The case for surgery in obstructive hypertrophic cardiomyopathy

Abstract

Relief of left ventricular (LV) outflow obstruction in patients with hypertrophic cardiomyopathy (HCM) and disabling symptoms refractory to maximum medical management has historically been a surgical problem. Surgical septal myectomy permanently abolishes systolic anterior motion of the mitral valve and mitral regurgitation, while normalizing LV pressures and wall stress. Also, these salutary goals are achieved without encumbering patients with post-procedural devices (e.g., pacemakers or defibrillators) or creating potentially arrhythmogenic substrates, as may occur with alcohol septal ablation. Procedural morbidity and mortality risk with myectomy is similar to, and in some institutions less than those for alcohol septal ablation. Over four decades, reports from numerous centers worldwide have consistently and unequivocably documented the benefits of surgery on hemodynamic and functional state, restoring normal and acceptable quality of life to patients of all ages by largely reversing the complications of heart failure. Long-term survival after myectomy is similar to that of the general population and superior to non-operated patients with obstruction. The LV outflow tract morphology in HCM is heterogeneous and not uncommonly includes congenital anomalies of the mitral valve apparatus for which the surgeon has the flexibility to adapt the repair, often employing an extended myectomy. In the current atmosphere of increasing and perhaps excessive enthusiasm for newer catheter-based interventions, it is a critical time to promote and re-emphasize that surgery is the time-honored (and presently the most effective) treatment strategy for relieving heart failure-related disability resulting from dynamic LV outflow obstruction in HCM, and is the primary treatment option for this subgroup of severely symptomatic drug-refractory patients.

Hypertrophic obstructive cardiomyopathy—the Leipzig experience

“…Mortality has been reported to be as high as 6% in centers with low surgical experience (22). However, increasing surgical expertise has been shown to correlate with a much better survival rates (23).…”

Anestesia para salpingectomia parcial bilateral em paciente com miocardiopatia hipertrófica idiopática: relato de um caso e revisão da literatura

“…Surgical treatment includes ventricular septal myomectomy (Morrow procedure), the first therapeutic option in obstructive hypertrophic cardiomyopathy (resting gradient after physiological challenge ≥ 50 mmHg) and severe symptoms refractory to clinical treatment. Those patients represent only about 5% of the total number of patients with hypertrophic cardiomyopathy 12 . Currently, little information on the anesthetic risks of patients with hypertrophic cardiomyopathy exists, probably because few patients with a confirmed diagnosis need an anesthesiologist 13 .…”

Surgical treatment for hypertrophic cardiomyopathy: a historical perspective

“…Furthermore, despite several case reports depicting successful treatment of midventricular obstruction (45)(46)(47), it remains uncertain whether ASA can reliably account for the complex anatomy involving the papillary muscles that is characteristic of pure midventricular obstruction in HCM (48). In regards to the mitral valve apparatus, ASA does not allow for additional intervention, such as in those instances where there is concurrent intrinsic mitral valve disease or a congenital anomaly (49).…”