Sandhya K. Balaram

Treatment of Obstructive Hypertrophic Cardiomyopathy Symptoms and Gradient Resistant to First-Line Therapy With β-Blockade or Verapamil

Background—There is controversy about preferred methods to relieve obstruction in hypertrophic cardiomyopathy patients still symptomatic after &bgr;-blockade or verapamil. Methods and Results—Of 737 patients prospectively registered at our institution, 299 (41%) required further therapy for obstruction for limiting symptoms, rest gradient 61±45, provoked gradient 115±49 mmu2009Hg, and followed up for 4.8 years. Disopyramide was added in 221 (74%) patients and pharmacological control of symptoms was achieved in 141 (64%) patients. Overall, 138 (46%) patients had surgical relief of obstruction (91% myectomy) and 6 (2%) alcohol septal ablation. At follow-up, resting gradients in the 299 patients had decreased from 61±44 to 10±25 mmu2009Hg (P<0.0001); New York Heart Association class decreased from 2.7±0.7 to 1.8±0.5 (P<0.0001). Kaplan–Meier survival at 10 years in the 299 advanced-care patients was 88% and did not differ from nonobstructed patients (P=0.28). Only 1 patient had sudden death, a low annual rate of 0.06%/y. Kaplan–Meier survival at 10 years in the advanced-care patients did not differ from that expected in a matched cohort of the US population (P=0.90). Conclusions—Patients with obstruction and symptoms resistant to initial pharmacological therapy with &bgr;-blockade or verapamil may realize meaningful symptom relief and low mortality through stepped management, adding disopyramide in appropriately selected patients, and when needed, by surgical myectomy.

Resection-Plication-Release for Hypertrophic Cardiomyopathy: Clinical and Echocardiographic Follow-Up

BACKGROUNDnAbnormal positioning and size of the mitral valve contribute to the systolic anterior motion and mitral-septal contact that are important components of obstructive hypertrophic cardiomyopathy (HCM). The RPR repair (resection of the septum, plication of the anterior leaflet, and release of papillary muscle attachments) addresses all aspects of this complex pathology. This study reports outcomes regarding effectiveness of the RPR repair.nnnMETHODSnFifty consecutive unselected patients (average age, 55.8 years) undergoing RPR repair for obstructive HCM from 1997 to 2007 were studied. Each patient underwent preoperative and postoperative transthoracic echocardiograms to document gradient, ejection fraction, degree of mitral regurgitation, and systolic anterior motion. Intraoperative transesophageal echocardiogram was used to guide all surgical repairs. Clinical follow-up included patient interviews to determine New York Heart Association (NYHA) status.nnnRESULTSnConcomitant operations were performed in 25 patients (50%). Postoperative mortality was 0%. Average mean left ventricular outflow tract gradients decreased from 134 +/- 40 to 2.8 +/- 8.0. Mitral regurgitation improved from a mean of 2.5 to 0.1 (p < 0.001). Average length of stay was 6.9 +/- 2.7 days. NYHA class improved from 3.0 +/- 0.6 to 1.2 +/- 0.5. Follow-up was 100%, with a mean of 2.5 +/- 1.8 years. Average mitral regurgitation at follow-up was 0.9, with no residual systolic anterior motion.nnnCONCLUSIONSnThe RPR repair is safe and effective for symptomatic obstructive HCM. Our data support repair of the mitral valve that results in good intermediate outcomes with respect to gradient, mitral regurgitation, and clinical status.

Long-Term Outcome of Leads and Patients Following Robotic Epicardial Left Ventricular Lead Placement for Cardiac Resynchronization Therapy

Introduction: In cardiac resynchronization therapy (CRT), positive clinical response and reverse remodeling have been reported using robotically assisted left ventricular (LV) epicardial lead placement. However, the long‐term performance of epicardial leads and long‐term outcome of patients who undergo CRT via robotic assistance are unknown. In addition, since the LV lead placement is more invasive than a transvenous procedure, it is important to identify patients at higher risk of complications.

Cell adhesion molecules and insulin-like growth factor-1 in vascular disease☆☆☆★

PURPOSEnRecent advances in the understanding of the biologic mechanisms of vascular diseases suggest that multifactorial stimulation of the endothelial cell and its subsequent adhesion to leukocytes is a prerequisite to the formation of atherosclerotic and restenotic lesions. As leukocyte-endothelial cell interaction is coordinated by a variety of cell adhesion molecules (CAMs), we hypothesized that the expression of certain CAMs is up-regulated in the vasculature of patients who have peripheral vascular disease. In addition, we proposed that insulin-like growth factor-1 (IGF-1) increases monocyte-endothelial adhesion by means of upregulation of these CAMs.nnnMETHODSnUsing immunohistochemical techniques, the expression of intracellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), E-selectin, and P-selectin was examined in human vascular disease specimens. Normal aortas obtained from the organ retrieval system were studied as control specimens. Adhesion studies between human umbilical vein endothelial cells (HUVECs) incubated with IGF-1 and purified human blood monocytes labeled with 51chromium were completed. Western blotting and flow cytometry were performed to show CAM expression on IGF-1-treated HUVECs.nnnRESULTSnOf the CAMs, ICAM-1, P-selectin, and E-selectin were distinctly increased in diseased specimens when compared with control specimens (p < 0.05). Adhesion studies showed an increase in monocyte-endothelial cell adhesion of as much as 40% to 45% (p < 0.01) over baseline, with peak adherence occurring 4 hours after treatment with IGF-1. IGF-1 increased adherence in a dose- and time-dependent manner. The threshold concentration of IGF-1 that induced increased adhesion was 20 ng/ml, with a maximum effect occurring at 150 ng/ml. This increased adhesion was attenuated by pretreatment with IGF-I receptor antibody, as well as with genistein and herbimycin-A, which are potent and selective tyrosine kinase inhibitors. Increased adhesion correlated with an increase in the expression of CAMs on the surface of the HUVECs. An additive effect on adhesion was observed between IGF-1 and tumor necrosis factor-alpha (TNF-alpha) and endothelin-1 (ET-1). Finally, immunohistochemical analysis of human vascular disease specimens revealed an increased expression of IGF-1 receptors as compared with control specimens (p < 0.05).nnnCONCLUSIONSnThese results suggest that IGF-1 may be important in the pathogenesis of peripheral vascular disease by increasing endothelial cell-monocyte adhesion by means of an increase in the expression of ICAM-1 and VCAM-1.

