Anita Nguyen

Does septal thickness influence outcome of myectomy for hypertrophic obstructive cardiomyopathy

OBJECTIVES Patients with hypertrophic obstructive cardiomyopathy and basal septal thickness <18 mm are often considered unsuitable candidates for myectomy. Mitral valve (MV) replacement is frequently performed instead. We aimed to determine whether septal thickness affects outcomes and adequacy of myectomy. METHODS Clinical and echocardiographic data were reviewed for 1486 consecutive adult patients with hypertrophic obstructive cardiomyopathy who underwent transaortic septal myectomy from January 2005 through December 2014. Comparisons between patients, grouped by septal thickness (<18 mm, n = 369; 18-21 mm, n = 612 and >21 mm, n = 505), were performed with the Kruskal-Wallis and the Pearson χ2 tests and semiparametric analysis of covariance. RESULTS Median group ages were 57, 57 and 54 years (P = 0.007); men comprised 50.4%, 56.7% and 62.0%, respectively (P = 0.003). Intrinsic MV disease was present in 5.9%, 5.2% and 4.6%, respectively (P = 0.80). All patients underwent transaortic septal myectomy. Additional mitral procedures were performed in 7.6%, 7.8% and 8.1%, respectively (P = 0.90). Reasons for MV surgery included intrinsic MV disease (66.7%), residual mitral regurgitation (30.8%) and residual gradient (2.6%). All groups had postoperative gradient relief (median reduction: 51, 54 and 50 mmHg; P = 0.11). Ventricular septal defect occurred in 4 patients (0.3%), and risk did not differ by group (P = 0.24). CONCLUSIONS Adequate relief of left ventricular outflow tract obstruction can be achieved via transaortic septal myectomy without concomitant MV procedures when septal thickness is < 18 mm, and the risk of ventricular septal defect is minimal. Concomitant MV repair/replacement should be reserved for patients with intrinsic MV disease or inadequate relief of mitral regurgitation/left ventricular outflow tract obstruction following adequate extended septal myectomy.

Early Outcomes of Repair of Left Ventricular Apical Aneurysms in Patients With Hypertrophic Cardiomyopathy

Apical aneurysms are outpouchings at the apex of the left ventricle, described as discrete, thin-walled dyskinetic or akinetic segments of the most distal portion of the ventricular chamber (Figure). Apical aneurysms are relatively rare in hypertrophic cardiomyopathy (HCM) with subaortic obstruction, but have been reported in 15% to 30% of patients with apical HCM (ApHCM) or midventricular obstruction (MVO). Aneurysms are associated with a wide spectrum of adverse outcomes including sudden cardiac death, ventricular arrhythmias, heart failure, and mortality.1,2 In a cohort of 93 patients with HCM and apical aneurysms, Rowin and colleagues1 reported a combined adverse event rate (cardiac-related mortality, heart failure, malignant arrhythmias requiring intervention, and thromboembolic events) of 6.4% per year. Furthermore, in a recent review, Jan et al2 reported overall mortality in patients with apical aneurysms of 9% to 10.5% over a mean/median follow-up of 2 to 6.5 years. Figure. Apical aneurysms in hypertrophic cardiomyopathy. A , Apical aneurysm of the left ventricle and midventricular obstruction. B , Dashed lines depict site of aneurysm resection and myectomy. C , Enlarged ventricular cavity, and resolution of midventricular obstruction and aneurysm following surgery. D , Preoperative transthoracic …

Electrical Storms in Patients with Apical Aneurysms and Hypertrophic Cardiomyopathy with Midventricular Obstruction - A Case Series

From the Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn. This work was supported by the Paul and Ruby Tsai Family. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication March 14, 2017; revisions received May 5, 2017; accepted for publication June 1, 2017; available ahead of print June 29, 2017. Address for reprints: Hartzell V. Schaff, MD, Department of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (E-mail: schaff@mayo.edu). J Thorac Cardiovasc Surg 2017;154:e101-3 0022-5223/

Mycobacterium chimaera: The ethical duty to disclose the minimal risk of infection to exposed patients

36.00 Copyright 2017 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2017.06.002

Surgical myectomy versus alcohol septal ablation for obstructive hypertrophic cardiomyopathy: A propensity score–matched cohort

