Totally endoscopic transmitral septal myectomy for the treatment of recurrent left ventricular outflow tract obstruction after alcohol septal ablation_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

WEI Peijian ^1,2 , WU Hongxiang ¹ , TAN Tong ^1,2 , QIU Hailong ^1,3 , XU Xiaowei ³ , ZHU Wei ⁴ , LU Guanyu ^2,5 , ZHUANG Jian ^1,3 ,  LIU Jian ^1,3 ,  GUO Huiming ^1,3

1. Department of Cardiac Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Cardiovascular Institute, Guangzhou, 510080, P. R. China;
2. Shantou University Medical College, Shantou, 515041, Guangdong, P. R. China;
3. Laboratory of Artificial Intelligence and 3D Technologies for Cardiovascular Diseases, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, P. R. China;
4. Department of Adult Cardiac Ultrasound Medicine, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Cardiovascular Institute, Guangzhou, 510080, P. R. China;
5. Department of Radiology, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, P. R. China;

Corresponding author：

LIU Jian, Email: jianliu_gdpph@sina.com; GUO Huiming, Email: guohuiming@gdph.org.cn

Keywords：

Totally endoscopic; septal myectomy; alcohol septal ablation; residual left ventricular outflow tract obstruction; three-dimensional printing

DOI：

10.7507/1007-4848.202108022

Video：

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Objective To investigate the surgical strategies and clinical efficacy of transmitral septal myectomy in the treatment of recurrent left ventricular outflow tract obstruction (LVOTO) after alcohol septal ablation. Methods The clinical data of patients with recurrent LVOTO after alcohol septal ablation from July 2020 to July 2021 in the Department of Cardiac Surgery, Guangdong Provincial People's Hospital were retrospectively analyzed. Patients were preoperatively evaluated by echocardiography, cardiac magnetic resonance imaging, cardiac computed tomography, 3D modeling and printing technology. A personalized surgical strategy was preoperatively developed according to multimodality imaging assessment, while visual exploration was performed on the digital model and simulated surgical resection was performed on the printed model. Results Two female patients were enrolled, aged 62 years and 64 years, respectively. Totally endoscopic transmitral extended myectomy was successfully performed on both patients with aortic cross-clamping time of 96 min and 85 min, respectively. LVOTO was relieved immediately (subaortic peak pressure gradient decreased from 100 mm Hg to 4 mm Hg and from 84 mm Hg to 6 mm Hg, respectively) and the mitral regurgitation significantly improved after the procedure. No patient had complete atrioventricular block or required permanent pacemaker implantation. The patients were discharged uneventfully without postoperative complications. Conclusion Personalized totally endoscopic transmitral extended myectomy combined with multimodality imaging assessment and 3D modeling and printing has an acceptable clinical effect in patients with recurrent LVOTO after alcohol septal ablation. The procedure can precisely resect the hypertrophic septal myocardium while avoiding serious complications such as septal perforation or complete atrioventricular block.

Citation： WEI Peijian, WU Hongxiang, TAN Tong, QIU Hailong, XU Xiaowei, ZHU Wei, LU Guanyu, ZHUANG Jian, LIU Jian, GUO Huiming. Totally endoscopic transmitral septal myectomy for the treatment of recurrent left ventricular outflow tract obstruction after alcohol septal ablation. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2023, 30(8): 1102-1111. doi: 10.7507/1007-4848.202108022 Copy

