title: Trans-aortic Alfieri stitch at the time of septal myectomy for hypertrophic obstructive cardiomyopathy.
abstract: BACKGROUND
  Systolic anterior motion (SAM) of the mitral valve, left ventricular outflow tract (LVOT) obstruction, and mitral regurgitation (MR) are known adverse outcomes that can occur after septal myectomy for hypertrophic obstructive cardiomyopathy. The objective of this study was to describe outcomes of a surgical technique to prevent these complications.
  
  
  METHODS
  We have adopted a technique where we place an Alfieri stitch in the mitral valve through the aortotomy while performing septal myectomy. A retrospective review was performed and outcomes associated with this technique were noted.
  
  
  RESULTS
  Twenty-four patients underwent septal myectomy and mitral valve repair using this technique. Mean age was 57 ± 10 years. Twenty patients were in class III/IV heart failure, and all had documented SAM. Mean LVOT gradient improved from 78 ± 48 mmHg preoperatively to 19 ± 20 mmHg after myectomy (p < 0.001). No patients had postoperative SAM, and no patients required a second aortic crossclamping for mitral repair. Seventeen of 19 patients with ≥mild MR had improvement in MR. During follow-up, 16 patients had no/trivial MR, seven had mild MR, and one had moderate MR. The mean postoperative mitral gradient was 4.5 ± 3.0 mmHg. Thirteen patients had postoperative complications including one death in a patient who developed a ventricular septal defect.
  
  
  CONCLUSIONS
  Trans-aortic Alfieri stitch placement during septal myectomy is feasible in most cases as an additional tool to improve MR and minimize SAM. This technique may have a role in addressing mitral disease, such as a long anterior leaflet or fibrotic mitral valve, at the time of myectomy without the need for left atriotomy for mitral exposure.
authors.affiliation: Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina.
authors.forename: Asad A
authors.initials: AA
authors.lastname: Shah
authors.affiliation: Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina.
authors.forename: Donald D
authors.initials: DD
authors.lastname: Glower
authors.affiliation: Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina.
authors.forename: Jeffrey G
authors.initials: JG
authors.lastname: Gaca
mesh_terms: D006348:Cardiac Surgical Procedures / Q000379:methods*; D002312:Cardiomyopathy, Hypertrophic / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D017548:Echocardiography, Transesophageal; D005260:Female; D005500:Follow-Up Studies; D006346:Heart Septum / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013536:Suture Techniques / Q000295:instrumentation*; D013537:Sutures; D016896:Treatment Outcome; D016277:Ventricular Function, Left / Q000502:physiology