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Transapical Beating-heart Septal Myectomy In Patients With Hypertrophic Obstructive Cardiomyopathy
Xiang Wei1, Jing Fang
1, Rui Li
1, Yue Chen
1, Song Wan
2;
1tongji hospital, Wuhan, China,
2Division of Cardiothoracic Surgery, HongKong, China
BACKGROUND: To simplify surgical septal reduction therapy for hypertrophic obstructive cardiomyopathy, we developed a novel transapical beating-heart septal myectomy procedure.
METHODS: Mini-thoracotomy was mostly performed in the fifth and (less commonly) in the sixth intercostal space at the left midclavicular line, as determined by the transthoracic echocardiography (TTE)-identified location of the left ventricle (LV) apex. Following incision and suspension of the pericardium, double-circumferential purse-string sutures with Teflon felt pledgets were placed in the avascular zone of the apex and secured with snares to provide haemostasis and LV entrance for the beating-heart myectomy device (BMD). An apical puncture was produced inside the purse-string and was dilated using a dilator along a guidewire. After deairing, the BMD in the OFF state was introduced into the LVOT through the apical puncture under the navigation of transesophageal echocardiography (TEE). The location of the resection window was three-dimensionally identified by TEE. Specifically, the depth of the BMD tip was identified in the mid-esophageal long-axis view. The orientation of the resection window was identified in the transgastric short-axis views at the basal and mid-ventricular levels. The morphology of the septal bulge, the left ventricular outflow tract gradient, the mitral regurgitation grade, and the remaining thickness of the target septum were evaluated after each resection. Subsequent resections were performed at the discretion of pre-procedural planning and real-time echocardiographic evaluations. The apical puncture was closed using the purse strings.
RESULTS: The TA-BSM procedure was highly efficient at abolishing LVOT obstruction and showed immediate satisfactory relief of symptoms in HOCM patients. In the absence of intrinsic valvular lesions, HOCM-induced mitral regurgitation was alleviated upon sufficient septal myectomy, and concomitant mitral surgery was mostly unnecessary. The TA-BSM procedure was applicable to all subtypes of HOCM and was technically less demanding (over much shorter procedural durations) than the conventional on-pump approach, so the former procedure will be easier to be disseminated than the latter.
CONCLUSIONS: Transapical beating-heart septal myectomy is feasible, safe, and efficient at abolishing left ventricular outflow tract obstruction and will improve the clinical outcomes of surgical septal reduction therapy in patients with hypertrophic obstructive cardiomyopathy.
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