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Izumi Y, Takanashi S, Kitamura M, Takamisawa I, Saito M, Otaki Y, Iwakura T, Takayama M. Morphological anomalies in obstructive hypertrophic cardiomyopathy: Insights from four-dimensional computed tomography and surgical correlation. J Cardiol 2024:S0914-5087(24)00130-8. [PMID: 39002717 DOI: 10.1016/j.jjcc.2024.07.002] [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: 05/16/2024] [Revised: 06/21/2024] [Accepted: 07/03/2024] [Indexed: 07/15/2024]
Abstract
Hypertrophic cardiomyopathy (HCM) is a genetic disorder in which left ventricular outflow tract obstruction critically affects symptoms and prognosis. Traditionally, left ventricular outflow tract obstruction was primarily attributed to septal hypertrophy with systolic anterior motion of the mitral valve. However, recent evidence highlights significant contributions from the mitral valve and papillary muscle anomalies, as well as an apical-basal muscle bundle observed in HCM patients. Accurate morphological assessment is essential when considering septal reduction therapy. While transesophageal echocardiography and cardiac magnetic resonance are recommended for assessing the anomalous structures, four-dimensional computed tomography offers superior spatial resolution and multiplanar reconstruction capabilities. These features enable the evaluation of details of the morphological anomalies, such as the apical-basal muscle band, papillary muscle anomalies, subaortic stenosis, and right ventricular outflow tract obstruction. Based on the detailed assessment of these morphological features, four-dimensional computed tomography has been utilized for planning of surgical correction in a comprehensive HCM center. This approach facilitates the intervention strategies and may improve outcomes in septal reduction therapy for obstructive HCM.
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Affiliation(s)
- Yuki Izumi
- Hypertrophic Cardiomyopathy Center, Sakakibara Heart Institute, Tokyo, Japan; Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan.
| | - Shuichiro Takanashi
- Hypertrophic Cardiomyopathy Center, Sakakibara Heart Institute, Tokyo, Japan; Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan
| | - Mitsunobu Kitamura
- Hypertrophic Cardiomyopathy Center, Sakakibara Heart Institute, Tokyo, Japan; Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Itaru Takamisawa
- Hypertrophic Cardiomyopathy Center, Sakakibara Heart Institute, Tokyo, Japan; Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Mika Saito
- Department of Pediatric Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Yuka Otaki
- Hypertrophic Cardiomyopathy Center, Sakakibara Heart Institute, Tokyo, Japan; Department of Radiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Tomohiro Iwakura
- Hypertrophic Cardiomyopathy Center, Sakakibara Heart Institute, Tokyo, Japan; Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan
| | - Morimasa Takayama
- Hypertrophic Cardiomyopathy Center, Sakakibara Heart Institute, Tokyo, Japan; Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
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Mustafic M, Jandér R, Marlevi D, Rickenlund A, Rück A, Saleh N, Abdi S, Eriksson MJ, Damlin A. Alcohol septal ablation for hypertrophic obstructive cardiomyopathy: do mitral valve leaflet length, septal thickness, or sex affect the outcome? Cardiovasc Interv Ther 2024:10.1007/s12928-024-01014-4. [PMID: 38807005 DOI: 10.1007/s12928-024-01014-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 05/13/2024] [Indexed: 05/30/2024]
Abstract
This retrospective cohort study aimed to assess whether basal septal wall thickness (BSWT), anterior (AML) and posterior (PML) mitral leaflet length, or sex were associated with remaining left ventricular outflow tract obstruction (LVOTO) in patients with hypertrophic obstructive cardiomyopathy (HOCM) undergoing alcohol septal ablation (ASA). One hundred fifty-four patients who underwent ASA at the Karolinska University Hospital in Stockholm, Sweden, between 2009 and 2021, were included retrospectively. Anatomical and hemodynamic parameters were collected from invasive catheterization before and during ASA, and from echocardiography (ECHO) examinations before, during, and at 1-year follow-up after ASA. Linear and logistic regression models were used to assess the association between sex, BSWT, AML, PML, and outcome, which was defined as the remaining LVOTO (≥ 30 mmHg) after ASA. The median follow-up was 364 days (interquartile range 334-385 days). BSWT ≥ 23 mm (n = 13, 12%) was associated with remaining LVOTO at follow-up (p = 0.004). Elongated mitral valve leaflet length (either AML or PML) was present in 125 (90%) patients. Elongated AML (> 24 mm) was present in 67 (44%) patients, although AML length was not associated with remaining LVOTO at follow-up. Elongated PML (> 14 mm) was present in 114 (74%) patients and was not associated with remaining LVOTO at follow-up. No significant sex differences were observed regarding the remaining LVOTO. ECHO measurement of BSWT can be effectively used to select patients for successful ASA and identify those patients with a risk of incomplete resolution of LVOTO after ASA.
