1
|
Haq IU, Shabtaie SA, Tan NY, Lachman N, Asirvatham SJ. Anatomy of the Ventricular Outflow Tracts: An Electrophysiology Perspective. Clin Anat 2024; 37:43-53. [PMID: 37337379 DOI: 10.1002/ca.24083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 06/06/2023] [Accepted: 06/08/2023] [Indexed: 06/21/2023]
Abstract
Outflow tract ventricular arrhythmias are the most common type of idiopathic ventricular arrhythmia. A systematic understanding of the outflow tract anatomy improves procedural efficacy and enables electrophysiologists to anticipate and prevent complications. This review emphasizes the three-dimensional spatial relationships between the ventricular outflow tracts using seven anatomical principles. In turn, each principle is elaborated on from a clinical perspective relevant for the practicing electrophysiologist. The developmental anatomy of the outflow tracts is also discussed and reinforced with a clinical case.
Collapse
Affiliation(s)
- Ikram U Haq
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Samuel A Shabtaie
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicholas Y Tan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nirusha Lachman
- Department of Anatomy, Mayo Clinic, Rochester, Minnesota, USA
| | - Samuel J Asirvatham
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Department of Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
2
|
Does a standard myectomy exist for obstructive hypertrophic cardiomyopathy? From the Morrow variations to precision surgery. Int J Cardiol 2023; 371:278-286. [PMID: 36130619 DOI: 10.1016/j.ijcard.2022.09.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 08/23/2022] [Accepted: 09/15/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The purpose of this work is to revisit the history of surgical treatment for obstructive hypertrophic cardiomyopathy (oHCM) over the last 60 years, in the light of advancing knowledge of the pathophysiology of obstruction. METHODS In this narrative review the contribution of the different surgical approaches to the field will be assessed in our personal experience in Florence. RESULTS Septal myectomy is the treatment of choice in patients with obstructive hypertrophic cardiomyopathy who remain symptomatic despite optimal medical treatment. Over the decades, numerous "theme variations" of the Morrow operation have been proposed, each of them targeting a specific pathophysiological determinant of left ventricular outflow tract obstruction. CONCLUSIONS Precision surgery in oHCM patients today depends on the ability of the surgeon to combine and master these variations, with the bird's eye view allowed by climbing on the shoulders of giants.
Collapse
|
3
|
Emerging Medical Treatment for Hypertrophic Cardiomyopathy. J Clin Med 2021; 10:jcm10050951. [PMID: 33804412 PMCID: PMC7957690 DOI: 10.3390/jcm10050951] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 02/18/2021] [Accepted: 02/19/2021] [Indexed: 02/06/2023] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is a common myocardial disease characterized by otherwise unexplained left ventricular hypertrophy. The main cause of disabling symptoms in patients with HCM is left ventricular outflow tract (LVOT) obstruction. This phenomenon is multifactorial, determined both by anatomical and functional abnormalities: myocardial hypercontractility is believed to represent one of its major determinants. The anatomical anomalies are targeted by surgical interventions, whereas attenuating hypercontractility is the objective of old and new drugs including the novel class of allosteric myosin inhibitors. This review summarizes the current treatment modalities and discusses the emerging therapeutical opportunities focusing on the recently developed cardiac myosin ATPase inhibitors Mavacamten and CK-274. Novel surgical and interventional approaches are also discussed.
Collapse
|
4
|
Abstract
Septal myectomy is currently the gold standard treatment for symptomatic patients with hypertrophic cardiomyopathy. The procedure needs to be tailored and performed in a personalized fashion, taking into consideration the anatomical spectrum of this disease. The procedure needs to address the various components that contribute to the clinical and pathological picture of this disease including, the fibrous trigones, accessory tissues, papillary muscles, mitral valve and myocardial bridges. The operation can be performed with very low mortality and morbidity in high-volume experienced centers with predictable excellent short and long-term outcomes. There is a need for broadening the experience of this procedure to the rest of the world and for future development of new enhanced precision imaging and surgical tools.
