Minimally Invasive Transmitral Septal Myectomy, Concomitant Mitral Repair Without Annuloplasty And Left-sided Cryomaze Procedure
Sreekumar Subramanian, Joshua Hall, Andrew T. McRae, III.
TriStar Centennial Medical Center, Nashville, TN, USA.
OBJECTIVE: Various minimally invasive surgical approaches to hypertrophic cardiomyopathy have been described. However, combined septal myectomy and surgical atrial fibrillation (AF) ablation have typically been performed via sternotomy. We report a case of minimally invasive transmitral septal myectomy, concomitant mitral valve repair without annuloplasty and left-sided cryoMAZE to highlight the decision-making and technical aspects.
METHODS: The chart of a patient referred for surgical myectomy and concomitant atrial fibrillation ablation was reviewed. In addition, a MEDLINETM search was performed to obtain articles on minimally invasive approaches to septal myectomy.
RESULTS: The patient is a 70-year old woman who had severe SAM-related mitral regurgitation, peak and mean LVOT gradients of 86 and 43 mm Hg, respectively, and paroxysmal AF. She underwent femoral cannulation, right mini-thoracotomy and transmitral septal myectomy with left atrial cryoMAZE procedure including left atrial appendage ligation. The augmentation of the anterior mitral leaflet was achieved with glutaraldehyde-fixed autologous pericardium. No annuloplasty was performed to avoid altering the mitral geometry and creating postoperative SAM. Completion TEE showed no residual SAM, mean LVOT gradient of 11-14 mm Hg and mild-moderate MR under hypovolemic conditions. She was discharged after an uneventful hospital stay on post-operative day 7. Echocardiogram at 2 months postoperatively showed mild MR, no dynamic LVOT obstruction and a mean transaortic gradient of 12 mm Hg. The patient remains NYHA Class I at 3 months. Literature review identified a total of 6 papers including 58 patients treated with minimally invasive approaches to septal myectomy. Robotic transmitral, partial upper sternotomy, right mini-thoracotomy transmitral and right mini-thoracotomy transaortic approaches have been reported. Excellent relief of LVOT obstruction and SAM-related mitral regurgitation was documented.
CONCLUSIONS: Right mini-thoracotomy transmitral septal myectomy and concomitant mitral valve repair without annuloplasty and left-sided cryoMAZE procedure is a useful therapeutic strategy. The addition of surgical ablation for atrial fibrillation would warrant selection of a minimally invasive transmitral versus transaortic approach. As experience accumulates with the lateral approaches for septal myectomy, we believe that, similar to degenerative mitral valve repair, sternotomy will be used less frequently and perhaps only when there are anatomic contraindications to the lateral approach.
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