Search

Transesophageal echocardiography (TEE) plays an important role for real-time procedural guidance during surgical smyectomy (SM) for hypertrophic obstructive cardiomyopathy (HOCM). We aimed to compare (1) interventricular septum (IVS) thickness using 2- (2D) and 3-dimensional (3D) intraoperative TEE and preoperative cardiac magnetic resonance (CMR) and (2) mitral valve (MV) leaflet length using 2D, 3D TEE, automatic quantification of mitral valve (AMVQ) and preoperative CMR. We prospectively studied 50 patients with HOCM (age 59 ± 12 years, 44% men) who underwent SM during 2018 to 2019. The maximal basal, mid, and distal anteroseptum (AS) and inferoseptum (IS) were measured by multiplanar 3D reconstruction on TEE and by short-axis imaging on preoperative CMR and classified as mild (≤18 mm), moderate (18 to 25 mm), or severe (≥25 mm) groups based on AS and IS thickness on CMR. MV leaflet lengths were evaluated by preoperative CMR and intraprocedural 2D TEE, zoom 3D TEE, and AMVQ (EchoPAC, General Electric, Wisconsin). There was a moderate correlation between AS and IS thickness on 3D TEE and CMR (R 2 = 0.46, p <0.01 and R 2 = 0.41, p <0.01, respectively), with 3D TEE showing an average overestimation of 3.8 and 4.7 mm versus CMR. The 3D TEE overestimated 14 patients (56%) with mild thickness as moderate and 5 patients (22%) with moderate thickness as severe. Assuming 3D TEE as the gold standard, the closest correlation for anterior mitral leaflet length was with CMR (average overestimation by CMR of 0.5 mm [root mean square deviation (RMSE%) 17]), intermediate correlation with 2D TEE (average deviation of 0.6 mm [RMSE% 21]) and no correlation with AMVQ (average deviation of 0.7 mm [RMSE% 24]). In conclusion, 3D TEE overestimates IVS thickness versus CMR in patients with HOCM who underwent SM, with greater discrepancy in those with thinner IVS. There are significant differences in MV lengths measured using different imaging techniques., Competing Interests: Declaration of competing interest Dr. Desai is a consultant and has research agreements with Bristol Myers Squibb, cytokinetics, Tenaya, Viz-AI, and Edgewise. Dr. Smedira is a consultant for Bristol Myers Squibb. No industry support was utilized in the conduct of this study. The authors have no competing interests to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: In patients with hypertrophic cardiomyopathy and left ventricular outflow tract (LVOT) obstruction, but without basal septal hypertrophy, we sought to identify mitral valve (MV) and papillary muscle (PM) abnormalities that predisposed to LVOT obstruction, using echo and cardiac magnetic resonance., Methods and Results: We studied 121 patients with hypertrophic cardiomyopathy hypertrophic cardiomyopathy (age, 49±17 years; 60% men; 57% on β-blockers) with a basal septal thickness of ≤1.8 cm who underwent echocardiography (rest+stress) and cine cardiac magnetic resonance. Echo measurements included maximal LVOT gradient (rest/provocable), MV leaflet length (parasternal long, 4 and 3-chamber views), and abnormal chordal attachment to mid/base of anterior MV. Cine cardiac magnetic resonance measurements included basal septal thickness, number/area of PM heads, and bifid PM mobility (in systole and diastole). Mean basal septal thickness, LVOT gradient, and LV ejection fraction were 1.5±0.3 cm, 72±54 mm Hg, and 61±6%, respectively. The number of anterolateral and posteromedial PM heads was 2.7±0.7 and 2.6±0.7, respectively. Anterolateral and posteromedial PM areas were 19.9±7 cm(2) and 17.1±6 cm(2), respectively. PM mobility was 11±6°. On multivariable analysis, predictors of maximal LVOT gradient were basal septal thickness, bifid PM mobility, anterior mitral leaflet length, and abnormal chordal attachment to base of anterior mitral leaflet. Forty-five patients underwent surgery to relieve LVOT obstruction, of which 52% needed an additional nonmyectomy (MV repair/replacement or PM reorientation) approach., Conclusions: In hypertrophic cardiomyopathy patients without significant LV hypertrophy, in addition to basal septal thickness, anterior MV length, abnormal chordal attachment, and bifid PM mobility are associated with LVOT obstruction. In such patients, additional procedures on MV and PM (±myectomy) could be considered., (© 2015 American Heart Association, Inc.)