Collapse
Affiliation(s)
- Hamood N Al Kindi
- Aswan Heart center, Aswan Governate, Egypt.,Department of Cardiothoracic Surgery, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | - Magdi H Yacoub
- Aswan Heart center, Aswan Governate, Egypt.,Department of Cardiac Surgery, Royal Brompton and Harefield NHS Trust, London, UK
| |
Collapse
|
5
|
Yacoub MH, Afifi A, Saad H, Aguib H, ElGuindy A. Current state of the art and future of myectomy. Ann Cardiothorac Surg 2017; 6:307-317. [PMID: 28944171 DOI: 10.21037/acs.2017.06.04] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Surgical relief of left ventricular outflow tract obstruction (LVOTO) in hypertrophic cardiomyopathy (HCM) requires more than septal myectomy. The procedure is currently the gold standard for all symptomatic HCM patients except those with comorbidities. The operation requires an individualized approach to restore the sophisticated functions of the left ventricular outflow tract (LVOT) without injury to the surrounding vital structures. The procedure should be tailored to deal with all the varied components of the obstruction including fibrous trigones, accessory tissues, and papillary muscle fusion. Preoperative multimodality imaging and numerical modeling combined with intraoperative transesophageal echocardiography (TEE) are essential to define existing anomalies as well as assess the adequacy of the repair. The mitral valve can be conserved in virtually all patients. The operation can be conducted with very low mortality and morbidity with predictable good outcomes both in the short and long term. Nevertheless, surgical relief of LVOTO is still grossly underused.
Collapse
Affiliation(s)
- Magdi H Yacoub
- National Heart and Lung Institute, Imperial College London, London, UK.,Aswan Heart Centre, Aswan Governorate, Egypt
| | - Ahmed Afifi
- Aswan Heart Centre, Aswan Governorate, Egypt
| | - Hesham Saad
- Aswan Heart Centre, Aswan Governorate, Egypt
| | - Heba Aguib
- National Heart and Lung Institute, Imperial College London, London, UK.,Aswan Heart Centre, Aswan Governorate, Egypt
| | - Ahmed ElGuindy
- National Heart and Lung Institute, Imperial College London, London, UK.,Aswan Heart Centre, Aswan Governorate, Egypt
| |
Collapse
|
6
|
Du GQ, Li HR, Xue JY, Chen S, Du P, Wu Y, Tian JW. Wave Intensity Analysis Can Identify Eccentric Cardiac Hypertrophy in Hypertensive Patients With Varied Left Ventricular Configurations. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:2019-2027. [PMID: 26432824 DOI: 10.7863/ultra.14.12007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 02/11/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES The primary aim of this study was to determine whether wave intensity can discriminate cases of eccentric hypertrophy in patients with essential hypertension who have varied left ventricular configurations. METHODS A total of 155 hypertensive patients with different ventricular configurations (27 normal configuration, 42 concentric remodeling, 62 concentric hypertrophy, and 24 eccentric hypertrophy) were recruited. We performed a noninvasive wave intensity analysis of the common carotid artery and conventional echocardiography. Blood pressure and flow velocity were measured in the right carotid artery of all patients. RESULTS The left ventricular ejection fraction (LVEF) in the eccentric hypertrophy group was significantly lower than the values in the other groups (P < .05). The R-W1 interval/W1-W2 interval ratio (where W1 indicates the first positive peak and W2 the second positive peak) in the eccentric hypertrophy group was much higher than the values in the other groups (P < .05). However, there were no significant differences in W1, W2, and negative area among these groups. Pearson correlation analysis showed that R-W1/W1-W2, R-W1, and W1-W2were correlated with the LVEF, whereas there was no correlation between W1, W2, negative area, and the reflection coefficient with the LVEF. CONCLUSIONS We propose that by using the R-W1/W1-W2 ratio, wave intensity analysis can identify hypertensive patients with eccentric hypertrophy without the need for echocardiography.
