Echocardiography Laboratory, Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL 33140, USA.
Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, 93200 Paris, France.
Rev Cardiovasc Med. 2021 Sep 24;22(3):983-990. doi: 10.31083/j.rcm2203107.
Septal myectomy is indicated in patients with obstructive hypertrophic cardiomyopathy (HCM) and intractable symptoms. Concomitant mitral valve (MV) surgery is performed for abnormalities contributing to systolic anterior motion (SAM), or for SAM-mediated mitral regurgitation (MR) with or without left ventricular outflow tract (LVOT) obstruction. One MV repair technique is anterior mitral leaflet extension (AMLE) utilizing bovine pericardium, stiffening the leaflet and enhancing coaptation posteriorly. Fifteen HCM patients who underwent combined myectomy-AMLE for LVOT obstruction or moderate-to-severe MR between 2009 and 2020 were analyzed using detailed echocardiography. The mean age was 56.6 years and 67% were female. The average peak systolic LVOT gradient and MR grade measured 73.4 mmHg and 2.3, respectively. Indications for myectomy-AMLE were LVOT obstruction and moderate-to-severe MR in 67%, MR only in 20%, and LVOT obstruction only in 13%. There was no mortality observed, and median follow-up was 1.2 years. Two patients had follow-up grade 1 mitral SAM, one of whom also had mild LVOT obstruction. No recurrent MR was observed in 93%, and mild MR in 7%. Compared with preoperative measures, there was a decrease in follow-up LV ejection fraction (68.2 vs 56.3%, = 0.02) and maximal septal wall thickness (25.5 vs 21.3 mm, < 0.001), and an increase in the end-diastolic diameter (21.9 vs 24.8 mm/m, = 0.04). There was no change in global longitudinal strain (-12.1 vs -11.6%, = 0.73) and peak LV twist (7.4 vs 7.3°, = 0.97). In conclusion, myectomy-AMLE is a viable treatment option for carefully selected symptomatic HCM patients with LVOT obstruction or moderate-to-severe MR.
间隔心肌切除术适用于梗阻性肥厚型心肌病（HCM）和难治性症状的患者。对于导致收缩期前向运动（SAM）的异常或伴有左心室流出道（LVOT）梗阻的 SAM 介导的二尖瓣关闭不全（MR），同时进行二尖瓣（MV）手术。一种 MV 修复技术是前二尖瓣叶延长术（AMLE），利用牛心包使瓣叶变硬，并在后部增强贴合。2009 年至 2020 年间，对 15 例因 LVOT 梗阻或中重度 MR 而行联合心肌切除术-AMLE 的 HCM 患者进行了详细的超声心动图分析。患者平均年龄为 56.6 岁，67%为女性。平均收缩期 LVOT 梯度和 MR 分级分别为 73.4mmHg 和 2.3。行心肌切除术-AMLE 的指征为 LVOT 梗阻和中重度 MR 占 67%，MR 仅占 20%，LVOT 梗阻仅占 13%。无死亡病例，中位随访时间为 1.2 年。2 例患者随访时出现 1 级二尖瓣 SAM，其中 1 例同时伴有轻度 LVOT 梗阻。93%患者未发生复发性 MR，7%患者发生轻度 MR。与术前测量值相比，随访时 LV 射血分数（68.2%比 56.3%， = 0.02）和最大室间隔厚度（25.5 毫米比 21.3 毫米， < 0.001）降低，舒张末期直径（21.9 毫米比 24.8 毫米/米， = 0.04）增加。整体纵向应变（-12.1%比-11.6%， = 0.73）和 LV 扭转峰值（7.4 度比 7.3 度， = 0.97）无变化。总之，对于精心选择的有症状的 HCM 患者，LVOT 梗阻或中重度 MR 患者，心肌切除术-AMLE 是一种可行的治疗选择。
