BACKGROUND:Patients with mild septal hypertrophy associated with extremely high left ventricular outflow tract gradients and severe mitral regurgitation often require concurrent septal myectomy and mitral valve repair. We firstly and successfully utilized a combination of two minimally invasive interventional technologies, transapical beating-heart septal myectomy (TA-BSM) and transapical transcatheter edge-to-edge mitral valve repair (TA-TEER), for the treatment of hypertrophic obstructive cardiomyopathy (HOCM) and functional mitral regurgitation in two elderly patients with comorbidities. This approach avoid the use for cardiopulmonary bypass (CPB), reducing the risk of complications.
METHODS:Both patients were over 70 years old and had hypertension and coronary artery disease, one of them had a history of percutaneous coronary intervention. They were symptomatic and being New York Heart Association (NYHA) class 3. The echocardiograms of the two patients showed mild ventricular septal hypertrophy (≤18 mm), severe left ventricular outflow tract obstruction (110, 134mmHg), and severe mitral valve disease (≥3+). Mini-thoracotomy was performed in the fifth intercostal space at the left mid-clavicular line, and the two procedures were performed in the same avascular zone of the apex under the navigation of transesophageal echocardiography (TEE). Schematic diagram showing the principle of the TA-BSM and TA-TEER (panels G-J).
RESULTS:There was no in-hospital or late death. After TA-BSM, the left ventricular outflow tract obstruction was immediately relieved in all patients but the mitral regurgitation was still above moderate (panels 1A-1D, 2A-2D). After TA-TEER, the obstruction that had been relieved was not affected and the mitral regurgitation basically disappeared (panels 1E-1F, 2E-2F). Surgery led to symptomatic improvement in all patients. All patients were class 1 NYHA at latest follow-up. None of the patients required a repeat procedure during follow-up period.
CONCLUSIONS:The combined use of micro-innovative one-stage technologies provides alternative treatments for elderly HOCM patients with comorbidities, showcasing a potential shift towards interventional and less invasive surgical techniques.
