Hypertrophic obstructive cardiomyopathy (HOCM) is a relatively common hereditary cardiomyopathy, which is featured by asymmetric myocardial hypertrophy and dynamic left ventricular outflow tract (LVOT) obstruction. Other than septal hypertrophy, mitral valve abnormalities are also quite common in HOCM patients, and they also contribute to systolic anterior motion of the mitral leaflets and LVOT obstruction. Septal myectomy is believed as the standard surgical treatment for HOCM, but whether to perform mitral valve procedures at the same time of myectomy is still debatable. In this article, we thoroughly explained the mitral valve abnormalities in HOCM patients and their surgical corrections. Besides, we also explained the controversies over mitral valve procedures based on the current clinical studies.
Objective To introduce a method of preoperative three-dimensional measurement by echocardiography to guide the surgical resection of hypertrophic obstructive cardiomyopathy (HOCM) and its long-term follow-up effect. MethodsBefore operation, each patient underwent transthoracic echocardiography to measure the length, width and thickness of diastolic ventricular septum hypertrophy on the long axis, short axis and four chamber sections, in order to establish three-dimensional measurement data of myocardial hypertrophy, and quantitatively estimate the location, depth and range of myocardium to be removed between 2014 and 2022 in our hospital. According to the quantitative data during operation, the hypertrophic myocardium of ventricular septum was resected to dredge the left ventricular outflow tract. ResultsForty-three patients were recruited, including 22 males and 21 females, aged 18-78 (49.2±5.1) years. Eighteen patietns underwent mitral valve surgery at the same time. All patients were satisfied with the relief of left ventricular outflow tract obstruction. Postoperative transesophageal echocardiography showed that the left ventricular outflow tract pressure gradient decreased significantly (94.2±28.1 mm Hg vs. 6.7±4.7 mm Hg, P<0.05). There was no ventricular septal perforation or complete atrioventricular block during the operation, and no one needed a secondary aorta-clamp for re-operation to remove hypertrophic myocardium again. Postoperative echocardiography showed that the mitral valve closed well or only had mild regurgitation, and the mitral systolic anterior motion sign basically disappeared. After 1.0-8.5 years of follow-up, the average pressure difference of left ventricular outflow tract remained below 10 mm Hg, and the clinical symptoms disappeared or improved significantly. Conclusion The quantitative prediction of the resection range of hypertrophic myocardium by three-dimensional measurement of preoperative echocardiography can accurately guide the surgical range of HOCM, avoid multiple blocking of aorta during operation, relieve left ventricular outflow tract obstruction to the greatest extent, and obtain better long-term results.
ObjectiveTo explore the effect and safety of surgical treatment for hypertrophic obstructive cardiomyopathy (HOCM) with mitral regurgitation (MR) through right mini-thoracotomy.MethodsFrom January 2008 to June 2018, 54 patients with HOCM and moderate-to-severe MR underwent modified Morrow procedure and edge-to-edge mitral valvuloplasty through right mini-thoracotomy, including 31 males and 23 females, with an average age of 47.1±12.6 years. All patients had systolic anterior motion (SAM) phenomenon. Preoperative left ventricular outflow tract pressure gradient (LVOTPG) was 93.6±32.8 mm Hg, interventricular septum thickness (IVST) was 24.8±2.8 mm.ResultsSurgeries in all patients were completed successfully. No early death or interventricular septal perforation occurred. One (1.9%) patient received permanent pacemaker implantation due to the complete atrial-ventricular block. At discharge, postoperative LVOTPG (18.1±6.2 mm Hg) and IVST (14.5±2.1 mm) were significantly decreased compared with the preoperative values (P<0.05). No MR or SAM was observed in all patients. The follow-up time was 6-132 months, and during this period, no death, MR or SAM occurred. The average LVOTPG was 19.4±5.7 mm Hg, and the average IVST was 14.2±1.5 mm.ConclusionMorrow procedure and edge-to-edge mitral valvuloplasty through right mini-thoracotomy is a safe and effective method for treatment of HOCM with moderate-to-severe MR.
