Hypertrophic cardiomyopathy surgery

Jump to navigation Jump to search

Hypertrophic Cardiomyopathy Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Hypertrophic Cardiomyopathy from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Study of Choice

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X Ray

Echocardiography and Ultrasound

CT scan

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Interventions

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Hypertrophic cardiomyopathy surgery On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Hypertrophic cardiomyopathy surgery

CDC on Hypertrophic cardiomyopathy surgery

Hypertrophic cardiomyopathy surgery in the news

Blogs on Hypertrophic cardiomyopathy surgery

Directions to Hospitals Treating Hypertrophic cardiomyopathy

Risk calculators and risk factors for Hypertrophic cardiomyopathy surgery

Editors-In-Chief: C. Michael Gibson, M.S., M.D. [1], Cafer Zorkun, M.D. [2], Caitlin J. Harrigan [3], Martin S. Maron, M.D., and Barry J. Maron, M.D. Soroush Seifirad, M.D.[4]

Overview

Septal myectomy is a surgical treatment for hypertrophic cardiomyopathy (HCM). Septal myectomies have been successfully performed for more than 25 years.

Cardiac transplantation can be performed in patients with HOCM and has been associated with better post-operative survival than those patients transplanted for ischemic cardiomyopathy.

Cardiac Transplantation

Cardiac transplantation can be performed in patients with HOCM and has been associated with better post-operative survival than those patients transplanted for ischemic cardiomyopathy. [1]

In cases that are refractory to all other forms of treatment, cardiac transplantation is an option.

2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy (DO NOT EDIT)[2]

Selection of Patients for Heart Transplantation (DO NOT EDIT) [2]

Class I
"1. Patients with advanced heart failure (end stage) and nonobstructive HCM not otherwise amenable to other treatment interventions, with EF less than or equal to 50% (or occasionally with preserved EF), should be considered for heart transplantation.[3][4] (Level of Evidence: B) "
"2. Symptomatic children with HCM with restrictive physiology who are not responsive to or appropriate candidates for other therapeutic interventions should be considered for heart transplantation.[5][6] (Level of Evidence: C) "
Class III (Harm)
"1. Heart transplantation should not be performed in mildly symptomatic patients of any age with HCM. (Level of Evidence: C) "

Septal Reduction Guidline

2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy (DO NOT EDIT)[2]

Septal Reduction Therapy (DO NOT EDIT)[2]

Class I
"1. Septal reduction therapy should be performed only by experienced operators in the context of a comprehensive HCM clinical program and only for the treatment of eligible patients with severe drug-refractory symptoms and LVOT obstruction.[7] (Level of Evidence: C)"
Class III (Harm)
"1. Septal reduction therapy should not be done for adult patients with HCM who are asymptomatic with normal exercise tolerance or whose symptoms are controlled or minimized on optimal medical therapy. (Level of Evidence: C) "
"2. Septal reduction therapy should not be done unless performed as part of a program dedicated to the longitudinal and multidisciplinary care of patients with HCM. (Level of Evidence: C) "
"3. Mitral valve replacement for relief of LVOT obstruction should not be performed in patients with HCM in whom septal reduction therapy is an option. (Level of Evidence: C) "

Sources


Septal Myectomy

Septal myectomy is a surgical treatment for hypertrophic cardiomyopathy (HCM). Septal myectomies have been successfully performed for more than 25 years.

History

It has been performed successfully for more than 25 years.

Indications

Surgical septal myectomy is the gold standard for relief of symptoms for patients who do not experience relief of symptoms from medications.[11] [12] [13] [14] [15] [16]

Technique

  • It involves a midline thoracotomy (general anesthesia, opening the chest, and cardiopulmonary bypass) and removing a portion of the interventricular septum.[11]
  • A modification of the Morrow myectomy termed extended myectomy, mobilization and partial excision of the papillary muscles has become the excision of choice. [12][17][18][19]
  • In selected patients with particularly large redundant mitral valves, anterior leaflet plication may be added to complete separation of the mitral valve and outflow.[19][20]

Efficacy and Procedural Success

Surgical septal myectomy uniformly decreases left ventricular outflow tract obstruction and improves symptoms, and in experienced centers has a surgical mortality of 1%.