Objective: Patients with severe heart failure might benefit from reduced operative trauma, but rarely undergo less-invasive valve surgery. The present study compared the outcomes of less-invasive heart valve surgery with those of complete sternotomy in such patients., Methods: From January 1995 to July 2010, 871 patients in New York Heart Association class III or IV underwent valve surgery (aortic or mitral, or both). A less-invasive approach was used in 205. Propensity score matching yielded 185 matched pairs for outcomes comparison adjusted for patient characteristics and 139 pairs adjusted further for individual surgeon., Results: Without considering surgeons, myocardial ischemic times (59 ± 27 vs 64 ± 26 minutes, P = .04), cardiopulmonary bypass times (75 ± 35 vs 86 ± 34 minutes, P < .0001), and intensive care unit stays (median, 24 vs 43 hours; P = .007) were shorter for less-invasive surgery. Hospital morbidity, mortality (1.6% [3 of 185] vs 2.7% [5 of 185]; P = .5), and long-term survival (53% and 48% at 12 years; P = .3) were similar. After considering the surgeon, these benefits were not apparent; rather, efficiency, safety, and effectiveness were equivalent to those of complete sternotomy. Thus, myocardial ischemic (63 ± 30 vs 62 ± 25 minutes, P = .8) and cardiopulmonary bypass (80 ± 40 vs 81 ± 31 minutes, P = .5) times were similar, as were intensive care unit stay (median, 28 vs 30 hours; P = .09), postoperative complications, in-hospital mortality (2.2% [3 of 139] vs 3.6% [5 of 139]; P = .5), and long-term survival (57% and 53% at 12 years; P = .5)., Conclusions: In selected patients with severe heart failure, less-invasive valve surgery is a viable option, yielding at least equivalent efficiency, safety, and effectiveness to complete sternotomy. However, achieving these outcomes requires surgeons experienced in less-invasive surgery., (Copyright © 2014. Published by Mosby, Inc.)

Background: Thoracic radiation leads to radiation-associated cardiac disease (RACD), associated with substantial cardiac morbidity and mortality, often requiring complex cardiothoracic surgery. In patients with RACD, along with valvular lesions, the aorto-mitral curtain (AMC, junction between base of anterior mitral leaflet and aortic root) thickness is increased on transthoracic echocardiography. We sought to identify clinical and transthoracic echocardiography predictors of long-term mortality in patients with RACD., Methods: We studied 173 patients with RACD (75% women, 63±14 years, 53% with breast cancer, 27% with Hodgkin lymphoma; mean time from radiation, 18±12 years), who underwent cardiothoracic surgery (26% redo) between 2000 and 2003. Clinical, transthoracic echocardiography (along with AMC), and surgical variables were recorded. Preoperative EuroSCORE and all-cause mortality were recorded., Results: Mean left ventricular ejection fraction, right systolic ventricular pressure, and AMC thickness were 0.49±0.13, 41±15 mm Hg, and 0.54±0.2 cm, respectively. Fifty-one percent of patients had II+ mitral regurgitation or greater, 29% patients had II+ aortic regurgitation or greater, 23% patients had severe aortic stenosis, and 34% patients had II+ tricuspid regurgitation or greater. In 7.6±3 years of follow-up, there were 95 (55%) deaths, with a 30-day mortality rate of only 7 (4%). Absence of β-blockers (hazard ratio, 0.49; 95% confidence interval, 0.31 to 0.79), aspirin (hazard ratio, 0.53; 95% confidence interval, 0.33 to 0.84), higher EuroSCORE (hazard ratio, 1.11; 95% confidence interval, 1.02 to 1.21), and greater AMC thickness (hazard ratio, 5.75; 95% confidence interval, 1.57 to 21.03; all p<0.01) independently predicted mortality. Aorto-mitral curtain thickness of at least 0.6 cm was associated with significantly increased mortality., Conclusions: Patients with RACD undergoing cardiothoracic surgery have high long-term mortality, which is independently predicted by AMC thickness, a higher preoperative risk score, and lack of cardioprotective medications., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Left ventricular outflow tract obstruction caused by a malpositioned prosthetic mechanical mitral valve has not been reported to date. In two cases of mitral valve replacement, the sewing ring was sutured to the mitral valve leaflet instead of the annulus, resulting in the ventricularization of a portion of the valve and partial obstruction of the outflow tract. Re-replacing the valve with the same type of mechanical valve, but within the annular plane, eliminated the obstruction.

