Surgical Myectomy for HOCM
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1 Surgical Myectomy for HOCM Volkmar Falk Deutsches Herzzentrum Berlin
2 Different Pathology of HOCM Impact on surgical strategy Said SM Expert Rev Cardiovasc Ther 2013
3 Different Pathology of HOCM Impact on surgical strategy Said SM Expert Rev Cardiovasc Ther 2013
4
5 Preoperative Assessment 1 = 24mm 2 = 26mm 3 = 12mm 4 = 33mm
6 Surgical Myectomy Aortic incision to noncoronary sinus Said SM Expert Rev Cardiovasc Ther 2013
7 Surgical Myectomy Exposure of LVOT through AV Said SM Expert Rev Cardiovasc Ther
8 Surgical Myectomy Resection I incision in the septum begins just to the right of the nadir of the right aortic cusp (to avoid membraneous septum and conduction system) Said SM Expert Rev Cardiovasc Ther 2013
9 Surgical Myectomy Resection II Incision extends left towards the anterior leaflet of the mitral valve. Left of L/R commissure is LV free wall. Said SM Expert Rev Cardiovasc Ther 2013
10 Surgical Myectomy Resection III Incision is then deepened and lengthened towards the apex of the heart to excise hypertrophied septum beyond the endocardial scar at the midventricular level (line 2). Said SM Expert Rev Cardiovasc Ther 2013
11 Surgical Myectomy Resection IV Completed Myectomy Said SM Expert Rev Cardiovasc Ther 2013
12 Surgical Myectomy
13 Surgical Myectomy Pre /Post
14 Surgical Myectomy Pre /Post
15 Surgical Myectomy Pre /Post Pre Post Pre Pre Post Post
16 Surgical Myectomy Pre /Post Gradient reduced from mmhg Goal: Gradient less than 10mmHg
17 Outcomes after Surgical Myectomy In series published after 2000: <1% operative mortality >95% 5y survival Ross RE Prog Cardiovasc Dis 2012
18 Outcomes after Surgical Myectomy n = 289 n = 820 n = 228 Survival free from HCM-related death: myectomy vs nonoperated obstructive HCM, p < myectomy vs nonobstructive HCM, p = 0.01 Ross RE Prog Cardiovasc Dis 2012
19 ASA vs Surgical Myectomy annual event rate for ventricular tachycardia/fibrillation (VT/ VF) is about 5%/year after ASA In high-risk HCM patients with defibrillators post-asa incidence of appropriate interventions for VT/VF is up to 10%/year appropriate interventions for VT/VF after surgical myectomy is 2% (annualized event rate 0,24%) Maron BJ EHJ 2011 McLeod CJ EHJ 2007
20 Survival free from death and aborted SCD including ICD appropriate therapy of patients with HOCM treated with ASA (n=91) and septal myectomy (n=40). ten Cate F Circ Heart Fail 2010;3:
21 Management of accessory papillary muscle (APM) arising from ventricular septum APM attach to the side of the AML. APM is excised in its entirety; the fibrous attachments to the side of the leaflet are cut and the papillary muscle is amputated at its base. Chordal attachments to the leading edge of theaml are preserved. Said SM Expert Rev Cardiovasc Ther 2013
22 Management of accessory papillary muscle (APM) Direct insertion of ALPM into AML The PM muscle is incised off the left ventricular septum and free wall down to its base (inset) in addition to performing an extended myectomy. Said SM Expert Rev Cardiovasc Ther 2013
23 Management of fibrous attachments between the side of the AML and ventricular septum or free wall All but those attachments that come to the leading edge of the AML are resected. Said SM Expert Rev Cardiovasc Ther 2013
24 Different Pathology of HOCM Impact on surgical strategy Said SM Expert Rev Cardiovasc Ther 2013
25
26 Apical Myectomy Said SM Expert Rev Cardiovasc Ther 2013
27 Apical Myectomy Said SM Expert Rev Cardiovasc Ther 2013
28 Apical Myectomy Incision Said SM Expert Rev Cardiovasc Ther 2013
29 Apical Myectomy Incision Var I Said SM Expert Rev Cardiovasc Ther 2013
30 Apical Myectomy Incision Var I Said SM Expert Rev Cardiovasc Ther 2013
31 Apical Myectomy Closure Said SM Expert Rev Cardiovasc Ther 2013 /
32 Hemodynamics after Apical Myectomy Incraese in Stroke Volume and LVEDV at lower LVEDP -> improved LV compliance Said SM Expert Rev Cardiovasc Ther 2013
33 Mitral insufficiency due to systolic anterior motion of AML in HOCM Normal mitral leaflets Normal LV function Functional LVOT obstruction (Venturi effect) Systolic anterior motion of AML -> mitral regurgitation
34
35 SAM MI in HOCM Transmitral approach
36 Resection of P2 reduction of SAM LVOT-Myectomy LVOT enlargement AML Patch-plasty LVOT enlargement
37 Resection of P2 reduction of SAM LVOT-Myectomy LVOT enlargement AML Patch-plasty LVOT enlargement
38 Advantages of Surgical Myectomy direct visualization of complex LV outflow tract anatomy recognition (and revision) of all structural abnormalities that contribute to mechanical subaortic obstruction in this notoriously heterogeneous phenotype
39 Advantages of Surgical Myectomy Correction for: irregular distribution of septal thickness anomalies of submitral structures including direct insertion of the anterolateral PM and accessory PM producing midcavity muscular obstruction elongated mitral valve leaflets and dynamic outflow obstruction (SAM) more extensive and broader muscular resection to midventricular level and reconstruction of subvalvular and valvular structures
40 Surgical Myectomy Allows for more controlled, extensive and broader muscular resection to midventricular level and reconstruction of subvalvular and valvular structures.
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