title: Bimanual examination for septal myectomy for hypertrophic cardiomyopathy.
abstract: OBJECTIVE
  Left ventricular septal myectomy is the therapeutic 'gold standard' for patients with obstructive hypertrophic cardiomyopathy whose symptoms are refractory to medical therapy. We describe our initial clinical experience with a new surgical technique for septal myectomy utilizing the 'bimanual examination' in order to more reliably complete extended septal myectomy during cardioplegic arrest.
  
  
  METHODS
  The bimanual examination was performed by inspecting the interventricular septum with two fingers inserted through the aortotomy (left index finger) and a small right atriotomy (right index finger). From January 2012 to February 2014, septal myectomy was performed in 35 patients. The mean patient age was 59.6 ± 13.7, and 60% were men. Systolic anterior motion was present in 30 (86%) patients. Most patients (94%) had moderate to severe mitral regurgitation (mean 2.1 ± 0.9). Of these, 16 (46%) underwent a concomitant mitral procedure. A total of 12 (34%) consecutive patients had bimanual examination utilized during extended myectomy. Patients were grouped into a standard (n = 23) and bimanual group (n = 12).
  
  
  RESULTS
  There were no significant differences between groups with respect to age, gender or New York Heart Association class. No mortality occurred. The bimanual group demonstrated a trend towards a lower postoperative left ventricular outflow tract gradient, compared with the standard group (2.5 ± 5.7 vs 7.4 ± 8.8 mmHg, P = 0.07), without the need for repeat cardiopulmonary bypass for inadequate myectomy/residual systolic anterior motion in any patient. Among those without organic mitral disease, the completeness rate of septal myectomy, defined by the percentage of patients avoiding mitral replacement, with residual systolic anterior motion or left ventricular outflow tract gradient greater than 20 mmHg, was 73 and 90% in the standard and bimanual group, respectively.
  
  
  CONCLUSIONS
  Our early clinical experience of bimanual examination for septal myectomy has proved to be clinically valuable. This technique should be utilized in order to facilitate a determined and well-performed myectomy.
authors.affiliation: Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, NY, USA.
authors.forename: Shinichi
authors.initials: S
authors.lastname: Fukuhara
authors.affiliation: Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, NY, USA.
authors.forename: Sara
authors.initials: S
authors.lastname: Edwards
authors.affiliation: Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, NY, USA.
authors.forename: Paul
authors.initials: P
authors.lastname: Kurlansky
authors.affiliation: Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, NY, USA ht2225@cumc.columbia.edu.
authors.forename: Hiroo
authors.initials: H
authors.lastname: Takayama
mesh_terms: D006348:Cardiac Surgical Procedures / Q000379:methods*; D002312:Cardiomyopathy, Hypertrophic / Q000175:diagnosis* / Q000601:surgery; D004452:Echocardiography; D005260:Female; D006801:Humans; D007432:Intraoperative Period; D008297:Male; D008875:Middle Aged; D010173:Palpation / Q000379:methods*; D015203:Reproducibility of Results; D012189:Retrospective Studies; D054088:Ventricular Septum / Q000000981:diagnostic imaging / Q000473:pathology* / Q000601:surgery
keywords: Hypertrophic cardiomyopathy; Septal myectomy; Systolic anterior motion