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Totally toracoscopic resection of idiopathic hypertrophic subaortic stenosis and mitral valve plasty through paramammary access
Radoslaw Smoczynski, Jakub Starolynski, Anna Witkowska, Domink Drobinski, Piotr Suwalski.
Central Teaching Hospital MSW, Warsaw, Poland.

OBJECTIVE: Idiopathic hypertrophic subaortic stenosis (IHSS) is type of hypertrophic obstructive cardiomyopathy (HOCM) which cause obstruction in outflow track from left ventricle (LV) and it usual co-exists with systolic anterior motion (SAM) of mitral valve anterior leaflet. Both pathologies create severe obstruction and led to LV hypertrophy, low LV diastolic volume, ventricular arrhythmias and sudden cardiac death. Resection of hypertrophic ventricular septum and mitral valve pasty is surgical strategy as alternative to percutaneous alcoholic ablation.
We present totally toracoscopic treatment of HSS and SAM as alternative to full-sternotomy or percutaneous methods.
METHODS: Two male patients (56 and 73 years old) with co-existing symptomatic IHSS and SAM were qualified to totally toracoscopic resection of hypertrophic ventricular septum and mitral valve plasty.
Surgical access was done through paramammary incision around right nipple and small silicone retractor was used. Additional port was performed for 2D variable angle toracoscope. Extracorporeal circulation by peripheral cannulation of femoral vessels was done and crystal cardioplegia for heart protection was perfused into aortic bulb.
Preoperative transthoracic (TTE) and intraoperative transesophageal (TEE) echocardiography was performed. 1 and 6 months clinical follow-up were done in postoperative period and wound satisfaction score was measured.
RESULTS: Totally toracoscopic resection of hypertrophic subaortic stenosis was performed in two cases. Additional anterior leaflet of mitral valve was re-implanted and stabilized by ring annuloplasty. Cross-clamp time was less then 120 minutes in both patients. Postoperative echo showed normal gradients in outflow track from LV. Histopathology sample from resected septum confirmed IHSS. In-hospital and late major adverse cardiac events (MACE) did not occurred in follow-up time. Patient wound satisfaction score were optimal.
CONCLUSIONS: Totally toracoscopic resection of idiopathic hypertrophic subaortic stenosis and mitral valve plasty through perimammary access is possible surgical treatment. Use of toracoscope provide excellent view into LV and help for better visualization of hypertrophic obstructive area. Resection of ventricular septum and correction of mitral valve anterior leaflet seem to be important for good final results of operation. Perimammary incision around nipple in follow-up observation gives ,,scar free” cosmetic effect and optimal wound satisfaction score.

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