From the Department of Cardiovascular Surgery and Division of Hematology, Mayo Clinic, Rochester, Minn. This work was supported by the Paul and Ruby Tsai Family. Disclosures: Authors have nothing to disclose with regard to commercial support. Anita Nguyen is a postdoctoral research fellow in the Department of Cardiovascular Surgery at Mayo Clinic. C. Christopher Hook is Associate Professor of Medicine at Mayo Clinic College of Medicine and Science and Consultant with the Division of Hematology, was founder of Mayo Clinic Ethics Consultation Services in Jacksonville, Florida, and Rochester, Minnesota, and the Mayo Clinical Ethics Council. He currently serves as the chair of Ethics Education in theMayo Enterprise Office of Ethics. Dr Hookwas a cardiac surgery patient in June 2016 and is a recipient of the M chimaera notification letter discussed in this article. Joseph A. Dearani is a Professor of Surgery at Mayo Clinic College of Medicine and Science and Chair of the Department of Cardiovascular Surgery at Mayo Clinic. He has led Mayo Clinic’s institutional response following the discovery ofM chimaera in certain heater-cooler units used during cardiac surgery. Hartzell V. Schaff is a Consultant in the Department of Cardiovascular Surgery and Stuart W. Harrington Professor of Surgery at Mayo Clinic. Received for publication Dec 15, 2016; revisions received Jan 24, 2017; accepted for publication Feb 10, 2017; available ahead of print March 25, 2016. Address for reprints: Hartzell V. Schaff, MD, Department of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (E-mail: schaff@mayo.edu). J Thorac Cardiovasc Surg 2017;153:1422-4 0022-5223/

Myectomy and Left Atrial-to-Left Ventricular Conduit for Severe Calcific Mitral Stenosis and Hypertrophic Cardiomyopathy

36.00 Copyright 2017 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2017.02.020 Anita Nguyen, MBBS

Response by Nguyen et al to Letter Regarding Article, “Early Outcomes of Repair of Left Ventricular Apical Aneurysms in Patients with Hypertrophic Cardiomyopathy”

Objectives: In patients with hypertrophic cardiomyopathy, obstruction of the left ventricular outflow tract can be relieved by surgical septal myectomy or alcohol septal ablation, but uncertainty remains regarding long‐term results and comparative effectiveness of alcohol septal ablation. This study aims to compare short‐ and long‐term outcomes of the 2 procedures. Methods: Between December 1998 and September 2016, 2407 patients underwent septal myectomy and 211 patients underwent alcohol septal ablation at our institution. After 2:1 propensity score matching, the study cohort included 334 patients who underwent myectomy and 167 patients who underwent alcohol septal ablation. Results: Median (interquartile range) ages of patients in the myectomy and alcohol septal ablation groups were 65 (58‐71) years and 64 (56‐73) years (P = .9), respectively. After intervention, median resting left ventricular outflow tract gradient at predischarge transthoracic echocardiography was 0 (0‐10) mm Hg in the myectomy group (n = 288) and 21 (10‐60) mm Hg in the alcohol septal ablation group (n = 63) (P < .001, tested at baseline gradients of 30 and 50 mm Hg). There were no differences in survival between the 2 groups (risk of death for alcohol septal ablation vs myectomy, hazard ratio, 1.5; 95% confidence interval, 0.9‐2.6; P = .1). Survival of patients undergoing septal myectomy was better than that of an age‐, sex‐, and race‐matched US population (82% vs 75% at 12 years, P = .01). Reintervention for left ventricular outflow tract obstruction was more likely to occur in patients who received alcohol septal ablation (hazard ratio, 33.3; 95% confidence interval, 4.4‐250.6; P < .001). Conclusions: There were no differences in survival of patients undergoing myectomy or alcohol septal ablation, but freedom from reintervention and early and late reduction of left ventricular outflow tract gradient are superior in patients undergoing septal myectomy.

The First Operation for Apical Hypertrophic Cardiomyopathy—Dr Dwight McGoon, 1972

Severe calcific mitral valve stenosis can rarely occur concomitantly with obstructive hypertrophic cardiomyopathy. In these patients, surgical decalcification of the stenotic mitral valve followed by mitral valve replacement carries substantial operative risk and may result in paravalvular leakage, atrioventricular groove disruption, and excessive bleeding. We report two cases of obstructive hypertrophic cardiomyopathy with severe calcific mitral valve stenosis successfully treated with concomitant transaortic septal myectomy and bypass of the stenotic mitral valve with the use of a valved left atrial-to-left ventricular conduit.

Surgical treatment for hypertrophic cardiomyopathy: a historical perspective

We thank Dr Madias for his comments regarding our recently published research letter.1 Certainly, further studies on apical aneurysms are needed, and comparisons between medically and surgically managed patients would provide valuable information for clinicians. Unfortunately, we do not have a cohort of medically managed patients who are as symptomatic as those who were treated surgically. A previous study from our institution described 29 patients with hypertrophic …

The Brockenbrough-Braunwald-Morrow sign

The first operation for apical hypertrophic cardiomyopathy (ApHCM) was performed on September 7, 1972 by Dr Dwight McGoon at Mayo Clinic on a 16-year-old boy who was thought to have a cardiac neoplasm.