Collapse
Affiliation(s)
- Guo-Qing Du
- Department of Ultrasound, Second Affiliated Hospital of Harbin Medical University, Harbin, China (G.-Q.D., H.-R.L., S.C., P.D., Y.W., J.-W.T.); and Department of Cardiology, First Affiliated Hospital of Harbin Medical University, Harbin, China (J.-Y.X.)
| | - Hai-Ru Li
- Department of Ultrasound, Second Affiliated Hospital of Harbin Medical University, Harbin, China (G.-Q.D., H.-R.L., S.C., P.D., Y.W., J.-W.T.); and Department of Cardiology, First Affiliated Hospital of Harbin Medical University, Harbin, China (J.-Y.X.)
| | - Jing-Yi Xue
- Department of Ultrasound, Second Affiliated Hospital of Harbin Medical University, Harbin, China (G.-Q.D., H.-R.L., S.C., P.D., Y.W., J.-W.T.); and Department of Cardiology, First Affiliated Hospital of Harbin Medical University, Harbin, China (J.-Y.X.)
| | - Shuang Chen
- Department of Ultrasound, Second Affiliated Hospital of Harbin Medical University, Harbin, China (G.-Q.D., H.-R.L., S.C., P.D., Y.W., J.-W.T.); and Department of Cardiology, First Affiliated Hospital of Harbin Medical University, Harbin, China (J.-Y.X.)
| | - Pei Du
- Department of Ultrasound, Second Affiliated Hospital of Harbin Medical University, Harbin, China (G.-Q.D., H.-R.L., S.C., P.D., Y.W., J.-W.T.); and Department of Cardiology, First Affiliated Hospital of Harbin Medical University, Harbin, China (J.-Y.X.)
| | - Yan Wu
- Department of Ultrasound, Second Affiliated Hospital of Harbin Medical University, Harbin, China (G.-Q.D., H.-R.L., S.C., P.D., Y.W., J.-W.T.); and Department of Cardiology, First Affiliated Hospital of Harbin Medical University, Harbin, China (J.-Y.X.)
| | - Jia-Wei Tian
- Department of Ultrasound, Second Affiliated Hospital of Harbin Medical University, Harbin, China (G.-Q.D., H.-R.L., S.C., P.D., Y.W., J.-W.T.); and Department of Cardiology, First Affiliated Hospital of Harbin Medical University, Harbin, China (J.-Y.X.)
| |
Collapse
|
7
|
El-Hamamsy I, Lekadir K, Olivotto I, El Guindy A, Merrifield R, Rega L, Yang G, Cecchi F, Yacoub MH. Pattern and degree of left ventricular remodeling following a tailored surgical approach for hypertrophic obstructive cardiomyopathy. Glob Cardiol Sci Pract 2012; 2012:9. [PMID: 25610840 PMCID: PMC4239823 DOI: 10.5339/gcsp.2012.9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Accepted: 05/30/2012] [Indexed: 01/20/2023] Open
Abstract
Background The role of a tailored surgical approach for hypertrophic cardiomyopathy (HCM) on regional ventricular remodelling remains unknown. The aims of this study were to evaluate the pattern, extent and functional impact of regional ventricular remodelling after a tailored surgical approach. Methods From 2005 to 2008, 44 patients with obstructive HCM underwent tailored surgical intervention. Of those, 14 were ineligible for cardiac magnetic resonance (CMR) studies. From the remainder, 14 unselected patients (42±12 years) underwent pre- and post-operative CMR studies at a median 12 months post-operatively (range 4–37 months). Regional changes in left ventricular (LV) thickness as well as global LV function following surgery were assessed using CMR Tools (London, UK). Results Pre-operative mean echocardiographic septal thickness was 21±4 mm and mean LV outflow gradient was 69±32 mmHg. Following surgery, there was a significant degree of regional regression of LV thickness in all segments of the LV, ranging from 16% in the antero-lateral midventricular segment to 41% in the anterior basal segment. Wall thickening was significantly increased in basal segments but showed no significant change in the midventricular or apical segments. Globally, mean indexed LV mass decreased significantly after surgery (120±29g/m2 versus 154±36g/m2; p<0.001). There was a trend for increased indexed LV end-diastolic volume (70±13 mL versus 65±11 mL; p=0.16) with a normalization of LV ejection fraction (68±7% versus 75±9%; p<0.01). Conclusion Following a tailored surgical relief of outflow obstruction for HCM, there is a marked regional reverse LV remodelling. These changes could have a significant impact on overall ventricular dynamics and function.
