão ao leitor apreciar a importância de uma abordagem individualizada, dada a quantidade de informações clínicas, anatômicas, funcionais e específicas de cada procedimento, necessárias para inclinar a balança em favor de uma ou de outra. Ambos os autores concordam com o benefício de ter uma equipe especializada e experiente para obter bons resultados com qualquer uma das técnicas.

Surgical treatment of severe aortic stenosis with septal hypertrophy / 中华胸心血管外科杂志

Objective To summarize the experience of surgical treatment of 18 cases of severe aortic stenosis with ventricular septum hypertrophy.Methods Clinical data of 18 patients with severe aortic stenosis admitted to the first affiliated hospital of zhengzhou university from January 2013 to December 2016 were collected.There were 7 males and 11 females.The mean age was (50.4 ±4.2) years old.All patients were diagnosed with severe stenosis of main artery valve by echocardiography before surgery,with mean aortic valve orifice area (0.57 ±0.11) cm2,cardiac function (NYHA classification) grade Ⅱ in 4 patients,grade Ⅲ in 9 patients,and grade ⅣV in 5 patients.There were 8 patients with mild aortic valve insufficiency,4 patients with mild to moderate mitral valve insufficiency,2 patients with moderate to severe aortic valve insufficiency,3 patients with ascending aorta dilatation (ascending aorta inner diameter ＞ 4.5 cm),and 1 patient with atrial fibrillation.Interventricular septum thickness (15.82 ± 2.04) mm,left ventricular posterior wall thickness (14.04 ± 1.28) mm,ratio of interventricular septum thickness to left ventricular posterior wall thickness (IVS/LVPW) 1.12 ±0.91,inner diameter of left ventricular outflow tract (19.01 ± 1.74) mm,cross-lobe differential pressure (102 ± 8.40) mmHg (1 mmHg =0.133 kPa),left ventricular ejection fraction (LVEF) mean 0.49 ± 0.05.Left ventricular end-diastolic diameter (LVEDD) (53.33 ± 4.00)mm,left ventricular end-systolic diameter (LVESD) (27.11 ± 1.99) mm,and left ventricular mass index (277.1 ± 37.3) g/m2.All patients underwent aortic valve replacement (AVR) and partial interventricular septum resection under general anesthesia and conventional extracorporeal circulation,2 patients underwent mitral valve formation (artificial valve ring),2 patients underwent ascending aorta formation,and 1 patient underwent ascending aorta wrapping.During the operation,the time of extracorporeal circulation,aortic occlusion,number of defibrillation during the operation,type of valve implantation and postoperative complications were recorded.Regular follow-up was conducted to analyze the changes of various indexes at different preoperative and postoperative time.Results There was no death in the whole group.2 patients were treated with temporary pacemakers.After drug treatment,sinus rhythm was restored on the 3rd and 6th day after surgery,and temporary pacemakers were removed.Echocardiography reexamination 1 week after the operation showed that all patients had a good artificial valve function and 2 patients had minor regurgitation of mitral valve.The difference in pressure across the valve,inner diameter of the left ventricular outflow tract,cardiac function classification,ventricular septum thickness,valve orifice area,and left ventricular mass index were significantly improved compared with the preoperative level (P ＜ 0.05).LVEF,LVEDD,and LVESD were compared with the preoperative level (P ＜ 0.05).After 6 months of follow-up,the difference in LVEF and LVEDD was statistically significant compared with the preoperative level (P ＜ 0.05).Conclusion Severe aortic stenosis combined with ventricular septum hypertrophy and partial ventricular septal muscle resection is a simple additional procedure in the AVR process,which does not increase the surgical risk and has a significant effect,and is conducive to postoperative left ventricular function recovery.

Surgical treatment of severe aortic stenosis with septal hypertrophy / 中华胸心血管外科杂志