Surgical myectomy resection focused just on the subaortic septum, to increase the size of the outflow tract to reduce Venturi forces may be inadequate to abolish systolic anterior motion (SAM) of the anterior leaflet of the mitral valve. With this limited sort of resection the residual mid-septal bulge still redirects flow posteriorly: SAM persists because flow still gets behind the mitral valve. It is only when the deeper portion of the septal bulge is resected that flow is redirected anteriorly away from the mitral valve, abolishing SAM.[12][21]

Outcomes

Septal myectomy is associated with a low perioperative mortality and a high late survival rate. A study at the Mayo Clinic found surgical myectomy performed to relieve outflow obstruction and severe symptoms in HCM was associated with long-term survival equivalent to that of the general population, and superior to obstructive HCM without operation. The results are shown below:[22]

Survival (all-cause mortality) *
Years With surgery Without surgery
1 98% 90%
5 96% 79%
10 83% 61%
Survival (HCM-related death)
Years With surgery Without surgery
1 99% 94%
5 98% 89%
10 95% 73%
Survival (sudden cardiac death)
Years With surgery Without surgery
1 100% 97%
5 99% 93%
10 99% 89%

* Includes 0.8% operative mortality.

Comparison with alcohol ablation

Either alcohol septal ablation or myectomy offers substantial clinical improvement for patients with hypertrophic obstructive cardiomyopathy.

Hemodynamic resolution of the obstruction and its sequelae is more complete with myectomy.[23]

2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy (DO NOT EDIT)[2]

Septal Myectomy (DO NOT EDIT)[2]

Class IIa
"1. Consultation with centers experienced in performing both surgical septal myectomy and alcohol septal ablation is reasonable when discussing treatment options for eligible patients with HCM with severe drug-refractory symptoms and LVOT obstruction. (Level of Evidence: C)"
"2. Surgical septal myectomy, when performed in experienced centers, can be beneficial and is the first consideration for the majority of eligible patients with HCM with severe drug-refractory symptoms and LVOT obstruction. (Level of Evidence: B)"
"3. Surgical septal myectomy, when performed at experienced centers, can be beneficial in symptomatic children with HCM and severe resting obstruction (>50 mm Hg) for whom standard medical therapy has failed. (Level of Evidence: C)"

