Genesis of systolic anterior motion of the mitral valve in hypertrophic cardiomyopathy: an anatomical or dynamic event?

Moro, E.; Cate, Folkert J. Ten; Leonard, James J.; Hugenholtz, Paul G.; Roelandt, Jos R.T.C.

doi:10.1093/oxfordjournals.eurheartj.a062218

Cited by 33 publications

(14 citation statements)

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“…The most commonly performed intervention is surgical myectomy according to the technique developed by Morrow et al 2 Hypertrophic cardiomyopathy, however, frequently presents with several anatomic alterations of the mitral valve apparatus, including increased mitral leaflet area (MLA), length, and laxity, as well as anterior displacement of the papillary muscles. [3][4][5][6][7][8][9][10][11][12] These structural abnormalities, which are not corrected after a successful myectomy, may predispose to residual SAM and result in a suboptimal outcome with persistence of outflow obstruction and mitral regurgitation. [13][14][15] We therefore performed anterior mitral leaflet extension (MLE), one of several repair techniques originally developed by Carpentier, 16 in combination with myectomy in patients with HOCM and an enlargement of the anterior mitral leaflet.…”

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confidence: 99%

Sustained Improvement After Combined Anterior Mitral Leaflet Extension and Myectomy in Hypertrophic Obstructive Cardiomyopathy

et al. 2003

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Background-Mitral leaflet extension (MLE) combined with septal myectomy is a new surgical approach to treat hypertrophic obstructive cardiomyopathy (HOCM) and an enlarged mitral leaflet area. The study presents the long-term clinical results and outcome of this technique. Methods and Results-MLE entails grafting a glutaraldehyde-preserved autologous pericardial patch onto the center portion of the anterior mitral valve leaflet. Twenty-nine patients with HOCM were studied. Mean follow-up (ϮSD) was 3.4Ϯ2.1 years (range 3 months to 7.7 years). The preoperative calculated mitral leaflet area was 16.7Ϯ3.4 cm 2 . New York Heart Association functional class improved significantly from 2.8Ϯ0.4 to 1.3Ϯ0.4 (PϽ0.05), width of the interventricular septum decreased from 23Ϯ4 to 17Ϯ2 mm (PϽ0.05), left ventricular outflow tract gradient decreased from 100Ϯ20 to 17Ϯ14 mm Hg (PϽ0.01), severity of mitral regurgitation graded on a scale from 0 to 4ϩ decreased from 2.5Ϯ0.9 to 0.5Ϯ0.6 (PϽ0.01), and severity of the systolic anterior motion of the mitral valve graded on a scale from 0 to 3ϩ decreased from 2.9Ϯ0.3 to 0.5Ϯ0.7 (PϽ0.01) postoperatively. There were no deaths associated with surgery. Conclusions-Long-term follow-up shows sustained improvement in functional status, reduction of outflow tract obstruction, and attenuation of mitral regurgitation and systolic anterior motion of the mitral valve. In this respect, the new technique widens the surgical applications in HOCM.

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confidence: 99%

Sustained Improvement After Combined Anterior Mitral Leaflet Extension and Myectomy in Hypertrophic Obstructive Cardiomyopathy

et al. 2003

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“…The mitral valve apparatus frequently demonstrates anomalies in HOCM (for instance, increased mitral leaflet area, length, and laxity, as well as anterior displacement of the papillary muscles [12][13][14][15] ). All of these abnormalities may predispose to residual systolic anterior motion (SAM) after successful myectomy.…”

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confidence: 99%

Percutaneous Versus Surgical Treatment for Patients With Hypertrophic Obstructive Cardiomyopathy and Enlarged Anterior Mitral Valve Leaflets

et al. 2005

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Background-The purpose of this study was to compare percutaneous transluminal septal myocardial ablation (PTSMA) and septal myectomy combined with mitral leaflet extension (MLE) in symptomatic hypertrophic obstructive cardiomyopathy patients with an enlarged anterior mitral valve leaflet (AMVL). Both PTSMA and myectomy reduce septal thickness and left ventricular outflow tract (LVOT) gradient; however, an uncorrected enlarged AMVL may predispose to residual systolic anterior motion (SAM) after successful standard myectomy or PTSMA. Myectomy with MLE previously demonstrated superior hemodynamic results compared with standard myectomy, but its value relative to PTSMA is unknown. Methods and Results-Twenty-nine patients (aged 44Ϯ12 years) underwent myectomy with MLE, and 43 patients (aged 52Ϯ17 years) underwent PTSMA. Mitral leaflet area was similar in both groups (16.7Ϯ3.4 versus 15.9Ϯ2.7 cm 2 , respectively). After PTSMA, 2 patients died, 4 needed a reintervention, and 4 required a permanent pacemaker for complete heart block. After surgery, only 1 patient needed a reintervention. At 1-year follow-up, LVOT gradients did not differ between surgical and PTSMA patients (17Ϯ14 versus 23Ϯ19 mm Hg, respectively). Preinterventional mitral regurgitation grade was more severe in the surgical group, but with myectomy combined with MLE, the residual grade was similar to that of PTSMA. Mean SAM grade decreased significantly more after surgery (from 2.9Ϯ0.3 to 0.5Ϯ0.7 mm Hg versus from 2.8Ϯ0.5 to 1.3Ϯ0.9 mm Hg, PϽ0.05). Conclusions-PTSMA in these selected patients with hypertrophic obstructive cardiomyopathy had more periprocedural complications and resulted in more reinterventions. Hemodynamic results (SAM grade and reduction in mitral regurgitation) were better in surgical patients. (Circulation. 2005;112:482-488.)