Objective@#To summarize the experience of surgical treatment of 18 cases of severe aortic stenosis with ventricular septum hypertrophy.@*Methods@#Clinical data of 18 patients with severe aortic stenosis admitted to the first affiliated hospital of zhengzhou university from January 2013 to December 2016 were collected. There were 7 males and 11 females. The mean age was (50.4±4.2) years old. All patients were diagnosed with severe stenosis of main artery valve by echocardiography before surgery, with mean aortic valve orifice area (0.57±0.11) cm2, cardiac function (NYHA classification) grade Ⅱ in 4 patients, grade Ⅲ in 9 patients, and grade Ⅳ in 5 patients. There were 8 patients with mild aortic valve insufficiency, 4 patients with mild to moderate mitral valve insufficiency, 2 patients with moderate to severe aortic valve insufficiency, 3 patients with ascending aorta dilatation (ascending aorta inner diameter>4.5 cm), and 1 patient with atrial fibrillation. Interventricular septum thickness (15.82±2.04)mm, left ventricular posterior wall thickness (14.04±1.28)mm, ratio of interventricular septum thickness to left ventricular posterior wall thickness (IVS/LVPW) 1.12±0.91, inner diameter of left ventricular outflow tract (19.01±1.74)mm, cross-lobe differential pressure (102±8.40) mmHg (1 mmHg=0.133 kPa), left ventricular ejection fraction (LVEF) mean 0.49±0.05. Left ventricular end-diastolic diameter (LVEDD) (53.33±4.00) mm, left ventricular end-systolic diameter (LVESD) (27.11±1.99) mm, and left ventricular mass index (277.1±37.3) g/m2. All patients underwent aortic valve replacement (AVR) and partial interventricular septum resection under general anesthesia and conventional extracorporeal circulation, 2 patients underwent mitral valve formation (artificial valve ring), 2 patients underwent ascending aorta formation, and 1 patient underwent ascending aorta wrapping. During the operation, the time of extracorporeal circulation, aortic occlusion, number of defibrillation during the operation, type of valve implantation and postoperative complications were recorded. Regular follow-up was conducted to analyze the changes of various indexes at different preoperative and postoperative time.@*Results@#There was no death in the whole group. 2 patients were treated with temporary pacemakers. After drug treatment, sinus rhythm was restored on the 3rd and 6th day after surgery, and temporary pacemakers were removed. Echocardiography reexamination 1 week after the operation showed that all patients had a good artificial valve function and 2 patients had minor regurgitation of mitral valve. The difference in pressure across the valve, inner diameter of the left ventricular outflow tract, cardiac function classification, ventricular septum thickness, valve orifice area, and left ventricular mass index were significantly improved compared with the preoperative level (P<0.05). LVEF, LVEDD, and LVESD were compared with the preoperative level (P<0.05). After 6 months of follow-up, the difference in LVEF and LVEDD was statistically significant compared with the preoperative level (P<0.05).@*Conclusion@#Severe aortic stenosis combined with ventricular septum hypertrophy and partial ventricular septal muscle resection is a simple additional procedure in the AVR process, which does not increase the surgical risk and has a significant effect, and is conducive to postoperative left ventricular function recovery.

Minimally Invasive Trans-Mitral Septal Myectomy to Treat Hypertrophic Obstructive Cardiomyopathy

A 43-year-old man with symptomatic hypertrophic obstructive cardiomyopathy (HOCM) was admitted to our hospital with aggravated exertional dyspnea and successfully treated with robotic transmitral septal myectomy. Minimally invasive transmitral septal myectomy may be a feasible surgical option for the treatment of HOCM in selected cases as an alternative to transaortic myectomy.

Application of Intro-operative Transesophageal Echocardiography for Extended Septal Myectomy in Patients With Obstructive Hypertrophic Cardiomyophathy / 中国循环杂志

Objective: To evaluate the intro-operative transesophageal echocardiography (TEE) for extended septal myectomy in patients with obstructive hypertrophic cardiomyophathy (HCM). Methods: A total of 56 obstructive HCM patients with extended septal myectomy in our hospital from 2012-01 to 2012-12 were retrospectively studied. The results of pre-operative transthoracic echocardiography, intro-operative TEE and post-operative transthoracic echocardiography were analyzed and compared. Results: There were 36 male and 20 female patients with the average age of (46.1 ± 11.3) years. The pre-operative width of inter ventricular septal was (26.1 ± 6.9) mm, left ventricular outlfow tract (LVOT) pressure gradient was (87.5 ± 12.5) mmHg. All patients received successful operation, no in-hospital death, no TEE related complication. The removed ventricular septal thickness was at (10.7 ± 2.1) mm, length at (39.1±5.5) mm. Compared with pre-operative transthoracic echocardiography, TEE indicated the immediate drop of post-operative LVOT peak velocity (4.57 ± 0.99)m/s vs (1.68±0.46)m/s and LVOT peak gradient (87.5 ± 34.4) vs (11.3 ± 7.0) mmHg, both P Conclusion: TEE is safe for extended septal myectomy in obstructive HCM patients. It may pre-operatively identify the cause and degree of MR, evaluate the post-operative improvement of LVOT obstruction and MR. Meanwhile, TEE may ifnd the surgical complication for in time correction in relevant patients.

Septal Myectomy and Mitral Valve Replacement for Hypertrophic Obstructive Cardiomyopathy Accompanied by Severe Mitral Regurgitation / 日本心臓血管外科学会雑誌

Septal myectomy and mitral valve surgery are performed for the treatment of hypertrophic obstructive cardiomyopathy (HOCM) ; however, there is a debate as to which is the better option. In this paper, we report on the eventless postoperative course of a patient who underwent septal myectomy and mitral valve replacement simultaneously to treat HOCM accompanied by severe mitral regurgitation. A 75-year-old woman was referred to our department for severe mitral regurgitation accompanied by exertional dyspnea; we observed systolic anterior motion of the anterior mitral leaflet and a left ventricular outflow tract pressure gradient of 130 mmHg that was not decreased by DDD pacing. A 15×6×15-mm rectangular parallele pipe-shaped section of the hypertrophied basal septum was resected via a transaortic approach. In addition, mitral valve replacement with a 25-mm SJM was performed during the same procedure, as lesions were observed in the mitral valve. After surgery, the left ventricular outflow tract pressure gradient decreased by 12.5 mmHg. Necessary and sufficient resection of the hypertrophied basal septum, after careful preoperative and intraoperative evaluation of the extent of myocardial resection and mitral valve lesions is important for improving left ventricular outflow tract pressure gradient in HOCM. Mitral valve replacement should also be performed, if necessary, to treat mitral valve lesions.