Indian Journal of Thoracic and Cardiovascular Surgery最新文献

Purpose: Hypertrophic obstructive cardiomyopathy (HOCM) remains a prevalent and clinically significant condition with a global prevalence of 1:200 to 1:500. In Ukraine, the estimated burden is approximately 75,000 patients, although national data remain limited. Since 2016, the Amosov National Institute of Cardiovascular Surgery in Kyiv has been a leading center for HOCM surgery, primarily performing septal myectomy (SM) with concomitant mitral valve (MV) repair. This review summarizes the evolution of the Institute's surgical program, outcomes, and challenges faced under extraordinary circumstances.

Methods: Institutional experience with SM and MV repair between 2016 and 2025 was reviewed. Preoperative evaluation included transthoracic echocardiography (TTE), cardiac magnetic resonance (CMR) imaging, and/or computed tomography (CT). A refined transaortic SM technique was applied to optimize septal resection, relieve left ventricular outflow tract (LVOT) obstruction, and address dynamic mitral regurgitation (MR).

Results: SM consistently reduced LVOT gradients and eliminated MR in the majority of patients. In-hospital mortality remained below 1%, with a low incidence of major complications directly attributable to myectomy. Despite significant external pressures, including the coronavirus disease 2019 (COVID-19) pandemic and the ongoing full-scale war in Ukraine, surgical activity continued without interruption. Innovations in operative techniques and perioperative management further enhanced safety and outcomes.

Conclusion: The Amosov Institute has established a high-performing national program for HOCM surgery, demonstrating durable results despite unprecedented challenges. Ongoing refinement of minimally invasive strategies and strengthened international collaboration remain essential to address the global shortage of experienced myectomy surgeons and ensure wider access to advanced surgical care.

Supplementary information: The online version contains supplementary material available at 10.1007/s12055-025-02125-0.

Hypertrophic obstructive cardiomyopathy (HOCM) is a prevalent inherited cardiomyopathy characterised by left ventricular hypertrophy (LVH) and dynamic left ventricular outflow tract (LVOT) obstruction. Whilst extended septal myectomy remains the gold standard for patients refractory to medical therapy, a subset of individuals continues to exhibit obstruction due to abnormalities of the mitral valve (MV) apparatus, particularly systolic anterior motion (SAM). In such cases, septal reduction alone is insufficient, and MV interventions become necessary. In selected patients, transaortic chordal cutting is emerging as an adjunctive surgical strategy in HOCM. By selectively dividing the secondary chordae that tether the anterior mitral leaflet (AML), transaortic chordal cutting alleviates SAM, restores MV geometry, and reduces LVOT gradients without compromising leaflet coaptation. Evidence from case series and cohort studies demonstrates significant reductions in resting and provoked LVOT gradients, improved New York Heart Association (NYHA) class, and sustained relief of obstruction. Comparative analyses with alternative mitral interventions, such as edge-to-edge repair, highlight the relative technical simplicity, reproducibility, and safety of this procedure. Importantly, its benefits extend to patients with both mild and marked septal hypertrophy. In this review article, we explore the current evidence surrounding transaortic chordal cutting as an adjunctive surgical strategy in HOCM.

Hypertrophic cardiomyopathy (HCM) is a primary disease of the myocardium, characterised by increased myocardial thickening, myocardial remodelling and reduced chamber size. Disarrayed arrangement of myocardial fibres leads to asymmetric or localised thickening of myocardial segments. When the left ventricle (LV) wall thickness exceeds 15 mm or more, with the septal to posterior wall thickness ratio above 1.3 either by echocardiography or cardiac magnetic resonance imaging (CMRI) without any identifiable causes, it is considered as HCM. Features common to HCM include dynamic left ventricle outflow tract obstruction (LVOTO), systolic anterior motion (SAM) of anterior mitral leaflet (AML) and mitral regurgitation (MR) with a posteriorly directed jet. Patients may be asymptomatic or present with dyspnoea, syncope, heart failure or sudden cardiac death (SCD) due to sustained ventricular tachycardia (VT). This review article highlights upon the anaesthetic considerations, intraoperative transoesophageal echocardiography (TEE) and postoperative management of obstructive HCM patient.

Supplementary information: The online version contains supplementary material available at 10.1007/s12055-025-02083-7.

Hypertrophic cardiomyopathy (HCM) is a genetic cardiac disorder characterized predominantly by left ventricular (LV) hypertrophy, frequently leading to dynamic obstruction of the left ventricular outflow tract (LVOT). Obstructive HCM is driven by structural abnormalities including asymmetric septal hypertrophy, systolic anterior motion of often elongated mitral valve leaflets, and alterations in the mitral sub-valvular apparatus such as displaced or hypertrophied papillary muscles. Pathophysiological mechanisms underlying HCM include hypercontractility due to increased actin-myosin cross bridges, myocyte hypertrophy and disarray, interstitial fibrosis, and coronary microvascular dysfunction-which contribute variably to disease expression, impaired myocardial relaxation, ischemia, fibrosis, and arrhythmogenesis. Diagnosis relies on integrating clinical presentation, physical examination, electrocardiographic features, genetic testing, and advanced imaging techniques. Transthoracic echocardiography remains the primary diagnostic and monitoring tool, accurately assessing patterns of hypertrophy, dynamic LVOT gradients, mitral valve abnormalities, and ventricular function, including strain imaging for early functional impairment. Cardiac magnetic resonance imaging complements echocardiography, providing superior anatomical delineation, precise quantification of LV mass, detection of apical and distal-dominant forms, identification of fibrosis via late gadolinium enhancement, and detailed tissue characterization. This review emphasizes the complex interplay of genetic, structural, and functional elements in obstructive HCM, underscoring the importance of comprehensive evaluation to facilitate individualized and effective therapeutic decisions.