ObjectiveTo compare clinical outcomes between modified and traditional Morrow procedures for the treatment of hypertrophic obstructive cardiomyopathy (HOCM). MethodsForty-two HOCM patients undergoing surgical correction in Beijing Anzhen Hospital between January 2005 and July 2011 were recruited in this study. According to different surgical techniques, all the patients were divided into 2 groups. In traditional Morrow procedure group, there were 16 patients including 13 males and 3 females with their age of 49±15 years. In modified Morrow procedure group, there were 26 patients including 14 males and 12 females with their age of 40±18 years. Preoperative and postoperative echocardiography were performed to compare ventricular septal thickness (VST), left ventricular outflow tract velocity (LVOTV)and left ventricular outflow gradient (LVOG)between the 2 groups. ResultsVST, LVOTV and LVOG of HOCM patients were significantly reduced after both traditional and modified Morrow procedure. There was statistical difference in preoperative and postoperative VST (23.10±3.64 mm vs. 17.38±4.39 mm), LVOTV (433.08±101.68 mm/s vs. 248.46±101.88 mm/s)and LVOG (78.57±40.16 mm Hg vs. 4.29±21.52 mm Hg)in traditional Morrow procedure group (P < 0.05). There was statistical difference in preoperative and postoperative VST (25.04±47.05 mm vs. 18.38±6.55 mm, P < 0.05), LVOTV (414.83±83.33 mm/s vs. 159.72±60.84 mm/s, P < 0.05)and LVOG (77.94±29.16 mm Hg vs. 17.56±9.39 mm Hg, P < 0.05)in modified Morrow procedure group (P < 0.05). Preoperative and postoperative difference in LVOG of modified Morrow procedure group was more significant than that of traditional Morrow procedure group (74.25±27.91 mm Hg vs. 34.63±30.66 mm Hg, P < 0.05). ConclusionModified Morrow procedure is superior to traditional Morrow procedure in reducing postoperative LVOG for HOCM patients.
ObjectiveTo explore the association between preoperative, perioperative parameters, especially estimated glomerular filtration rate (eGFR) and postoperative atrial fibrillation (POAF) after modified extended Morrow procedure.MethodsA total of 300 hypertrophic obstructive cardiomyopathy (HOCM) patients who underwent modified extended Morrow procedure in our hospital from January 2012 to March 2018 were collected. There were 197 (65.67%) males and 103 (34.33%) females with an average age of 43.54±13.81 years. Heart rhythm was continuously monitored during hospitalization. The patients were divided into a POAF group (n=68) and a non-POAF group (n=232). The general data, perioperative parameters and echocardiographic results were collected by consulting medical records for statistical analysis. Univariate and multivariate logistic regression models were used to analyze the risk factors for POAF.ResultsOverall incidence of POAF during hospitalization was 22.67% (68/300). Compared with patients without POAF, patients with POAF were older, had higher incidence of chest pain and syncope, lower level of preoperative eGFR, higher body mass index and heart function classification (NYHA), larger preoperative left atrial diameter and left ventricular end diastolic diameter, and longer ventilator-assisted time, ICU stay and postoperative hospital stay. Age, heart function classification (NYHA)≥Ⅲ, hypertension, syncope history and eGFR were independent risk factors for POAF. Receiver operating characteristic curve analysis showed that the area under the curve of eGFR was 0.731 (95%CI 0.677-0.780, P<0.001), and the sensitivity and specificity were 82.4% and 57.8%, respectively.ConclusionIncreased age, high preoperative heart function classification (NYHA), hypertension, preoperative syncope history and decreased eGFR are independent risk factors for POAF in HOCM patients who underwent surgical septal myectomy. Preoperative decreased eGFR can moderately predict the occurrence of POAF after modified extended Morrow procedure.
Objective To summary the clinical experiences of ventricular septal myotomymyectomy on hypertrophic obstructive cardiomyopathy(HOCM) and investigate the treatment strategies during perioperative period for better clinical results. Methods From October 1996 to June 2009, 62 patients with HOCM underwent surgical treatment. There were 41 male and 21 female, aged 668 years with mean 34.05 years. The ventricular septal myotomymyectomy operation (Morrow operation or modified Morrow operation) was performed through the aortic incision under general anesthesia and hypothermic cardiopulmonary bypass (CPB). The concomitant operations included coronary artery bypass grafting (5 cases), mitral valve replacement (12 cases), mitral valve plasty(9 cases), aortic valve replacement (4 cases), tricuspid valve plasty(2 cases) and ductus arteriosus closure (2 cases). During the perioperative period, the patients were examined by echocardiography or transesophageal echocardiograph(TEE), electrocardiogram or dynamic echocardiogram and chest radiography. Left atrial diameter，left ventricular enddiastolic [CM(159mm]diameter，left ventricular outflow tract (LVOT) pressuregradient，interventricular