1.	Semsarian C, Ingles J, Maron MS, et al. New perspectives on the prevalence of hypertrophic cardiomyopathy. J Am Coll Cardiol, 2015, 65(12): 1249-1254.
2.	中国心血管健康与疾病报告编写组. 中国心血管健康与疾病报告2020概要. 中国循环杂志, 2021, 36(6): 521-545.
3.	Rowin EJ, Maron BJ, Olivotto I, et al. Role of exercise testing in hypertrophic cardiomyopathy. JACC Cardiovasc Imaging, 2017, 10(11): 1374-1386.
4.	Hodges K, Rivas CG, Aguilera J, et al. Surgical management of left ventricular outflow tract obstruction in a specialized hypertrophic obstructive cardiomyopathy center. J Thorac Cardiovasc Surg, 2019, 157(6): 2289-2299.
5.	Rastegar H, Boll G, Rowin EJ, et al. Results of surgical septal myectomy for obstructive hypertrophic cardiomyopathy: The tufts experience. Ann Cardiothorac Surg, 2017, 6(4): 353-363.
6.	Sorajja P, Binder J, Nishimura RA, et al. Predictors of an optimal clinical outcome with alcohol septal ablation for obstructive hypertrophic cardiomyopathy. Catheter Cardiovasc Interv, 2013, 81(1): E58-E67.
7.	Batzner A, Pfeiffer B, Neugebauer A, et al. Survival after alcohol septal ablation in patients with hypertrophic obstructive cardiomyopathy. J Am Coll Cardiol, 2018, 72(24): 3087-3094.
8.	Nguyen A, Schaff HV, Hang D, et al. Surgical myectomy versus alcohol septal ablation for obstructive hypertrophic cardiomyopathy: A propensity score-matched cohort. J Thorac Cardiovasc Surg, 2019, 157(1): 306-315.
9.	Kimmelstiel C, Zisa DC, Kuttab JS, et al. Guideline-based referral for septal reduction therapy in obstructive hypertrophic cardiomyopathy is associated with excellent clinical outcomes. Circ Cardiovasc Interv, 2019, 12(7): e007673.
10.	Cerqueira MD, Weissman NJ, Dilsizian V, et al. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart. A statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. Circulation, 2002, 105(4): 539-542.
11.	Writing Committee Members, Ommen SR, Mital S, et al. 2020 AHA/ACC guideline for the diagnosis and treatment of patients with hypertrophic cardiomyopathy: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg, 2021, 162(1): e23-e106.
12.	Sigwart U. Non-surgical myocardial reduction for hypertrophic obstructive cardiomyopathy. Lancet, 1995, 346(8969): 211-214.
13.	Maron BJ. Controversies in cardiovascular medicine. Surgical myectomy remains the primary treatment option for severely symptomatic patients with obstructive hypertrophic cardiomyopathy. Circulation, 2007, 116(2): 196-206.
14.	罗晓亮, 袁建松, 杨伟宪. 中国医学科学院阜外医院经皮室间隔心肌消融术临床操作规范. 中国分子心脏病学杂志, 2021, 21(3): 3913-3917.
15.	Veselka J, Jensen MK, Liebregts M, et al. Long-term clinical outcome after alcohol septal ablation for obstructive hypertrophic cardiomyopathy: Results from the Euro-ASA registry. Eur Heart J, 2016, 37(19): 1517-1523.
16.	Nagueh SF, Groves BM, Schwartz L, et al. Alcohol septal ablation for the treatment of hypertrophic obstructive cardiomyopathy. A multicenter North American registry. J Am Coll Cardiol, 2011, 58(22): 2322-2328.
17.	Quintana E, Bajona P, Arguis MJ, et al. Septal myectomy after failed septal alcohol ablation. Ann Cardiothorac Surg, 2017, 6(4): 394-401.
18.	Quintana E, Sabate-Rotes A, Maleszewski JJ, et al. Septal myectomy after failed alcohol ablation: Does previous percutaneous intervention compromise outcomes of myectomy? J Thorac Cardiovasc Surg, 2015, 150(1): 159-167.
19.	Fitzgerald P, Kusumoto F. The effects of septal myectomy and alcohol septal ablation for hypertrophic cardiomyopathy on the cardiac conduction system. J Interv Card Electrophysiol, 2018, 52(3): 403-408.
20.	Valeti US, Nishimura RA, Holmes DR, et al. Comparison of surgical septal myectomy and alcohol septal ablation with cardiac magnetic resonance imaging in patients with hypertrophic obstructive cardiomyopathy. J Am Coll Cardiol, 2007, 49(3): 350-357.
21.	Talreja DR, Nishimura RA, Edwards WD, et al. Alcohol septal ablation versus surgical septal myectomy: Comparison of effects on atrioventricular conduction tissue. J Am Coll Cardiol, 2004, 44(12): 2329-2332.
22.	Cui H, Schaff HV, Nishimura RA, et al. Conduction abnormalities and long-term mortality following septal myectomy in patients with obstructive hypertrophic cardiomyopathy. J Am Coll Cardiol, 2019, 74(5): 645-655.
23.	Ji Q, Wang Y, Yang Y, et al. Surgical septal myectomy for the treatment of residual left ventricular outflow tract obstruction following failed alcohol septal ablation. Int Heart J, 2021, 62(2): 329-336.
24.	Yang Q, Zhu C, Cui H, et al. Surgical septal myectomy outcome for obstructive hypertrophic cardiomyopathy after alcohol septal ablation. J Thorac Dis, 2021, 13(2): 1055-1065.
25.	Wehman B, Ghoreishi M, Foster N, et al. Transmitral septal myectomy for hypertrophic obstructive cardiomyopathy. Ann Thorac Surg, 2018, 105(4): 1102-1108.
26.	Yang DH, Kang JW, Kim N, et al. Myocardial 3-dimensional printing for septal myectomy guidance in a patient with obstructive hypertrophic cardiomyopathy. Circulation, 2015, 132(4): 300-301.

