Υπερτροφική Αποφρακτική Μυοκαρδιοπάθεια Κατάλυση ή Μυεκτομή; Ματθαίος Σ. Παναγιώτου MD, FETCS Καρδιοχειρουργός Ιατρικό Κέντρο Αθηνών

Χαρακτηριστικά της HOCM Ασύμμετρη υπερτροφία του μεσοκοιλιακού Υπερτροφία κοιλιακού μυοκαρδίου Στενή αορτο-μιτροειδική γωνία Περίσσεια ιστού οπίσθιας γλωχίνας Παθολογική πρόσθια γλωχίνα SAM Ανώμαλη θέση θηλοειδών μυών

Surgical management Septal myotomy( Brock,Cleland,Migelow) Septal myectomy (Morrow) Carpentier integrated technique Mitral valve replacement (Cooley) RPR (Resection-Plication Release) Extended septal myectomy

Μυεκτομή κατά Morrow

Carpentier Εκτεταμένη Μυεκτομή μέσα από τον αριστερό κόλπο

Carpentier Περικαρδιακό εμβάλωμα στην πρόσθια γλωχίνα Μείωση του ύψους της οπίσθιας εάν είναι >2cm

Surgical Myectomy for HOCM Jan 1994 - Jan 2005 716 pts 323 isolated SM for HOCM Slightly evolved procedure over the study period extended myectomy (removal of muscle over both papillary muscles extending to both trigones)

Current Effectiveness and Risks of isolated Septal Myectomy for HOCM IVS thickness reduction (2.3±0.46 cm to 1.6± 0.37) Peak LVOT gradient fell from 68±43 mmhg to 17 ± 11 mmhg continued to fall 3 months postmyectomy SAM fell from 99% to 52% postop NYHA class improvement No hospital deaths New permanent pacemakers in 22 of the 280 pts without preop pacemakers 8 HOCM related reoperations after 30 days postmyectomy (Redo myectomy, MVR, Alfieri stich, AVR/MVR) Smedira N, et al. Current Effectiveness and Risks of isolated Septal Myectomy for HOCM. Ann Thorac Surg 2008; 85: 127-34

Risk of Septal Myectomy Low or zero mortality (4% 1995 to 0% 2008) New VSDs succesfully repaired : 2 Need for new AVR late after myectomy: Direct injury to the aortic cusps, Distabilization of the annulus by beginning the myectomy too close to the RC cusp Thick residual septum (if IVS 1.7 cm or greater) additional muscle resection Need for permanent pacemaker (3% if normal conduction preop, 77% if RBBB preop) Ann Thorac Surg 2008;85:127-34

HOCM and mitral valve morphology Degenerative: thin leaflets with excessive mobility Restrictive chordae: single or multiple secondary chordae redtricting anterior leaflet mobiliy and tending leaflet into LVOT Kaple RK, et al. Mitral valve abnormalities in HOCM: Echocardiographic features and surgical outcomes. Ann Thorac Surg 2008; 85: 1527-36

HOCM and mitral valve morphology Myxomatous with thickened redundant leaflets Restrictive leaflet: thickened leaflet often associated with annular calcification Kaple RK, et al. Mitral valve abnormalities in HOCM: Echocardiographic features and surgical outcomes. Ann Thorac Surg 2008; 85: 1527-36

HOCM and mitral valve morphology Papillary muscle most common variant: large antero-medial papillary muscle inserting directly into A1 segment Long leaflet: anterior leaflet > 2.5 cm posterior leaflet > 2.0 cm, one or both can be elongated. Kaple RK, et al. Mitral valve abnormalities in HOCM: Echocardiographic features and surgical outcomes. Ann Thorac Surg 2008; 85: 1527-36

HOCM και μιτροειδής βαλβίδα Σε 44-70% των ασθενών αυξημένη επιφάνεια των γλωχίνων Σε διάφορες χειρουργικές σειρές 11%-20% των ασθενών απαιτείται ταυτόχρονη επέμβαση στη μιτροειδή βαλβίδα Η ανεπάρκεια μιτροειδούς χωρίς SAM και η πρόσθια κατεύθυνση ενός jet είναι ισχυροί δείκτες οργανικής μιτροειδικής βλάβης