Sources

Related Chapters

References

  1. Martin S. Maron; Benjamin M. Kalsmith; James E. Udelson; Wenjun Li and David Denofrio.Survival Following Cardiac Transplantation in Patients with Hypertrophic Cardiomyopathy.doi: 10.1161/CIRCHEARTFAILURE.109.922872
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW (2011). "2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Journal of the American College of Cardiology. 58 (25): e212–60. doi:10.1016/j.jacc.2011.06.011. PMID 22075469. Retrieved 2011-12-19. Unknown parameter |month= ignored (help)<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
  3. Harris KM, Spirito P, Maron MS; et al. (2006). "Prevalence, clinical profile, and significance of left ventricular remodeling in the end-stage phase of hypertrophic cardiomyopathy". Circulation. 114 (3): 216–25. doi:10.1161/CIRCULATIONAHA.105.583500. PMID 16831987. Unknown parameter |month= ignored (help)<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
  4. Biagini E, Spirito P, Leone O; et al. (2008). "Heart transplantation in hypertrophic cardiomyopathy". Am. J. Cardiol. 101 (3): 387–92. doi:10.1016/j.amjcard.2007.09.085. PMID 18237606. Unknown parameter |month= ignored (help)<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
  5. Gajarski R, Naftel DC, Pahl E; et al. (2009). "Outcomes of pediatric patients with hypertrophic cardiomyopathy listed for transplant". J. Heart Lung Transplant. 28 (12): 1329–34. doi:10.1016/j.healun.2009.05.028. PMID 19782603. Unknown parameter |month= ignored (help)<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
  6. Towbin JA (2002). "Cardiomyopathy and heart transplantation in children". Curr. Opin. Cardiol. 17 (3): 274–9. PMID 12015478. Unknown parameter |month= ignored (help)<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
  7. van der Lee C, Scholzel B, ten Berg JM; et al. (2008). "Usefulness of clinical, echocardiographic, and procedural characteristics to predict outcome after percutaneous transluminal septal myocardial ablation". Am. J. Cardiol. 101 (9): 1315–20. doi:10.1016/j.amjcard.2008.01.003. PMID 18435964. Unknown parameter |month= ignored (help)<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
  8. 8.0 8.1 Epstein AE, DiMarco JP, Ellenbogen KA, Estes NAM III, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO. ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices). Circulation. 2008; 117: 2820–2840. PMID 18483207
  9. 9.0 9.1 Vardas PE, Auricchio A, Blanc JJ, Daubert JC, Drexler H, Ector H; et al. (2007). "Guidelines for cardiac pacing and cardiac resynchronization therapy. The Task Force for Cardiac Pacing and Cardiac Resynchronization Therapy of the European Society of Cardiology. Developed in collaboration with the European Heart Rhythm Association". Europace. 9 (10): 959–98. doi:10.1093/europace/eum189. PMID 17726043.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
  10. 10.0 10.1 Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW (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 Developed in Collaboration With the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Journal of the American College of Cardiology. 58 (25): 2703–38. doi:10.1016/j.jacc.2011.10.825. PMID 22075468. Retrieved 2011-12-19. Unknown parameter |month= ignored (help)<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
  11. 11.0 11.1 Maron BJ (2002). "Hypertrophic cardiomyopathy: a systematic review". JAMA. 287 (10): 1308–20. PMID 11886323.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
  12. 12.0 12.1 12.2 Sherrid MV, Chaudhry FA, Swistel DG (2003). "Obstructive hypertrophic cardiomyopathy: echocardiography, pathophysiology, and the continuing evolution of surgery for obstruction". Ann Thorac Surg. 75 (2): 620–32. PMID 12607696.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
  13. Wigle ED, Rakowski H, Kimball BP, Williams WG (1995). "Hypertrophic cardiomyopathy. Clinical spectrum and treatment". Circulation. 92 (7): 1680–92. PMID 7671349.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
  14. Maron BJ, McKenna WJ, Danielson GK, Kappenberger LJ, Kuhn HJ, Seidman CE; et al. (2003). "American College of Cardiology/European Society of Cardiology clinical expert consensus document on hypertrophic cardiomyopathy. A report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents and the European Society of Cardiology Committee for Practice Guidelines". J Am Coll Cardiol. 42 (9): 1687–713. PMID 14607462.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
  15. Sherrid MV, Barac I, McKenna WJ, Elliott PM, Dickie S, Chojnowska L; et al. (2005). "Multicenter study of the efficacy and safety of disopyramide in obstructive hypertrophic cardiomyopathy". J Am Coll Cardiol. 45 (8): 1251–8. doi:10.1016/j.jacc.2005.01.012. PMID 15837258.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
  16. Morrow AG (1978). "Hypertrophic subaortic stenosis. Operative methods utilized to relieve left ventricular outflow obstruction". J Thorac Cardiovasc Surg. 76 (4): 423–30. PMID 581298.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
  17. Messmer BJ (1994). "Extended myectomy for hypertrophic obstructive cardiomyopathy". Ann Thorac Surg. 58 (2): 575–7. PMID 8067875.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
  18. Schoendube FA, Klues HG, Reith S, Flachskampf FA, Hanrath P, Messmer BJ (1995). "Long-term clinical and echocardiographic follow-up after surgical correction of hypertrophic obstructive cardiomyopathy with extended myectomy and reconstruction of the subvalvular mitral apparatus". Circulation. 92 (9 Suppl): II122–7. PMID 7586394.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
  19. 19.0 19.1 Balaram SK, Sherrid MV, DeRose JJ, Hillel Z, Winson G, Swistel DG. Beyond extended myectomy for hypertrophic cardiomyopathy: The RPR (Resection–Plication–Release) Repair. Annals of Thoracic Surgery 2005; 80:217–23
  20. McIntosh CL, Maron BJ, Cannon RO, Klues H. Initial results of combined anterior mitral valve plication and ventricular septal myotomy–myectomy for relief of left ventricular outflow obstruction in patients with hypertrophic cardiomyopathy. Circulation 1992; 86:II 60–7
  21. Nakatani S, Schwammenthal E, Lever HM, Levine RA, Lytle BW, Thomas JD (1996). "New insights into the reduction of mitral valve systolic anterior motion after ventricular septal myectomy in hypertrophic obstructive cardiomyopathy". Am Heart J. 131 (2): 294–300. PMID 8579024.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
  22. Ommen S, Maron B, Olivotto I, Maron M, Cecchi F, Betocchi S, Gersh B, Ackerman M, McCully R, Dearani J, Schaff H, Danielson G, Tajik A, Nishimura R (2005). "Long-term effects of surgical septal myectomy on survival in patients with obstructive hypertrophic cardiomyopathy". J Am Coll Cardiol. 46 (3): 470–6. PMID 16053960.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>
  23. Ralph-Edwards A, Woo A, McCrindle B, Shapero J, Schwartz L, Rakowski H, Wigle E, Williams W (2005). "Hypertrophic obstructive cardiomyopathy: comparison of outcomes after myectomy or alcohol ablation adjusted by propensity score". J Thorac Cardiovasc Surg. 129 (2): 351–8. PMID 15678046.<templatestyles src="Module:Citation/CS1/styles.css"></templatestyles>


Template:WikiDoc Sources