1. Semsarian C, Ingles J, Maron MS, et al. New perspectives on the prevalence of hypertrophic cardiomyopathy. J Am Coll Cardiol, 2015, 65(12): 1249-1254.
2. 中国心血管健康与疾病报告编写组. 中国心血管健康与疾病报告2020概要. 中国循环杂志, 2021, 36(6): 521-545.
3. Rowin EJ, Maron BJ, Olivotto I, et al. Role of exercise testing in hypertrophic cardiomyopathy. JACC Cardiovasc Imaging, 2017, 10(11): 1374-1386.
4. Hodges K, Rivas CG, Aguilera J, et al. Surgical management of left ventricular outflow tract obstruction in a specialized hypertrophic obstructive cardiomyopathy center. J Thorac Cardiovasc Surg, 2019, 157(6): 2289-2299.
5. Rastegar H, Boll G, Rowin EJ, et al. Results of surgical septal myectomy for obstructive hypertrophic cardiomyopathy: The tufts experience. Ann Cardiothorac Surg, 2017, 6(4): 353-363.
6. Sorajja P, Binder J, Nishimura RA, et al. Predictors of an optimal clinical outcome with alcohol septal ablation for obstructive hypertrophic cardiomyopathy. Catheter Cardiovasc Interv, 2013, 81(1): E58-E67.
7. Batzner A, Pfeiffer B, Neugebauer A, et al. Survival after alcohol septal ablation in patients with hypertrophic obstructive cardiomyopathy. J Am Coll Cardiol, 2018, 72(24): 3087-3094.
8. Nguyen A, Schaff HV, Hang D, et al. Surgical myectomy versus alcohol septal ablation for obstructive hypertrophic cardiomyopathy: A propensity score-matched cohort. J Thorac Cardiovasc Surg, 2019, 157(1): 306-315.
9. Kimmelstiel C, Zisa DC, Kuttab JS, et al. Guideline-based referral for septal reduction therapy in obstructive hypertrophic cardiomyopathy is associated with excellent clinical outcomes. Circ Cardiovasc Interv, 2019, 12(7): e007673.
10. Cerqueira MD, Weissman NJ, Dilsizian V, et al. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart. A statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. Circulation, 2002, 105(4): 539-542.
11. Writing Committee Members, Ommen SR, Mital S, et al. 2020 AHA/ACC guideline for the diagnosis and treatment of patients with hypertrophic cardiomyopathy: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg, 2021, 162(1): e23-e106.
12. Sigwart U. Non-surgical myocardial reduction for hypertrophic obstructive cardiomyopathy. Lancet, 1995, 346(8969): 211-214.
13. Maron BJ. Controversies in cardiovascular medicine. Surgical myectomy remains the primary treatment option for severely symptomatic patients with obstructive hypertrophic cardiomyopathy. Circulation, 2007, 116(2): 196-206.
14. 罗晓亮, 袁建松, 杨伟宪. 中国医学科学院阜外医院经皮室间隔心肌消融术临床操作规范. 中国分子心脏病学杂志, 2021, 21(3): 3913-3917.
