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TRANSMITRAL SEPTAL MYECTOMY FOR SUBVALVULAR AORTIC STENOSIS: MINIMALLY INVASIVE SOLUTION.
DANIYAR SH. GILMANOV, STEFANO BEVILACQUA, MARCO SOLINAS, MATTEO FERRARINI, ENKEL KALLUSHI, PIER ANDREA FARNETI, MATTIA GLAUBER.
G. MONASTERIO TUSCANY FOUNDATION - G. PASQUINUCCI HEART HOSPITAL, MASSA, Italy.

OBJECTIVE: Transaortic left ventricular septal myectomy described by Morrow is classical procedure for the treatment of systolic anterior motion of the mitral apparatus associated with hypertrophic obstructive cardiomyopathy (HOCM). We reviewed our results of transmitral septal myectomy and mitral valve repair/replacement in minimally invasive setting.
METHODS: Between 2005 and 2012, 16 patients (37.5% men, mean age 68.1±14.2 years) were treated with minimally invasive approach for degenerative mitral regurgitation (MR) and HOCM. Preoperative peak left ventricular outflow tract gradient was 61.4±23 mm Hg. Severe MR was diagnosed in 13 cases (81%). New York Heart Association functional class III-IV heart failure was present in 11 patients (69%). 2 patients of this series were previously operated on for septal myectomy and 1 - for aortic valve disease (reintervention cohort - n=3; 19%).
RESULTS: 14 patients (87.5%) underwent mitral valve replacement and 2 patients - mitral valve repair. Video assisted right anterolateral minithoracotomy, central arterial cannulation into the ascending aorta and transfemoral venous cannulation were standard setups for procedure. LVOT obstruction was corrected directly in all patients via the mitral valve with septal myectomy/myotomy, avoiding aortotomy in majority of the patients (n=15, 94%). No significant prolongation of extracorporeal circulation/aortic cross clamping times was observed (p=0.36) when compared with similar population without HOCM. No iatrogenic ventricular septal defect developed in treated patients (0%). No hospital mortality occurred (0%). Resting LVOT gradient reduced at discharge to 15±23 mm Hg (p<0.03). Median hospital stay length was 7 days.
CONCLUSIONS: Transmitral left ventricular septal myectomy in patients with degenerative mitral valve disease is quite simple, feasible and effective technique and does not require aortotomy in the most of cases. It can be performed with low early mortality and satisfactory resolution of LVOT obstruction in minimally invasive setting.


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