Severe Hypertrophic Obstructive Cardiomyopathy Treated Through Periareolar Minithoracotomy
ELIANA RAVIOLA, CARLOTTA BREGA, MAURIZIO PIN, FABIO ZUCCHETTA, MARCO PANZAVOLTA, FRANCESCO TIZZANO, ELISA MIKUS, ALBERTO TRIPODI, SIMONE CALVI, ALBERTO ALBERTINI.
MARIA CECILIA HOSPITAL, COTIGNOLA, Italy.
BackgroundHypertrophic obstructive cardiomyopathy (HOCM) and mitral regurgitation causing systolic anterior motion can be safely and effectively performed through periareolar minithoracotomyMethodsA patient affected by HOCM and mitral valve regurgitation conditioning systolic anterior motion presented with severe obstruction of the outflow tract of the left ventricle. Magnetic resonance showed left ventricle hypertrophy from the basal anterior portion of the septum to the apical inferior wall and an accessory anterior bifid papillary muscle. Through a right periareolar skin incision an anterolateral thoracotomy is performed at the 4th intercostal space and a 5 mm 0° thoracoscope is introduced through the same intercostal space laterally. After onset of extracorporeal circulation through femoral vessels and crystalloid cardioplegia infusion, left atrium is opened and retracted. The insertion of the anterior leaflet is cut between the commissures and the leaflet fixed to the posterior annulus. A trans-mitral myectomy of the interventricular septum is performed and extended to the origin of the papillary muscles. The anterior head of the accessory bifid papillary muscle is cut. A pericardial patch is sutured to the anterior annulus and to the detached portion of the anterior leaflet in order to extend the surface of the leaflet and move backward the coaptation of the mitral valve. Two neochords are implanted on the anterolateral and posteromedial papillary muscles and lead to the free margin of the anterior leaflet. ResultsPost-operative echocardiography revealed no intraventricular gradient or mitral regurgitation. At 6 months cardiac magnetic resonance the left ventricular volume is fully restored without any residual outflow obstruction, the mitral shows deep, posteriorized coaptation and normal leaflets mobility.ConclusionsHypertrophic cardiomiopathy has an estimated prevalence at 0.16% to 0.29% in the general adult population worldwide. One third present with obstruction of the left ventricle outflow tract. At the present time, when pahramacological therapy is not sufficient, surgery is the gold standard of treatment. We think that, when performed in a high volume centre by expert surgeons, minimally invasive approach can be a safe and effective alternative to standard sternotomy to treat these patients to permit a faster recovery.
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