Collapse
Affiliation(s)
- Ismail El-Hamamsy
- Department of Cardiac Surgery, Montreal Heart Institute, Universite de Montreal, Montreal, Canada ; Harefield Heart Science Center, National Heart and Lung Institute, Imperial College London, UK
| | | | - Iacopo Olivotto
- Department of Cardiology, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | - Ahmed El Guindy
- Harefield Heart Science Center, National Heart and Lung Institute, Imperial College London, UK
| | | | - Luigi Rega
- Department of Radiology, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | | | - Franco Cecchi
- Department of Cardiology, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | - Magdi H Yacoub
- Harefield Heart Science Center, National Heart and Lung Institute, Imperial College London, UK
| |
Collapse
|
8
|
Biagini E, Lorenzini M, Olivotto I, Rocchi G, Lovato L, Lai F, Rosmini S, Pazzi C, Pasquale F, Reggiani MLB, Fattori R, Rapezzi C. Effects of myocardial fibrosis assessed by MRI on dynamic left ventricular outflow tract obstruction in patients with hypertrophic cardiomyopathy: a retrospective database analysis. BMJ Open 2012; 2:bmjopen-2012-001267. [PMID: 23065447 PMCID: PMC3488754 DOI: 10.1136/bmjopen-2012-001267] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND While implications of myocardial fibrosis on left ventricular (LV) function at rest have been studied in hypertrophic cardiomyopathy (HCM), the pathophysiological consequences on dynamic LV outflow tract (LVOT) gradient have so far not been investigated in detail. OBJECTIVE To evaluate the influence of myocardial fibrosis, detected by MRI as late-gadolinium enhancement (LGE), on LVOT gradient in HCM. DESIGN Retrospective database analysis. SETTING A single Italian cardiomyopathies referral centre. PATIENTS Seventy-six HCM patients with normal ejection fraction at rest. INTERVENTIONS Patients underwent cardiac MR and performed bicycle exercise echocardiogram within a month. RESULTS LGE was present in 54 patients (71%), ranging from 0.2% to 32.4% of LV mass. There was a weak correlation between the amount of fibrosis and LVOT gradient variation during exercise in the overall population (r=-0.243, p=0.034) and a stronger correlation in patients with obstructive HCM at rest (r=-0.524, p=0.021). Patients with an LVOT gradient increase ≥50 mm Hg during exercise had a significantly lesser extent of fibrosis than those with an increase <50 mm Hg (0.7% (IQR 0-2.4) vs 3.2% (IQR 0.2-7.4), p=0.006). The extent of fibrosis was significantly lower among the highest quartiles of LVOT gradient increase (p=0.009). CONCLUSIONS In patients with HCM and normal ejection fraction at rest, myocardial fibrosis was associated with a lower increase in LVOT gradient during exercise, probably due to a lesser degree of myocardial contractility recruitment. This negative association was more evident in patients with an obstructive form at rest.
Collapse
Affiliation(s)
- Elena Biagini
- Institute of Cardiology, Bologna University and S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Massimiliano Lorenzini
- Institute of Cardiology, Bologna University and S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Iacopo Olivotto
- Referral Center for Myocardial Diseases, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | - Guido Rocchi
- Institute of Cardiology, Bologna University and S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Luigi Lovato
- Cardiovascular Radiology Department, Bologna University and S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Francesco Lai
- Institute of Cardiology, Bologna University and S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Stefania Rosmini
- Institute of Cardiology, Bologna University and S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Chiara Pazzi
- Institute of Cardiology, Bologna University and S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Ferdinando Pasquale
- Institute of Cardiology, Bologna University and S. Orsola-Malpighi Hospital, Bologna, Italy
| | | | - Rossella Fattori
- Cardiovascular Radiology Department, Bologna University and S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Claudio Rapezzi
- Institute of Cardiology, Bologna University and S. Orsola-Malpighi Hospital, Bologna, Italy
| |
Collapse
|