title: Characteristics and surgical outcomes of symptomatic patients with hypertrophic cardiomyopathy with abnormal papillary muscle morphology undergoing papillary muscle reorientation.
abstract: OBJECTIVE
  In patients with hypertrophic cardiomyopathy with bifid hypermobile papillary muscles and a dynamic left ventricular outflow tract gradient, we performed surgical papillary muscle reorientation, fixing the mobile papillary muscle to the posterior left ventricle to reduce mobility. We report the outcomes of patients with hypertrophic cardiomyopathy undergoing surgical papillary muscle reorientation versus those of patients undergoing standard surgical procedures.
  
  
  METHODS
  We studied 204 consecutive patients with hypertrophic cardiomyopathy undergoing surgical intervention (after consensus decision) for symptomatic left ventricular outflow tract gradient. Preoperative and postoperative maximal (resting/provocable) left ventricular outflow tract gradients were recorded by using echocardiographic analysis.
  
  
  RESULTS
  The population was divided into 3 groups: (1) isolated myectomy (n = 143; age, 54 +/- 14 years; 48% men), (2) myectomy plus mitral valve repair/replacement (n = 39; age, 54 +/- 13 years; 54% men), and (3) papillary muscle reorientation with or without myectomy (n = 22; age, 50 +/- 14 years; 59% men). The mean preoperative (103 +/- 32, 103 +/- 32, and 114 +/- 36 mm Hg; P = .3) and predischarge (15 +/- 18, 14 +/- 14, and 16 +/- 21 mm Hg; P = .9) maximal left ventricular outflow tract gradients were similar. There were no deaths either in the hospital or at 30 days. At a median follow-up of 166 days (interquartile range, 74-343 days), 21 of 22 patients in group 3 were asymptomatic. One patient in group 3 had a symptomatic left ventricular outflow tract gradient (87 mm Hg) requiring mitral valve replacement.
  
  
  CONCLUSIONS
  In patients with hypertrophic cardiomyopathy with bifid hypermobile papillary muscles (even with a basal septal thickness <1.5 cm), papillary muscle reorientation reduces the symptomatic left ventricular outflow tract gradient. Long-term outcomes need to be ascertained.
authors.affiliation: Tomsich Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA.
authors.forename: Deborah H
authors.initials: DH
authors.lastname: Kwon
authors.forename: Nicholas G
authors.initials: NG
authors.lastname: Smedira
authors.forename: Maran
authors.initials: M
authors.lastname: Thamilarasan
authors.forename: Bruce W
authors.initials: BW
authors.lastname: Lytle
authors.forename: Harry
authors.initials: H
authors.lastname: Lever
authors.forename: Milind Y
authors.initials: MY
authors.lastname: Desai
mesh_terms: D000328:Adult; D000368:Aged; D006348:Cardiac Surgical Procedures / Q000009:adverse effects; D002312:Cardiomyopathy, Hypertrophic / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D015150:Echocardiography, Doppler; D005260:Female; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000601:surgery; D010210:Papillary Muscles / Q000473:pathology / Q000601:surgery*; D012042:Registries; D013997:Time Factors; D016896:Treatment Outcome; D016277:Ventricular Function, Left; D014694:Ventricular Outflow Obstruction / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*