septal thickness, ejection fraction[CM)](EF), the changes of mitral valve construction and function were evaluated. Results The time of CPB and aortic occlusion were 104.23±47.14 min and 66.76±36.32 min, respectively. The endotracheal intubation time was 13.23±11.76 h and the postoperative intensive care unit(ICU) stay was 42.53±37.41 h. Four patients died and the mortality was 6.45％(4/62). The main causes of death included septic shock complicated with acute renal failure(1 case), refractory arrhythmia, ventricular fibrillation, atrial flutter complicated with severe low cardiac output syndrome (1 case), severe acute renal failure(1 case) and Ⅲ°atrioventricular(AV) block complicated with low cardiac output syndrome(1 case). Postoperative left atrial diameter (34.56±6.45 mm vs.43.46±7.21 mm，t=6.948,P=0.000), left ventricular enddiastolic diameter (37.14±6.31 mm vs.42.03±6.23 mm，t=3.145,P=0.020), LVOT pressure gradient (23.54±17.78 mm Hg vs. 103.84±44.04 mm Hg,t=13.618,P=0.000) and interventricular septal thickness (17.12±5.67 mm vs.26.93±5.23 mm, t=10.694,P=0.000) decreased significantly compared with those before operation. There was no mitral valve regurgitation, or only mild mitral valve regurgitation. No systolic anterior motion(SAM) was found. The main postoperative arrhythmias included complete left bundle branch block, intraventricular block, complete atrioventricular block and atrial fibrillation. All the 58 cases were cured and discharged. Fiftythree cases were followed up for 3 months12 years, and 5 cases were lost. No death, complication and reoperation were found. Symptoms relieved significantly. The cardiac function was in New York Heart Association grade Ⅰ-Ⅱ. The quality of life improved significantly. Conclusion Most patients with HOCM can achieve satisfactory relief of LVOT obstruction and SAM via ventricular septal myotomymyectomy. The main arrhythmias after operation are bundle branch block and atrial fibrillation. Satisfactory effects can be achieved by accurate surgical technique and effective drug treatments.
ObjectiveTo summarize the perioperative management strategies and early results of modified Morrow expanded operation and coronary artery bypass grafting (CABG) in patients with hypertrophic obstructive cardiomyopathy (HOCM) and coronary atherosclerotic heart disease.MethodsBetween January 2012 and December 2017, in the Second Inpatient Department of Fuwai Hospital, 32 patients (20 females and 12 males) underwent modified expanded Morrow operation and CABG. The median age was 53.7±8.7 years (interquartile range 37 to 67 years). Preoperative chest distress symptom was found in 24 patients, chest pain symptom was found in 14 patients, history of syncope in 6 patients. Cardiac echocardiography, electrocardiogram, chest X-ray, magnectic resonance imaging (MRI) were performed routinely after operation and follow-up to analyze structure and function of heart and mitral valve.ResultsAll patients underwent modified and expanded Morrow combined with CABG. The preoperative left ventricular outflow tract peak pressure difference (LVOTG) was 40 to 152 (79.6±28.7) mm Hg. Four patients underwent myocardial bridge releasing in the same period, mitral valve replacement in 2 patients, mitral valve angioplasty in 3 patients, Maze operation in 2 patients and tricuspid valveoplasty in 3 patients. There was no hospital mortality. CABG surgery in patients with branches included anterior descending artery in 26 patients, diagonal branch in 16 patients, left circumflex in 8 patients, right coronary artery in 11 patients. There were 15 patients with one coronary artery (CA) bypass graft, 5 patients with two CA bypass grafts, and 12 patients with 3 CA bypass grafts. The average of CA bypass grafts was 1.9±0.6. The postoperative ICU time ranged from 1–13 (4.1±2.8) days and postoperative hospital stay ranged from 7 to 30 (12.6±5.5) days. No severe postoperative complications were found and 1 patient had postoperative incision healing. The postoperative new arrhythmia included left bundle branch block in 6 patients. Compared with the preoperative values, postoperative left ventricular outflow tract peak pressure (79.6±28.7 mm Hg vs. 10.8±5.9 mm Hg, P<0.001), interventricular septum thickness (1.9±0.4 cm vs. 1.3±0.5 cm, P<0.001) were decreased obviously. Mitral valve closure is good or only mild reflux, mitral valve forward movement (SAM sign) disappeared. The patients were followed up for 6-68 months, with an average of 38.8±20.6 months. All patients were followed up with symptoms disappeared or only mild symptoms. NYHA classification decreased Ⅰ to Ⅱ grade after surgery, without long-term mortality, complications or reoperation.ConclusionFor patients with hypertrophic obstructive cardiomyopathy with coronary atherosclerotic heart disease, the application of improved expand morrow operation at the same time undergoing coronary artery bypass grafting is safe. It can significantly improve patients' survival and reduce symptoms, play a synergistic effect, and do not increase the patient's surgical complications.
