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Combined Transapical Beating-heart Septal Myectomy And Tavi For Hypertrophic Obstructive Cardiomyopathy With Severe Aortic Stenosis
cai cheng1, Xiaoxue Zhang2, Ningxin Hou1, Chenhe Li1.
1The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China, 2Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
BACKGROUND: The coexistence of Hypertrophic Obstructive Cardiomyopathy (HOCM) and severe Aortic Stenosis (AS) presents a complex hemodynamic challenge. Conventional surgical septal myectomy combined with valve replacement is the gold standard but carries prohibitive risks for elderly patients with significant comorbidities. We report the first successful application of a fully minimally invasive, beating-heart hybrid strategy combining Transapical Beating-Heart Septal Myectomy (TA-BSM) and Transcatheter Aortic Valve Implantation (TAVI) to treat this dual pathology without cardiopulmonary bypass (CPB).
METHODS: A 65-year-old female (EuroSCORE II 7.99%) presented with severe AS (mean gradient 111 mmHg) and HOCM (septal thickness 19 mm; Left Ventricular Outflow Tract [LVOT] gradient 61 mmHg). Due to high surgical risk and refusal of open surgery, a novel staged approach was employed. First, TA-BSM was performed via a mini-thoracotomy using a specialized echocardiography-guided Beating-Heart Myectomy Device (BMD) to resect the hypertrophied septum on the beating heart. Subsequently, a 24 mm self-expanding valve (VitaFlow) was implanted via the femoral artery.
RESULTS: The procedure was technically successful. TA-BSM effectively reduced the septal thickness from 19 mm to 11 mm, and the LVOT gradient dropped significantly from 61 mmHg to 7 mmHg after three targeted resections. Following TAVI deployment, the aortic valve mean pressure gradient decreased from 111 mmHg to 28 mmHg, with invasive measurements showing a reduction to 0 mmHg. No perivalvular leakage or conduction disturbances were observed. The patient recovered uneventfully, and 3-month follow-up confirmed stable hemodynamics.
CONCLUSIONS: This case demonstrates that combining TA-BSM with TAVI is a feasible and safe strategy for high-risk patients with coexisting HOCM and severe AS. By eliminating the need for CPB and aortic cross-clamping, this novel "beating-heart" technique offers a promising minimally invasive alternative to conventional open surgery for complex left ventricular outflow obstruction.
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