Transmitral Septal Myectomy and Mitral Valve Surgery via Right Mini-Thoracotomy

Abstract

Background Transmitral myectomy for symptomatic hypertrophic obstructive cardiomyopathy is possible with existence of substantial mitral valve disease. We present herein our experience of minimally invasive transmitral septal myectomy combined with mitral valve surgery through right anterior mini-thoracotomy in the past 4 years at our institution.

Methods Between March 2017 and October 2020, 14 patients with hypertrophic obstructive cardiomyopathy and mitral valve disease required minimally invasive transmitral septal myectomy combined with mitral valve reconstruction or replacement at our institution. Mean age of patients was 54.2 ± 11.4 and 42.9% (n = 6) were female. Twelve patients (85.1%) were in New York Heart Association class III to IV and 6 patients (42.9%) presented with persistent atrial fibrillation. Clinical data were prospectively entered into our institutional database.

Results Cardiopulmonary bypass time accounted for 140.2 ± 32.6 minutes and the myocardial ischemic time was 78.5 ± 12.4 minutes. Thirty-day mortality and overall mortality were zero. Peak ventricular outflow gradient decreased from 75.2 ± 12.7 to 9.4 ± 2.3 mm Hg (p < 0.0001). Simultaneously, mitral valve reconstruction and replacement were performed in 11 (78.6%) and 3 (21.4%) patients, respectively. No systolic anterior motion was seen in patients with mitral valve repair. No conversion to full sternotomy and/or rethoracotomy was noted. During a mean follow-up period of 24 ± 13 months, no patient required reoperation, no recurrence mitral regurgitation, and left ventricular outflow tract obstruction.

Conclusion Transmitral septal myectomy combined with mitral valve surgery through right anterior mini-thoracotomy can be performed safely with excellent surgical outcomes.

Keywords

minimally invasive surgery (includes port access - mini-thoracotomy) - mitral valve surgery - cardiomyopathy

Publication History

Received: 21 September 2021

Accepted: 27 January 2022

Article published online:
29 May 2022

• References

• 1 Fifer MA, Vlahakes GJ. Management of symptoms in hypertrophic cardiomyopathy. Circulation 2008; 117: 429-439
• 2 Nguyen A, Schaff HV. Transaortic septal myectomy for obstructive hypertrophic cardiomyopathy. Oper Tech Thorac Cardiovasc Surg 2018; 106: 670-675
• 3 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
• 4 Nguyen A, Schaff HV. Surgical myectomy subaortic, midventricular, and apical. Cardiol Clin 2019; 37: 95-104
• 5 Wu JJ, Seco M, Medi C. et al. Surgery for hypertrophic cardiomyopathy. Biophys Rev 2015; 7: 117-125
• 6 Seeburger J, Borger MA, Falk V. et al. Minimal invasive mitral valve repair for mitral regurgitation: results of 1339 consecutive patients. Eur J Cardiothorac Surg 2008; 34 (04) 760-765
• 7 Schmitto JD, Mokashi SA, Cohn LH. Minimally-invasive valve surgery. J Am Coll Cardiol 2010; 56: 455-462
• 8 Aybek T, Dogan S, Risteski PS. et al. Two hundred forty minimally invasive mitral operations through right minithoracotomy. Ann Thorac Surg 2006; 81: 1618-1624
• 9 Kilic A, Szeto WY, Atluri P, Acker MA, Clark Hargrove W. Operative outcomes of concomitant minimally invasive mitral and tricuspid valve surgery. Innovations (Phila) 2019; 14 (05) 412-418
• 10 Gilmanov DSh, Bevilacqua S, Solinas M. et al. Minimally invasive septal myectomy for the treatment of hypertrophic obstructive cardiomyopathy and intrinsic mitral valve disease. Innovations (Phila) 2015; 10 (02) 106-113
• 11 Sakaguchi T, Totsugawa T, Tamura K, Hiraoka A, Chikazawa G, Yoshitaka H. Minimally invasive trans-mitral septal myectomy for diffuse-type hypertrophic obstructive cardiomyopathy. Gen Thorac Cardiovasc Surg 2018; 66 (06) 321-326
• 12 Ommen S, Maron BJ, Olivotto L. 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
• 13 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
• 14 Desai M, Bhonsale A, Smedira N. et al. Predictors of long-term outcomes in symptomatic hyper- trophic obstructive cardiomyopathy patients undergoing surgical relief of left ventricular outflow tract obstruction. Circulation 2013; 128: 209-216
• 15 Sedehi D, Finocchiaro G, Tibayan Y. et al. Long-term outcomes of septal reduction for obstructive hypertrophic cardiomyopathy. J Cardiol 2015; 66 (01) 57-62
• 16 Gutermann H, Pettinari M, Van Kerrebroeck C. et al. Myectomy and mitral repair through the left atrium in hyper- trophic obstructive cardiomyopathy: the preferred approach for contemporary surgical candidates?. J Thorac Cardiovasc Surg 2014; 147: 1833-1836
• 17 Mohr FW, Seeburger J, Misfeld M. Keynote Lecture-transmitral hypertrophic obstructive cardiomyopathy (HOCM) repair. Ann Cardiothorac Surg 2013; 2: 729-732
• 18 Casselman F, Vanermen H. Idiopathic hypertrophic subaortic stenosis can be treated endoscopically. J Thorac Cardiovasc Surg 2002; 124: 1248-1249
• 19 Bakhtiary F, El-Sayed Ahmad A, Amer M. et al. Video-assisted minimally invasive aortic valve replacement through right anterior minithoracotomy for all comers with aortic valve disease. Innovations (Phila) 2021; 16 (02) 169-174
• 20 Vriesendorp PA, Schinkel AFL, Soliman OI. et al. Long-term benefit of myectomy and anterior mitral leaflet extension in obstructive hyper- trophic cardiomyopathy. Am J Cardiol 2015; 115: 670-675
• 21 Shomura Y, Okada Y, Nasu M. et al. Late results of mitral valve repair with glutaraldehyde-treated autologous pericardium. Ann Thorac Surg 2013; 95: 2000-2006