ObjectiveTo summarize the surgical strategy on treating mitral desease patient associated with hypertrophic obstructive cadiomyopathy (HOCM). MethodsWe retrospectively analyzed the clinical data of 17 patients with HOCM underwent surgical treatment from November 2003 to May 2015 year. There were 10 males and 7 females with a mean age of 42.2±15.5 years ranging from 7-62 years. There were 16 patients underwent modified Morrow procedure and 1 patient underwent modified Konno procedure to relieve the obstruction of left ventricular outflow tract. And different surgical treatment of mitral valve disease was implemented depending on the severity of regurgitation and under monitoring of transesophageal echocardiography. About 2 weeks after the surgery, we performed transthoracic echocardiography to evaluate the effect of operation. ResultsNo hospital death occurred and the surgery obviously improved the symptom and cardiac function in all cases. After surgery, echocardiography revealed that the mean thickness of the ventricular septum statistically decreased (P < 0.0001), the systolic anterior motion disappeared, the outflow track pressure of left ventricle statistically decreased (P < 0.0001), and the peak flow rate of left ventricle statistically decreased. However, there was no statistical difference in the change of the left ventricular ejection fraction(P=0.083). Nine patients with no mitral regurgitation (MR) or mild MR only underwent the unblock of the left ventricular outflow track, the MR decreased to mild or disappeared. Four patients with moderate or severe MR underwent mitral valve repair, and the MR decrease to mild or disappear. There were no complications occurred regarding to prosthesis implantation over the 4 patients underwent mitral valve replacement for infective endocarditis or other causes. ConclusionFor the HOCM patients with mild MR, the unblock of the left ventricular outflow track alone can effectively improve the MR. For those combined with moderate or severe MR, we should choose mitral valve repair or replacement based on individual situation of patient.
ObjectiveTo evaluate the efficacy and safety of modified maze Ⅳ (Cox-maze Ⅳ) in hypertrophic obstructive cardiomyopathy (HOCM) patients.MethodsFrom June 2016 to June 2019, 30 HOCM and persistent atrial fibrillation (pAF) patients received Cox-maze Ⅳ operation with modified extended Morrow operation, including 21 males and 9 females. The average age was 51.36±10.27 years and the average weight was 72.48±11.29 kg. All patients underwent left atrial appendectomy. Recurrence of AF, improvement of symptoms, cardiac function (NYHA) were assessed during follow-up.ResultsThere was no death during the perioperative period. Postoperative left ventricular outflow tract gradient was significantly decreased compared with that before operation (P<0.01), and all systolic anterior motion (SAM) signs disappeared after operation. Thirty patients were all effectively followed up for 3-40 (16.24±8.26) months. During the follow-up period, there was no death, and the cardiac function (NYHA) of all patients recovered to gradeⅠ-Ⅱ. At the end of follow-up, twenty-four patients (80.00%) maintained sinus rhythm, and twenty-seven patients (90.00%) maintained sinus rhythm after amiodarone conversion. Univariate analysis showed that the smoking history (P=0.04), left atrial diameter≥55 mm before operation (P=0.03), left atrial diameter≥50 mm after operation (P=0.02), postoperative tricuspid regurgitation (P=0.02) were closely related to postoperative AF recurrence. The increase of left atrial diameter after operation was an independent risk factor for AF recurrence (P=0.02).ConclusionMorrow/Cox-maze Ⅳ procedure is safe and effective in treatment of patients with HOCM complicated with pAF, which helps to maintain postoperative sinus rhythm, and to improve the cardiac function. The increase of left atrial diameter after operation is an independent risk factor for AF recurrence.
ObjectiveTo analyze the surgical procedures and clinical effects of surgical treatment for patients with hypertrophic obstructive cardiomyopathy (HOCM). MethodsWe retrospectively analyzed the clinical data of sixty-five consecutive patients with HOCM who underwent modified Morrow procedure in Wuhan Asia Heart Hospital between June 2010 and December 2013. There were 40 males and 25 females with mean age of 48.4±11.5 years (ranged 18-70 years). ResultsThere was no in-hospital mortality. There was no valve injury or ventricular septal perforation occurred during operation. Postoperative LVOT gradient, interventricular septum (IVS), left ventricular end-diastolic diameter (LVEDD), left ventricular ejection fraction (LVEF) and mitral regurgitation (MR) were significantly lower than preoperative values (P<0.05). Complete atrioventricular block occurred in 3 patients, complete left bundle branch block occurred in 7 patients, and left anterior division block occurred in 3 patients. All patients were followed up for 6-35 months. During the following-up time, the clinical symptoms diminished in 55 patients and ameliorated significantly in other 10 patients. All patients had a NewYork Heart Association functional class Ⅰ/Ⅱ during the follow-up. ConclusionSurgical septal myectomy can eliminate obstruction of left ventricular outflow tract and relief symptoms obviously. The early and mid-term outcomes are satisfactory.