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Surgery Insight: septal myectomy for obstructive hypertrophic cardiomyopathy—the Mayo Clinic experience

Abstract

Septal myectomy has been the gold standard treatment for the relief left ventricular outflow tract obstruction and cardiac symptoms in both adults and children with obstructive hypertrophic cardiomyopathy. In almost all circumstances, abnormalities of the mitral valve and subvalvar mitral apparatus can be managed without the need for mitral valve replacement, and other cardiac lesions can be repaired simultaneously. In the current era, the operative mortality for isolated septal myectomy at an experienced center is low in both children and adults (approximately 1%). Excellent late results with myectomy are gratifying: 90% of patients improve by at least one NYHA class, and improvements persist in most individuals on late follow-up. Late survival in patients with obstructive hypertrophic cardiomyopathy who undergo myectomy exceeds that of patients who do not receive surgical treatment and, in addition, myectomy may be associated with reduced long-term risk of sudden cardiac death. These results should serve as a basis for comparison with newer nonsurgical treatment regimens.

Key Points

  • Septal myectomy relieves left ventricular outflow tract obstruction and cardiac symptoms effectively in both adults and children with obstructive hypertrophic cardiomyopathy

  • Abnormalities of the mitral valve and subvalvar mitral apparatus can be addressed without the need for mitral valve replacement in almost all circumstances, and other cardiac lesions can be repaired at the time of myectomy

  • In experienced centers, the operative mortality and morbidity for isolated septal myectomy in both children and adults is low (approximately 1%) and continues to improve

  • Symptomatic improvement with myectomy is gratifying: 90% of patients improve by at least one NYHA class, and most remain improved on late follow-up

  • Late survival is better in patients with obstructive hypertrophic cardiomyopathy who receive surgery than in those who do not

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Figure 1: Two operative approaches for performing septal myectomy in obstructive hypertrophic cardiomyopathy68
Figure 2: Survival in three subgroups of patients with hypertrophic cardiomyopathy: obstructive with surgical myectomy (n = 289), obstructive without surgical myectomy (n = 228), and nonobstructive (n = 820)
Figure 3: Probability of pediatric patient survival after septal myectomy59 compared with the survival curve for symptomatic pediatric patients with hypertrophic cardiomyopathy treated nonsurgically as reported by McKenna and colleagues58
Figure 4: Surgical approaches to the treatment of mitral valve anomalies68

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Acknowledgements

Jacqueline A Hart, Medscape, Boston, MA and Ariana Del Negro, Medscape Cardiology, New York, NY are the authors of and are solely responsible for the content of the learning objectives, questions and answers of the Medscape-accredited continuing medical education activity associated with this article.

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Correspondence to Joseph A Dearani.

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Dearani, J., Ommen, S., Gersh, B. et al. Surgery Insight: septal myectomy for obstructive hypertrophic cardiomyopathy—the Mayo Clinic experience. Nat Rev Cardiol 4, 503–512 (2007). https://doi.org/10.1038/ncpcardio0965

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