Background: Functional and intrinsic mitral valve (MV) abnormalities are common in hypertrophic cardiomyopathy (HCM); however, morphologic characteristics constituting indications for surgical intervention are incompletely defined. This study was conducted to define the echocardiographic features of MV pathology in patients with HCM and relate these to repairability of the MV, MV procedures performed, durability of repair, and survival., Methods: From 1986 to 2003, 851 patients with HCM underwent operation, and 115 had a concomitant MV procedure. Detailed analysis of their 784 transthoracic and transesophageal echocardiograms, performed intraoperatively and postoperatively, was conducted. Outcomes were assessed by cross-sectional follow-up., Results: Sixty-seven patients (58%) underwent MV repair, and 48 (42%) had MV replacement. The mean left ventricular outflow tract peak gradient was 70 +/- 50 mm Hg. Systolic anterior motion was present in 95%. Valve abnormalities were degenerative in 36 (31%), myxomatous in 23 (20%), papillary muscle in 23 (20%), restrictive chordal in 22 (19%), restrictive leaflet in 80 (70%), and long leaflet in 64 (56%). Patients undergoing MV repair had higher prevalence of long leaflets and degenerative MV pathology. The anterior mitral leaflet was 3.0 +/- 0.49 cm in the repair group vs 2.5 +/- 0.40 cm in the replacement group (p = 0.0001). MV replacement patients were older, more symptomatic, and had more renal dysfunction and lower hematocrits. By 3 years, 91% of patients with a repair were free of reoperation., Conclusions: Intrinsic MV pathology is frequently observed in HCM patients with symptomatic obstruction who undergo myectomy. Echocardiography can identify MV features predictive of successful valve repair. Repair, although durable, is feasible in only about half of patients.

By geometric analysis of real-time 3-dimensional echocardiography performed in 39 patients with hypertrophic obstructive cardiomyopathy and definite systolic anterior motion of the mitral valve, we found that the angle between the mitral annular plane and basal portion of the anterior mitral valve leaflet, and the angle between the basal portion of the anterior leaflet and its tip portion measured in the medial and central anteroposterior planes, were significantly smaller than those in the lateral plane. The distance between the interventricular septum and the anterior mitral valve tip in the medial and central plane was also significantly smaller than that in the lateral plane. The lateral distance between the interventricular septum and the anterior mitral valve tip was the only independent determinant of left ventricular outflow tract pressure gradient by multiple stepwise regression analysis. In conclusion, systolic anterior motion of the mitral valve develops predominantly in the medial side, resulting in laterally located narrow left ventricular outflow tract opening in patients with hypertrophic obstructive cardiomyopathy.

In this experimental study, small intestinal submucosa was implanted as an atrial prosthesis in calves. Echocardiography and histology showed this to be an impermeable prosthesis that develops a neointimal nonthrombogenic surface making it safe for repair of defects in a low-pressure system. Further study with small intestinal submucosa in an intracardiac position is warranted.

Background: Left ventricular (LV) reconstruction surgery leads to early improvement in LV function in ischemic cardiomyopathy (ICM) patients. This study was designed to evaluate the impact of mitral valve (MV) repair associated with LV reconstruction on LV function 1-year after surgery in ICM patients assessed by real-time 3-dimensional echocardiography (3DE)., Methods and Results: Sixty ICM patients who underwent the combination surgery (LV reconstruction in 60, MV repair in 30, and revascularization in 52 patients) were studied. Real-time 3DE was performed and LV volumes were obtained at baseline, discharge, 6-month and >or=12-month follow-up. Reduction in end-diastolic volumes (EDV) by 29% and in end-systolic volumes by 38% were demonstrated immediately after surgery and remained at subsequent follow-up (P<0.0001). The LV ejection fraction significantly increased by about 10% at discharge and was maintained >or=12-month (P<0.0001). Although the LV volumes were significantly larger in patients with MV repair before surgery (EDV, 235+/-87 mL versus 193+/-67 mL, P<0.05), they were similar to LV volumes of the patients without MV repair at subsequent follow-ups. However, the EDV increased from 139+/-24 mL to 227+/-79 mL (P<0.01) in 7 patients with recurrent mitral regurgitation (MR). Improvement in New York Heart Association functional class occurred in 81% patients during late follow-up., Conclusions: Real-time 3DE demonstrates that LV reconstruction provides significant reduction in LV volumes and improvement in LV function which is sustained throughout the 1-year follow-up with 84% cardiac event free survival. If successful, MV repair may prevent LV redilation, while recurrent MR is associated with increased LV volumes.

Although the Cox-Maze III procedure cures atrial fibrillation in the majority of patients, it has not had widespread application. Development of new operations that use alternate energy sources and different lesion sets have caused resurgence in the surgical treatment of atrial fibrillation. Microwave creates lines of conduction block by thermal damage and subsequent scar formation. We describe a rapid and simple technique for microwave ablation of atrial fibrillation in patients having mitral valve operations.

