Characteristics and surgical outcomes of symptomatic patients with hypertrophic cardiomyopathy with abnormal papillary muscle morphology undergoing papillary muscle reorientation

Kwon, Deborah H.; Smedira, Nicholas G.; Thamilarasan, Maran; Lytle, Bruce W.; Lever, Harry; Desai, Milind Y.

doi:10.1016/j.jtcvs.2009.10.045

« Previous Next »The Journal of Thoracic and Cardiovascular Surgery
Volume 140, Issue 2 , Pages 317-324, August 2010

Characteristics and surgical outcomes of symptomatic patients with hypertrophic cardiomyopathy with abnormal papillary muscle morphology undergoing papillary muscle reorientation

Deborah H. Kwon, MD
- Tomsich Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
Nicholas G. Smedira, MD
- Department of Cardiothoracic Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
Maran Thamilarasan, MD
- Tomsich Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
Bruce W. Lytle, MD
- Department of Cardiothoracic Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
Harry Lever, MD
- Tomsich Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
Milind Y. Desai, MD
- Tomsich Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
- Address for reprints: Milind Y. Desai, MD, Tomsich Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Av, Cleveland, OH 44195.

Received 14 May 2009; received in revised form 3 August 2009; accepted 25 October 2009. published online 28 December 2009.

Objective

In patients with hypertrophic cardiomyopathy with bifid hypermobile papillary muscles and a dynamic left ventricular outflow tract gradient, we performed surgical papillary muscle reorientation, fixing the mobile papillary muscle to the posterior left ventricle to reduce mobility. We report the outcomes of patients with hypertrophic cardiomyopathy undergoing surgical papillary muscle reorientation versus those of patients undergoing standard surgical procedures.

Methods

We studied 204 consecutive patients with hypertrophic cardiomyopathy undergoing surgical intervention (after consensus decision) for symptomatic left ventricular outflow tract gradient. Preoperative and postoperative maximal (resting/provocable) left ventricular outflow tract gradients were recorded by using echocardiographic analysis.

Results

The population was divided into 3 groups: (1) isolated myectomy (n = 143; age, 54 ± 14 years; 48% men), (2) myectomy plus mitral valve repair/replacement (n = 39; age, 54 ± 13 years; 54% men), and (3) papillary muscle reorientation with or without myectomy (n = 22; age, 50 ± 14 years; 59% men). The mean preoperative (103 ± 32, 103 ± 32, and 114 ± 36 mm Hg; P = .3) and predischarge (15 ± 18, 14 ± 14, and 16 ± 21 mm Hg; P = .9) maximal left ventricular outflow tract gradients were similar. There were no deaths either in the hospital or at 30 days. At a median follow-up of 166 days (interquartile range, 74–343 days), 21 of 22 patients in group 3 were asymptomatic. One patient in group 3 had a symptomatic left ventricular outflow tract gradient (87 mm Hg) requiring mitral valve replacement.

Conclusions

In patients with hypertrophic cardiomyopathy with bifid hypermobile papillary muscles (even with a basal septal thickness <1.5 cm), papillary muscle reorientation reduces the symptomatic left ventricular outflow tract gradient. Long-term outcomes need to be ascertained.

CTSNet classification: 17.1, 35.4, 36.2, 36.3

Abbreviations and Acronyms: CMR, cardiac magnetic resonance, HCM, hypertrophic cardiomyopathy, LVOT, left ventricular outflow tract, SAM, systolic anterior motion