Combined transaortic and transapical approach to septal myectomy in patients with complex hypertrophic cardiomyopathy.

OBJECTIVES

Residual midventricular obstruction after transaortic myectomy may lead to recurrent symptoms and reoperation in patients with hypertrophic cardiomyopathy and long-segment septal hypertrophy. A combined transaortic and transapical approach to septal myectomy during initial operation allows for the complete relief of subaortic and midventricular gradients and may reduce the risk of poor late functional results.

METHODS

We analyzed the early outcomes of 86 patients aged 18 years or more who underwent combined transaortic and transapical septal myectomy for left ventricular outflow tract obstruction due to systolic anterior motion and midventricular obstruction or cavitary obliteration due to apical hypertrophic cardiomyopathy.

RESULTS

Midventricular obstruction was present in 59 patients (68.6%); 12 patients (14.0%) had cavitary obliteration, and 15 patients (17.4%) had a combination of both. Overall, median (25th, 75th percentile) prebypass and postbypass directly measured intracavitary gradients were 85 mm Hg (48, 125) and 4 mm Hg (0, 10.8), respectively; median predischarge transthoracic left ventricular outflow tract and midventricular gradients were 0 mm Hg (0, 0) and 0 mm Hg (0, 8.5). Median crossclamp and perfusion times were 35 minutes (27, 44) and 48.5 minutes (40, 64). The 30-day and 1-year survivals were both 95%, with 2 early deaths. Functional status beyond 30 days postoperatively was available in 42 patients, and 41 patients reported improvement in symptoms and were in New York Heart Association class I/II.

CONCLUSIONS

Combined transaortic and transapical septal myectomy is an effective and reasonably safe approach for patients with hypertrophic cardiomyopathy with complex septal hypertrophy. This method may prevent residual midventricular obstruction and permits myectomy to augment diastolic filling and improve left ventricular stroke volume in patients with apical hypertrophic cardiomyopathy.