Intraoperative assessment of all cardiac structures and their function is critical to the operative planning and post-intervention assessment of septal myectomy and all operations on the left ventricular outflow tract. Using a single case study, I will share my approach to both pre- and post-intervention transesophageal echocardiography assessment and how it guides decision making. [ABSTRACT FROM AUTHOR]

The surgical management of patients with hypertrophic obstructive cardiomyopathy can be extremely challenging. Relieving the left ventricular outflow tract obstruction in these patients is often achieved by performing a septal myectomy. However, in many instances, septal reduction alone is not enough to relieve the obstruction. Interventions on the sub-valvular apparatus, including the anomalous chordae tendineae and the abnormal papillary muscles, are often required. In this review, we summarize the embryology and the pathophysiology of the different elements that may contribute to the left ventricular outflow tract obstruction in the setting of hypertrophic obstructive cardiomyopathy. In addition, we highlight the different surgical procedures that a surgeon may adopt to relieve the left ventricular outflow tract obstruction, beyond the septal myectomy. [ABSTRACT FROM AUTHOR]

Hypertrophic obstructive cardiomyopathy (HOCM) is one of the more common genetic disorders. The pathophysiology and natural history of the disease have been well studied. Left ventricular outflow tract obstruction (LVOTO) and systolic anterior motion (SAM) of the anterior mitral leaflet can result in sudden cardiac death, progressive heart failure and arrythmias. Surgical septal myectomy for HOCM is the standard of care and is routinely performed through a median sternotomy. Septal myectomy has also been performed using the trans-atrial, trans-mitral approach either directly or with robotic assistance. In cases with severe LVOT obstruction in the setting of only mild to moderate proximal septal hypertrophy, intrinsic problems with the mitral valve contribute. Typically, these are hypermobile papillary muscles and or excessive height of the anterior mitral leaflet. Combining septal myectomy with reorientation of hypermobile anteriorly positioned papillary muscles has shown to prevent SAM and thereby additionally decrease the subvalvular aortic outflow obstruction. Our extensive experience in both septal myectomy and robotic mitral valve repair has given us a different perspective in approaching the primary mitral regurgitation in HOCM patients where a combined septal myectomy, papillary muscle reorientation and complex mitral valve repair has been safely performed using the less invasive robotic-assisted approach.Our objective here is to discuss the technical aspects of the procedure. [ABSTRACT FROM AUTHOR]

: BackgroundComplex mitral regurgitation (MR) jets can make repair challenging; edge-to-edge (Alfieri) repair augments the repertoire of repair techniques. Objectives of this study were to demonstrate causes of MR amenable to edge-to-edge repair and to determine safety, obstructive potential, and durability of edge-to-edge repair.: MethodsFrom January 1997 to October 2001, 224 patients underwent Alfieri repair. Indications included ischemic cardiomyopathy (n = 143, 64%), myxomatous disease (n = 31, 14%), dilated cardiomyopathy (n = 27, 12%), and hypertrophic obstructive cardiomyopathy (n = 14, 6%). Concomitant ring annuloplasty was performed in 188 patients (84%). Two additional patients had takedown of an Alfieri repair in the operating room for obstruction. Preoperative MR was 4+ in 109 patients (50%) and 3+ in 65 (30%). Postoperative and follow-up mitral gradient and return of MR were assessed using 396 transthoracic echocardiograms and longitudinal analyses.: ResultsHospital mortality was 2% (5 of 224). Mitral valve mean gradient was low (3.7 mm Hg) and nonprogressive (p = 0.7), although peak gradient rose slightly, from mean 8.4 to 10.0 mm Hg (p = 0.01). During the first 3 postoperative months, absence of MR declined to 40%, and prevalence of 3+ MR increased to 14%, then rose slowly thereafter. Fourteen patients—12 within 2 years—underwent mitral valve reoperation, none for stenosis; 7 patients—6 within 2 years—underwent heart transplantation.: ConclusionsAlfieri mitral repair can be used in a variety of settings with a low risk of creating mitral stenosis. However, in ischemic MR, steadily increasing prevalence of moderately severe and severe regurgitation after edge-to-edge repair suggests other techniques are needed. [Copyright &y& Elsevier]

Examines whether mitral valve inertance in humans is a critical factor in Doppler estimation of transvalvular blood pressure gradients. Assessment of the effect of the inertial term on the transmitral pressure-flow relation; Echocardiography; Factors to consider when assessing diastolic filling and pressure difference across normal mitral valves.

Determines whether early transmitral deceleration times (E[subDT] might provide a quantitative estimate of left ventricular operating stiffness (K[subLV] in humans. Effect of varying preload on both E[subDT] and K[subLV]; Quantitative prediction of K[subLV] using E[subDT]; Effects of positive pressure ventilation.