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A New Twist On An Old Problem: Robotic Septal Myectomy and Anterior Mitral Valve Leaflet Enlargement for Hypertrophic Obstructive Cardiomyopathy
Sarah L. Breves1, Thomas M. Kelley, Jr.2, James McCarthy1, Mohammed Kashem1, G. William Moser1, Daniel L. Dries1, Clifton T. Lewis3, T. Sloane Guy4.
1Temple University School of Medicine, Philadelphia, PA, USA, 2Dwight D. Eisenhower Army Medical Center, Augusta, GA, USA, 3Princeton Baptist Medical Center, Birmingham, AL, USA, 4Weill Cornell School of Medicine, New York Presbyterian Hospital, New York, NY, USA.

OBJECTIVE: Open transaortic myomectomy is the traditional treatment of hypertrophic obstructive cardiomyopathy (HOCM). While the defining feature of HOCM is left ventricular hypertrophy, the condition is also characterized by anterior mitral valve leaflet enlargement. As a result, surgical treatment should simultaneously address the ventricular septum and the mitral valve. Our minimally invasive method utilizes robotic techniques and a transmitral approach to perform an extended septal myectomy along with anterior mitral valve leaflet augmentation. We reviewed our experience with this technique in order to understand the hemodynamic effects and outcomes of this novel robotic approach.
METHODS: We conducted a retrospective review of 10 consecutive patients with HOCM that underwent robotic septal myectomy and anterior mitral valve leaflet augmentation from August 2012 to September 2015. We received Institutional Review Board approval. Chart review was conducted to determine patient demographics and procedural outcomes. Data was analyzed using Microsoft Excel.
RESULTS: Totally endoscopic robotic septal myectomy and anterior mitral valve leaflet augmentation was successfully completed in 10 (100%) patients. The mean age of the patients undergoing the procedure was 53.6±9.0 years (42-66 years), and 40% (4/10) were male. The baseline mean left ventricular ejection fraction was 64.5±7.6% (50-80%). The patients had an average preoperative mitral valve regurgitation of 2.8±0.6, with 70% (7/10) of patients presenting with ≥ 3+ mitral regurgitation. The mean basal septal thickness was 22.3±5.3 mm (17-32 mm). All patients demonstrated systolic anterior motion (SAM) of the mitral valve and LVOT obstruction. The average gradient across the LVOT was 128.2±38.9 mmHg (57-186 mmHg) with or without provocation. There were no mortalities, and no patients have required reoperation. Postoperative echocardiograms showed single digit gradients and no mitral regurgitation or SAM of the mitral valve. The mean follow-up was 8.9±13.2 months (2 weeks- 3 years), and follow-up transthoracic echocardiograms completed in 6/10 patients showed consistently low LVOT gradients.
CONCLUSIONS: Totally endoscopic robotic septal myectomy and anterior mitral leaflet augmentation is a safe and effective procedure for the treatment of HOCM. The totally endoscopic robotic approach increases visualization of the LVOT and expedites patient recovery. Continued evaluation and longer-term follow-up is needed.

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