July 1, 2017Open Access
Current state of the art and future of myectomy
Key Result
Surgical septal myectomy remains the gold standard for relieving left ventricular outflow tract obstruction in symptomatic hypertrophic cardiomyopathy patients, providing excellent long-term survival.
Structured PICO
P
Population
Symptomatic hypertrophic cardiomyopathy (HCM) patients with left ventricular outflow tract obstruction (LVOTO) without prohibitive comorbidities
I
Intervention
Surgical relief of LVOTO (septal myectomy)
Surgical myectomy remains the gold standard for symptomatic HCM patients with LVOTO, requiring an individualized approach and multimodality imaging for optimal outcomes, though it remains underutilized.
Limitations
- Surgical relief of left ventricular outflow tract obstruction is currently grossly underused worldwide.
- Lack of familiarity and experience with the operation can lead to high mortality in centers performing small numbers per year.
Abstract
Surgical relief of left ventricular outflow tract obstruction (LVOTO) in hypertrophic cardiomyopathy (HCM) requires more than septal myectomy. The procedure is currently the gold standard for all symptomatic HCM patients except those with comorbidities. The operation requires an individualized approach to restore the sophisticated functions of the left ventricular outflow tract (LVOT) without injury to the surrounding vital structures. The procedure should be tailored to deal with all the varied components of the obstruction including fibrous trigones, accessory tissues, and papillary muscle fusion. Preoperative multimodality imaging and numerical modeling combined with intraoperative transesophageal echocardiography (TEE) are essential to define existing anomalies as well as assess the adequacy of the repair. The mitral valve can be conserved in virtually all patients. The operation can be conducted with very low mortality and morbidity with predictable good outcomes both in the short and long term. Nevertheless, surgical relief of LVOTO is still grossly underused.