Characteristics and surgical outcomes of symptomatic patients with hypertrophic cardiomyopathy with abnormal papillary muscle morphology undergoing papillary muscle reorientation
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.
Tomsich Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
Department of Cardiothoracic Surgery, 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.
ABSTRACT