15. Veselka J, Jensen MK, Liebregts M, et al. Long-term clinical outcome after alcohol septal ablation for obstructive hypertrophic cardiomyopathy: Results from the Euro-ASA registry. Eur Heart J, 2016, 37(19): 1517-1523.
16. Nagueh SF, Groves BM, Schwartz L, et al. Alcohol septal ablation for the treatment of hypertrophic obstructive cardiomyopathy. A multicenter North American registry. J Am Coll Cardiol, 2011, 58(22): 2322-2328.
17. Quintana E, Bajona P, Arguis MJ, et al. Septal myectomy after failed septal alcohol ablation. Ann Cardiothorac Surg, 2017, 6(4): 394-401.
18. Quintana E, Sabate-Rotes A, Maleszewski JJ, et al. Septal myectomy after failed alcohol ablation: Does previous percutaneous intervention compromise outcomes of myectomy? J Thorac Cardiovasc Surg, 2015, 150(1): 159-167.
19. Fitzgerald P, Kusumoto F. The effects of septal myectomy and alcohol septal ablation for hypertrophic cardiomyopathy on the cardiac conduction system. J Interv Card Electrophysiol, 2018, 52(3): 403-408.
20. Valeti US, Nishimura RA, Holmes DR, et al. Comparison of surgical septal myectomy and alcohol septal ablation with cardiac magnetic resonance imaging in patients with hypertrophic obstructive cardiomyopathy. J Am Coll Cardiol, 2007, 49(3): 350-357.
21. Talreja DR, Nishimura RA, Edwards WD, et al. Alcohol septal ablation versus surgical septal myectomy: Comparison of effects on atrioventricular conduction tissue. J Am Coll Cardiol, 2004, 44(12): 2329-2332.
22. Cui H, Schaff HV, Nishimura RA, et al. Conduction abnormalities and long-term mortality following septal myectomy in patients with obstructive hypertrophic cardiomyopathy. J Am Coll Cardiol, 2019, 74(5): 645-655.
23. Ji Q, Wang Y, Yang Y, et al. Surgical septal myectomy for the treatment of residual left ventricular outflow tract obstruction following failed alcohol septal ablation. Int Heart J, 2021, 62(2): 329-336.
24. Yang Q, Zhu C, Cui H, et al. Surgical septal myectomy outcome for obstructive hypertrophic cardiomyopathy after alcohol septal ablation. J Thorac Dis, 2021, 13(2): 1055-1065.
25. Wehman B, Ghoreishi M, Foster N, et al. Transmitral septal myectomy for hypertrophic obstructive cardiomyopathy. Ann Thorac Surg, 2018, 105(4): 1102-1108.
26. Yang DH, Kang JW, Kim N, et al. Myocardial 3-dimensional printing for septal myectomy guidance in a patient with obstructive hypertrophic cardiomyopathy. Circulation, 2015, 132(4): 300-301.

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Totally endoscopic transmitral septal myectomy for the treatment of recurrent left ventricular outflow tract obstruction after alcohol septal ablation

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