Europe has played a foundational role in understanding hypertrophic cardiomyopathy (HCM), yet surgical treatment-particularly septal myectomy-has seen uneven adoption across the continent. Widespread reliance on alcohol septal ablation (ASA) and the more recent introduction of cardiac myosin inhibitors (CMIs) have contributed to a decline in surgical expertise. This perspective reviews the historical evolution of HCM surgery in Europe and the impact of contemporary figures and centers. Drawing on direct correspondence with active European surgeons and institutional data, the manuscript outlines the status of myectomy programs, revealing wide disparities in access, volume, and national coordination. With the data attained here, only three European centers perform more than 25 septal myectomies per year. It also evaluates the clinical and economic implications of surgical versus pharmacological approaches. Emphasis is placed on the urgent need for structured training, procedural standardization, and broader recognition of myectomy as a definitive and cost-effective treatment for obstructive HCM.

Surgical septal myectomy remains the definitive treatment for symptomatic patients with obstructive hypertrophic cardiomyopathy (oHCM), with symptomatic improvement in over 90% of patients, sustained relief of left ventricular outflow tract (LVOT) obstruction, and remarkably low operative mortality rates - less than 0.5% at experienced centers. The operation addresses septal hypertrophy and dynamic systolic anterior motion-mediated mitral valve (MV) regurgitation. Most patients require only isolated septectomy, and adjunctive MV procedures are reserved for patients with additional intrinsic MV pathology. Institutional volume strongly correlates with outcomes of transaortic septal myectomy; centers performing fewer than one myectomy annually have significantly higher rates of MV replacement and complications compared to high-volume institutions. Septal myectomy restores life expectancy to levels comparable with age- and sex-matched populations, and often exceeds outcomes seen with alcohol septal ablation, particularly in patients with marked hypertrophy or complex anatomy. Although novel pharmacologic therapies are emerging, surgical myectomy remains the gold-standard therapy for patients with refractory symptoms due to dynamic LVOT obstruction. Continued refinement of techniques and patient selection has solidified its role as one of the safest and most effective open-heart operations available.

The diverse phenotypes of hypertrophic cardiomyopathy (HCM) - including subaortic, midventricular, and apical hypertrophy - present distinct surgical challenges. While transaortic septal myectomy remains the standard approach for relieving subaortic obstruction, it may not offer adequate exposure to the midventricle and apex, limiting its effectiveness in patients with midventricular obstruction (MVO), apical HCM, or complex long-segment septal hypertrophy. To address these potential limitations, surgeons at the Mayo Clinic have utilized a transapical incision for myectomy at the mid and distal portions of the left ventricle. Over the past three decades, transapical myectomy has proved to be a safe and effective adjunct or alternative surgical strategy. This approach offers direct visualization of the hypertrophied midventricular septum and papillary muscles, allowing for complete resection and relief of intracavitary gradients in MVO. In patients with apical HCM and diastolic heart failure, apical myectomy increases left ventricular end-diastolic volume and stroke volume, improving symptoms and exercise capacity. The transapical route also facilitates repair of apical aneurysms when present. Procedural morbidity and mortality are low, and we have observed durable symptomatic relief and favorable long-term survival. In select patients with advanced heart failure symptoms who are not candidates for, or wish to defer, heart transplantation, apical myectomy represents a viable and effective surgical alternative. This review outlines the clinical indications, surgical technique, and outcomes of transapical myectomy, underscoring its role in the contemporary surgical management of complex HCM phenotypes.

Hypertrophic cardiomyopathy (HCM) is the most common monogenic cardiac disease, affecting approximately 0.2% of the general population. Despite its prevalence, it remains significantly underdiagnosed clinically. Surgical management of obstructive HCM has advanced extensively, particularly in understanding the mitral valve's contribution to left ventricular outflow tract obstruction (LVOTO). Historically, LVOTO was attributed mainly to septal hypertrophy and treated through isolated septal myectomy. However, contemporary insights highlight the importance of mitral leaflet elongation and abnormal papillary muscle dynamics in this pathology. Mitral leaflet shortening, either through horizontal plication or direct excision (ReLex), alongside the release of abnormal papillary muscle attachments, has emerged as a complementary strategy to standard septal myectomy. These combined approaches have demonstrated improved surgical outcomes, including reduced mitral regurgitation, alleviation of LVOTO, and excellent mid-term survival. This review synthesizes current evidence and clinical experiences, providing insights into mitral leaflet shortening's role and the comprehensive surgical strategies for managing obstructive HCM.

Supplementary information: The online version contains supplementary material available at 10.1007/s12055-025-02051-1.

Left ventricular outflow tract obstruction (LVOTO) commonly occurs in patients with hypertrophic cardiomyopathy (HCM). Management options include drugs-beta-blockers, disopyramide, and myosin inhibitors like mavacamten and aficamten. Septal reduction therapy should be considered for patients who remain symptomatic despite medical therapy. Surgical myectomy is considered the gold standard. However, alcohol septal ablation and surgical myectomy have good and comparable long-term outcomes. Surgical myectomy has a lower incidence of heart block and a lower residual gradient. Surgical myectomy may be preferred in the presence of intrinsic mitral valve disease, papillary muscle abnormalities, markedly thickened septum, multiple levels of obstruction, long length of mid-cavity obstruction, and absence of a suitable septal artery. Alcohol septal ablation should be preferred in individuals who are at high surgical risk. In most other patients, both procedures may be considered, and the choice should be based on available resources and patient preferences.