HOCM και μιτροειδής βαλβίδα Restricted leaflets : leaflet extension with glouteraldehyde treated pericardium. Elongated leaflets : Leaflet plication along the long axis. Annuloplasty: oversized incomplete band Edge to edge stich (Alfieri ) Chordal or papillary muscle resectionmobilization Mitral valve replacement (metallic or low profile bioprosthesis careful orientation of the struts)

Septal Ablation vs. Surgical Myectomy Septal myotomy-myectomy and trancoronary septal alcohol ablation in HOCM. A comparison of clinical, haemodynamic and exercise outcomes S. Firoozi, P.M. Elliot, W.J. McKenna et al. European Heart Journal 2002; 23: 1617-24 Similar reduction of peak gradient Similar improvements in NYHA class reduction Myectomy resulted in greater improvement: in peak oxygen consumption in work rate achieved

Septal Ablation vs. Surgical Myectomy Septal myotomy-myectomy and trancoronary septal alcohol ablation in HOCM. A comparison of clinical, haemodynamic and exercise outcomes S. Firoozi, P.M. Elliot, W.J. McKenna et al. European Heart Journal 2002; 23: 1617-24 Conclusion: superior effect of surgical myectomy on exercise test parameters

Septal Ablation vs. Surgical Myectomy Updated Meta-Analysis of Septal Alcohol Ablation Versus Myectomy for Hypertrophic Cardiomyopathy Shikhar Agarwal, Nicholas Smedira, Samir Kapadia et al. J Am Coll Cardiol 2010; 55: 823-34 No significant differences between SA and SM short and long term mortality post-intervention functional status improvement in NYHA class ventricular arrhythmia occurrence re-interventions performed post-procedure MR However ----

Septal Ablation vs. Surgical Myectomy Updated Meta-Analysis of Septal Alcohol Ablation Versus Myectomy for Hypertrophic Cardiomyopathy Shikhar Agarwal, Nicholas Smedira, Samir Kapadia et al. J Am Coll Cardiol 2010; 55: 823-34 SA was found to increase the risk of RBBB along with the need for permanent pacemaker implantation postprocedure There is a small yet significantly higher residual LVOTG among the SA group patients

Septal Ablation vs. Surgical Myectomy Updated Meta-Analysis of Septal Alcohol Ablation Versus Myectomy for Hypertrophic Cardiomyopathy Shikhar Agarwal, Nicholas Smedira, Samir Kapadia et al. J Am Coll Cardiol 2010; 55: 823-34 Conclusion: Although SM continues to be the gold-standard treatment for refractory HOCM, SA has emerged to be an attractive alternative

Advantages of PTSMA vs MYECTOMY Less invasive technique? Shorter hospital stay? 2% mortality. Pacemaker needs 0-40%, mean 21%. Frequently leads to RBBB Significant resting or provokable obstruction may remain in some pts

Advantages of PTSMA vs MYECTOMY Avoidance of cardiopulmonary bypass Shorter hospital stay? Shorter recovery time Less expence

Disadvantages of PTSMA Procedural mortality of PTSMA somewhat higher than for surgery in HOCM referral institutions Aproximately 20% might require repeated procedures Unresolved issue of PTSMA-intramyocardial scars as potential arrhytmogenic substrate Unsatisfactory reduction of LVOTG in younger pts with thick IVS

Advantages of SM More immediate and complete relief of resting and provoked obstruction and concomitant mitral regurgitation Smaller incidence of complete heart block Excellent long -term results( 20-30 years) No risk of coronary dissection or unwanted MI No evidence of long-term arrythmogenicity

Advantages of SM Ability to deal with concomitant problems: mid-ventricular obstruction Muscle bridges over the LAD CABG surgery Relief of the RVOTO Concurrent papillary muscle dysfunction Abnormal PM insertion MV abnormalities

Advantages of SM Can be performed in pts with septal anatomy unfavourable for PTSMA: Very small septal branches that cannot be cannulated A single large septal perforator (risk of massive septal infarct) Particularly thick septum

Septal Ablation vs. Surgical Myectomy Surgical myectomy continues to be the gold standard treatment for severely symptomatic,drug-refractory pts with obstructive HOCM Alcohol septal ablation has emerged to be an important alternative treatment for pts : at increased operative risk, without access to expert surgical centers patients who refuse operation after both options have been discussed

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