Totally endoscopic transaortic septal myectomy for hypertrophic obstructive cardiomyopathy

Hypertrophic obstructive cardiomyopathy is characterized by asymmetric septal hypertrophy and dynamic left ventricular outflow tract obstruction, often associated with systolic anterior motion of the mitral valve. In symptomatic patients who are not responders to medical therapy, surgical septal myectomy is considered the gold standard. We present a case of totally endoscopic transaortic septal myectomy performed in a symptomatic patient with severe left ventricular outflow tract obstruction and systolic anterior motion of the mitral valve. Preoperative imaging demonstrated marked asymmetric septal hypertrophy, hyperdynamic ventricular function and significant outflow tract gradient. The procedure was performed using a totally endoscopic approach with femoro-femoral cardiopulmonary bypass and transthoracic aortic cross-clamping. After the pericardial opening and aortotomy, a transaortic septal myectomy was performed under three-dimensional endoscopic visualization. Intraoperative transoesophageal echocardiography confirmed resolution of systolic anterior motion and marked reduction of outflow tract obstruction. Postoperative transthoracic echocardiography demonstrated preserved ventricular function and absence of systolic anterior motion, and a peak gradient of 18 mmHg. This case highlights the feasibility and reproducibility of a totally endoscopic approach for septal myectomy, combining the effectiveness of conventional surgery with the advantages of a non-sternotomy technique.