The role of gender in coronary surgery

Gender-based outcome data in coronary artery bypass graft (CABG) surgery has been the focus of extensive research over the last two decades. Increased awareness in gender-specific health and advancements in scientific research have produced evidence that risk profiles vary between genders and alter operative mortality after CABG. Some of these data remain controversial, emphasizing the complexity of gender as an independent variable and questioning processes of care that are intimately associated with outcome. Although patient gender cannot be changed, understanding gender-specific risks and modifying surgical practice may be helpful in improving patient outcomes.

Surgical Myectomy for Hypertrophic Cardiomyopathy in the 21st Century, the Evolution of the “RPR” Repair: Resection, Plication, and Release

Since its first description in the 1950s, the pathophysiology of hypertrophic cardiomyopathy has been clarified by advanced echocardiographic technologies. Improved pharmacotherapy now successfully treats most afflicted individuals. Along with these advances, surgical management has also evolved, as the role of the mitral valve and the subvalvular structures in causing obstruction has been identified. Over the last 2 decades, a variety of options to surgically manage the complex patient with obstruction have been described. Successful surgical management is dependent on the complete evaluation of the causes of obstruction in the specific individual, as the heterogeneity of the anatomy may confound the direction of therapy. Mitral valve replacement may no longer be necessary in individuals who have a relatively thin septum and instead obstruct from an elongated mitral anterior leaflet or the presence of accessory papillary muscles and chords. Techniques for mitral valve plication have been successfully used with mid- to long-term success. A systematic strategy for the evaluation of obstruction in hypertrophic cardiomyopathy and the various surgical options are summarized in a procedure termed RPR for resection (extended myectomy), plication (mitral valve shortening), and release (papillary muscle manipulation).

Does Surgical Relief of Obstruction Improve Prognosis for Hypertrophic Cardiomyopathy

Unique genetic characteristics of hypertrophic cardiomyopathy (HCM), including heterogeneity and incomplete penetrance, have made making predictions about prognosis complex. We reviewed data from septal myectomy results as published from 1980 to 2011, most of which come from specialized tertiary care centers. We also performed a retrospective review of 132 consecutive patients who underwent HCM surgery at our institution. At a mean follow-up of 4.2 ± 3.2 years (range, 3 days to 14.2 years), there were no deaths within 30 days of surgery for our cohort. Over the course of 15 years, 2 deaths occurred in older patients, both of whom had surgery for HCM along with additional cardiac procedures. Age, the presence of comorbidities, and concomitant cardiac procedures were not statistically significant risk factors for mortality. Overall survival at 1, 5, and 10 years was excellent: 99%, 99%, and 92%, respectively. Surgical myectomy has been proven to be a safe and effective procedure for symptomatic obstructive HCM, and it confers excellent survival similar to that of the healthy population.

Robotic-assisted resection of an intrapericardial bronchogenic cyst

The advantages of robotic-assisted surgery have been well described and include improved three-dimensional visualization, increased precision of dissection, and the absence of tremor. These characteristics are particularly useful in the mediastinal dissection of major vascular structures. We present a case of an intrapericardial bronchogenic cyst resected with robotic assistance. Bronchogenic cysts are congenital thoracic anomalies that typically occur in the mediastinum or lung parenchyma, and occasionally within the pericardium. Historically a sternotomy was required for complete resection, although a thoracoscopic approach has now been widely adopted. We report the resection of an intrapericardial bronchogenic cyst utilizing a robotic-assisted thoracoscopic approach and a review of the literature regarding the incidence, diagnosis, and management of this rare condition.

The Role of Sex and Gender in Cardiothoracic Surgery

Publisher Summary nExamination of factors that may contribute to gender disparities among patients with cardiac disease has been based on a large volume of both prospective and retrospectively collected surgical data from local and national registries. Prospective, randomized controlled trials have clearly proven that coronary artery bypass surgery (CABG) is a safe and effective method of treatment of coronary artery atherosclerosis. Surgical outcomes for this specific procedure have been intensely studied, categorized, and documented. As a result, a number of trends have been documented over the past several years. For example, a review of early coronary revascularization studies shows that fewer numbers of women underwent CABG; typically <30% of bypass patients were women. This was followed by a consistent finding of increased postoperative mortality when compared with men, suggesting that women had a physiologic predisposition to complications and poor outcome after surgical intervention. The reasons for these outcomes in coronary surgery in women became widely studied in the early 1990s, as the importance of sex differences became more widely recognized. Sex differences are based on unique biological and hormonal factors in the etiology of the disease that lead to differences in risk factors, survival, and prognosis. Risk factors have been shown to play a crucial role for both men and women and their importance has been paramount in determining why sex differences exist in the outcomes of cardiothoracic surgery.