What is the best surgical treatment for obstructive hypertrophic cardiomyopathy and degenerative mitral regurgitation?
BACKGROUND
Many prefer mitral valve replacement (MVR) for patients with obstructive hypertrophic cardiomyopathy (HCM) and concomitant degenerative mitral regurgitation (MR). We reviewed our results of septal myectomy combined with mitral valve repair (MVrep) and MVR when these problems coexist.


METHODS
Between 1990 and 2006, 32 patients (56% men; mean age, 60.7 +/- 16.7 years) underwent extended septal myectomy for HCM with concomitant MVrep or MVR for degenerative MR (4% of myectomies and 3% of isolated MVrep during the same period). Preoperatively, 63% were in New York Heart Association (NHYA) functional class III/IV. Preoperative peak left ventricular outflow tract (LVOT) gradient was 63.7 +/- 37.6 mm Hg. Systolic anterior motion (SAM) was present in 94%, with severe MR in 88%.


RESULTS
Extended septal myectomy included concomitant MVrep in 28 (88%) or mechanical MVR in 4 (12%). MVrep included leaflet resection in 10 (36%), edge-to-edge stitch in 6 (21%), and leaflet plication in 8 (29%). An annuloplasty ring/band was used in 19 (68%) and commissural annuloplasty in 2 (7%). There was one early death (3%). At discharge, resting LVOT gradient was reduced to 10.2 +/- 19.0 mm Hg (p < 0.005). Dismissal echocardiography in MVrep patients demonstrated chordal SAM in 6 (21%, p < 0.005). MR was absent or mild in 21 (75%) and moderate in 6 (21%; p < 0.005 vs preoperatively). At late follow-up, LVOT gradient was 2.5 +/- 5.8 mm Hg, SAM resolved in all patients, and 2 had moderate MR; 24 (83%) were in NYHA class I/II (p < 0.005).


CONCLUSIONS
Concomitant MVrep with myectomy for HCM and degenerative MR can be performed with low early mortality with satisfactory relief of LVOT obstruction and MR. Most patients have significant relief of symptoms. MVR can be avoided in most patients with degenerative MR and HCM.
Wan
Calvin K N
CK
Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA
Dearani
Joseph A
JA
Sundt
Thoralf M
TM
Ommen
Steve R
SR
Schaff
Hartzell V
HV
D000328:Adult; D000368:Aged; D002312:Cardiomyopathy, Hypertrophic / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D015897:Comorbidity; D005260:Female; D005500:Follow-Up Studies; D006346:Heart Septum / Q000000981:diagnostic imaging / Q000601:surgery*; D019918:Heart Valve Prosthesis Implantation; D006352:Heart Ventricles / Q000000981:diagnostic imaging / Q000601:surgery*; D006439:Hemodynamics / Q000502:physiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000000981:diagnostic imaging / Q000601:surgery*; D008944:Mitral Valve Insufficiency / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000401:mortality; D012189:Retrospective Studies; D016019:Survival Analysis; D014463:Ultrasonography