Subaortic stenosis associated with systolic anterior motion

Incidence of Reoperation After Surgical Procedure for Left Ventricular Outflow Tract Obstruction in Children and Young Adults

BACKGROUND

The common causes of subaortic left ventricular outflow tract obstruction (LVOTO) are hypertrophic cardiomyopathy (HCM) and membranous/tunnel subaortic stenosis (SAS). Reoperation after corrective surgery may be due to recurrent disease, associated congenital defects, or complications of the initial procedure. This study compares the late outcomes of young patients with HCM and SAS.

METHODS

We studied clinical, echocardiographic, and operative data of patients ≤21 years of age at the time of surgery for LVOTO between August 1963 and August 2018. We stratified patients into HCM (n = 152) and congenital SAS (n = 63) groups and compared survival and cumulative incidence of reoperation.

RESULTS

At initial repair, patients with HCM were older than patients with SAS (median [interquartile range] age, 15 [10-19] years vs 8 [5-13] years; P < .001), and patients with HCM were more symptomatic with dyspnea (P < .001), chest pain (P = .002), and presyncope/syncope (P = .005). Thirty-day mortality was 1.3% vs 0% for HCM and SAS groups. During a median follow-up of 13.1 years, survival was similar through the first 10 years; but during the second decade, patients with HCM had poorer survival (survival at 20 years, 80% vs 91% for patients with SAS; P = .007). Ten years after repair, reoperation for recurrent LVOTO was performed in 5% of patients with HCM vs 31% in those with SAS (P < .001).

CONCLUSIONS

In this surgical cohort, patients with HCM were more symptomatic preoperatively than those with SAS. Late survival of patients with SAS was superior to that of patients with HCM despite a greater need for reoperation.

Awareness of 'Systolic Anterior Motion' in Different Conditions

Perioperative echocardiography, especially transesophageal echocardiography, is of paramount importance in evaluating and managing refractory hypotension, a potential cause of which is systolic anterior motion (SAM) of anterior mitral leaflet. Dynamically moving anterior mitral valve leaflet towards the left ventricular outflow tract (LVOT) is described as SAM. Although SAM was initially observed in patients with hypertrophic cardiomyopathy, it can also be seen in patients with complex dynamic anatomy of the left ventricle. Interestingly, SAM may or may not give rise to clinically significant LVOT obstruction. Hence, it is of paramount importance for perioperative physician to know such ‘dynamic SAM’ which can potentially and significantly affect and alter perioperative management.

Echocardiography as a Predicting Method in Diagnosis, Evaluation and Assessment of Children with Subvalvar Aortic Stenosis

BACKGROUND:

Obstruction to the left ventricular outflow of the heart may be above the aortic valve (5%), at the valve (74%), or in the subvalvar region (23%). These anomalies represent 3 to 6% of all patients with congenital heart defects (CHD), and it occurs more often in males (male-female ratio of 4:1).

AIM:

The purpose of this study was to determine the sensitivity and specificity of transthoracic echocardiography in diagnosis of discrete subaortic membrane, to determine convenient time for surgical intervention, and for identifying involvement of the aortic valve by subaortic shelf.

MATERIAL AND METHODS:

A retrospective review of the medical records and echocardiograms of 18 patients [14 male (77%) and 4 female (23%)] with discrete subaortic membrane, aged 11 month to 12 years, with mean age of 5 years and 3 month, diagnosed at the Pediatric Clinic in Prishtina, during the period September, 1999 and December, 2010 were done.

RESULTS:

Four patients, in neonatal age were operated from critical coarctation of the aorta and, initial signs of congestive heart failure were presented. 2 of them were operated in Belgrade, Serbia and 2 in Lausanne, Switzerland.

CONCLUSION:

In all presented patients bicuspid aortic valve was noted, but none of them subaortic membrane was registered.