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“…1,2,7,8 However, these 2 factors may be associated during DDD because pacing-induced asynchronous septal contraction is automatically accompanied by decreased LV synchrony and contractility. 8,18 From a fundamental point of view, there are several anatomical and functional explanations for the development of LV outflow obstruction, including Venturi or drag forces, 21,22 septal bulge, 22 elongation of the mitral leaflets, 22 and anterior displacement of the papillary muscles. 23 Of these, septal bulge is considered essential in narrowing the LV outflow tract and setting the stage for systolic anterior motion of the mitral leaflets via Venturi force.…”

Section: Implications For the Mechanism Of Responsiveness To Dddmentioning

confidence: 99%

Effects of Dual-Chamber Pacing on Regional Myocardial Deformation in Patients With Hypertrophic Obstructive Cardiomyopathy

Hozumi

Ito

Suwa

et al. 2006

Circ J

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ual-chamber pacing (DDD) is a therapeutic alternative to surgical septal myotomy -myectomy for patients with hypertrophic obstructive cardiomyopathy (HOCM). A reduction in the left ventricular (LV) outflow obstruction by DDD has been demonstrated in previous studies, 1-8 and although pacing-induced paradoxical septal motion is the most conceivable mechanism, 1,2,7,8 there are no data regarding the effects of DDD on regional wall deformation, particularly of the ventricular septum.Myocardial deformation can be quantified by echocardiographic strain and strain rate (SR) imaging, 9-12 techniques based on processing the velocity data from tissue velocity imaging. These methods are able to identify regional changes associated with a range of pathologies, 13,14 and in particular, those associated with pacing. 15,16 Recently, Breithardt et al reported that in heart failure patients, the peak strain and SR in the ventricular septum was decreased by cardiac resynchronization therapy, indicating that there was more ejection force during systole. 15 Given that DDD decreases global LV contractility in HOCM patients, 17,18 the opposite phenomenon might occur during DDD and could be the underlying mechanism of the responsiveness to DDD. Strain and SR imaging are a noninvasive approach to determining such changes in regional wall deformation, Circulation Journal Vol.70, January 2006which was the aim of the present study. Methods PatientsBetween December 1994 and April 2001, 18 patients with HOCM underwent pacemaker implantation (DDD) at Osaka Medical College for persistently high LV pressure gradient (LVPG). Of these, 2 patients died from sudden cardiac death during follow-up and of the remaining 16 patients, 14 accepted the study protocol and were enrolled. Each patient had been stable in clinical condition (functional class I or II) on the basis of long-term DDD. Exclusion criteria included chronic atrial fibrillation, dilated phase of disease process, and prior septal myotomy -myectomy operation. Atrioventricular delay was optimized in individual patients to achieve the lowest LVPG at their last visit to the outpatient department. Each patient gave informed consent before the echocardiographic examination. Two-Dimensional and Doppler EchocardiographyAll patients underwent 2-dimensional Doppler, and tissue velocity imaging during DDD and immediately after the DDD was turned off. We used a commercially available echocardiographic apparatus (Vivid 7 echocardiographic (GE-Vingmed Ultrasound, Horten, Norway)) with a 2.5-MHz transducer. Changes in LV volume were assessed by modified Simpson's rule using the apical 4-chamber view. Parameters of LV diastolic function were also assessed by pulsed Doppler echocardiography: early and atrial filling velocity at the mitral valve and their ratio, and the decelera-

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Genesis of systolic anterior motion of the mitral valve in hypertrophic cardiomyopathy: an anatomical or dynamic event?

Cited by 33 publications

References 0 publications

Sustained Improvement After Combined Anterior Mitral Leaflet Extension and Myectomy in Hypertrophic Obstructive Cardiomyopathy

Sustained Improvement After Combined Anterior Mitral Leaflet Extension and Myectomy in Hypertrophic Obstructive Cardiomyopathy

Percutaneous Versus Surgical Treatment for Patients With Hypertrophic Obstructive Cardiomyopathy and Enlarged Anterior Mitral Valve Leaflets

Effects of Dual-Chamber Pacing on Regional Myocardial Deformation in Patients With Hypertrophic Obstructive Cardiomyopathy

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