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Affiliation(s)
- Mesud Mustafic
- Division of Clinical Physiology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Rebecka Jandér
- Division of Clinical Physiology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - David Marlevi
- Division of Clinical Physiology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Anette Rickenlund
- Division of Clinical Physiology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Physiology, Karolinska University Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Andreas Rück
- Department of Cardiology, Karolinska University Hospital, Karolinska University Hospital, Stockholm, Sweden
- Unit of Cardiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Nawzad Saleh
- Department of Cardiology, Karolinska University Hospital, Karolinska University Hospital, Stockholm, Sweden
- Unit of Cardiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Sam Abdi
- Department of Internal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Maria J Eriksson
- Division of Clinical Physiology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Physiology, Karolinska University Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Damlin
- Division of Clinical Physiology, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
- Department of Clinical Physiology, Karolinska University Hospital, Karolinska University Hospital, Stockholm, Sweden.
- Department of Cardiology, Karolinska University Hospital, Karolinska University Hospital, Stockholm, Sweden.
- Unit of Cardiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.
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Ayati A, Khoshfetrat M, Davoodi S, Ahmadi Tafti SH, Arefizadeh R. Comparing long-term outcomes of septal myectomy and mitral valve replacement in hypertrophic cardiomyopathy patients: A retrospective cohort study in Iran. Health Sci Rep 2024; 7:e2045. [PMID: 38629112 PMCID: PMC11019255 DOI: 10.1002/hsr2.2045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 03/21/2024] [Accepted: 03/24/2024] [Indexed: 04/19/2024] Open
Abstract
Background Hypertrophic cardiomyopathy (HCM) affects millions of individuals worldwide. In severe cases, it can cause life-threatening conditions such as left ventricular outflow tract (LVOT) obstruction, mitral regurgitation (MR), and sudden cardiac death, making surgical treatment necessary. This study aimed to report the long-term outcomes of HCM patients undergoing septal myectomy or mitral valve replacement (MVR) and compare the results between different types of surgeries. Methods This was a retrospective cohort study on HCM patients who underwent surgical treatment in an Iranian referral center between 2005 and 2021. Patients were divided into three groups according to the type of surgery received: septal myectomy, MVR, or a combination of both surgeries. Patient characteristics, surgical and echocardiographic features, and in-hospital and long-term outcomes were reported and compared between the three groups. Results A total of 102 patients with an average age of 53.3 ± 16.9 were included. Twenty-six patients had septal myectomy, 23 had MVR, and 53 had combined septal myectomy and MVR surgery. All surgeries were associated with a significant reduction in interventricular septum thickness and LVOT gradients. After a median of 6.8-year follow-up time, patients with an isolated septal myectomy had significantly lower mortality and major adverse cardiac and cerebrovascular events rates than the other groups. Conclusion Isolated septal myectomy showed better long-term survival rates and can correct HCM-related MR, while MVR should be preserved only for intrinsic valve defects. More extensive studies are needed to confirm these findings and achieve a comprehensive guideline on surgical treatment of HCM.
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Affiliation(s)
- Aryan Ayati
- Trauma and Surgery Research CenterAja University of Medical SciencesTehranIran
- Tehran Heart Center, Cardiovascular Diseases Research InstituteTehran University of Medical SciencesTehranIran
| | - Mehran Khoshfetrat
- Trauma and Surgery Research CenterAja University of Medical SciencesTehranIran
| | - Saeed Davoodi
- Tehran Heart Center, Cardiovascular Diseases Research InstituteTehran University of Medical SciencesTehranIran
| | - Seyed Hossein Ahmadi Tafti
- Tehran Heart Center, Cardiovascular Diseases Research InstituteTehran University of Medical SciencesTehranIran
| | - Reza Arefizadeh
- Trauma and Surgery Research CenterAja University of Medical SciencesTehranIran
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Marzlin N, Barrett N, Burke D, Nfor T, Tajik AJ, Muthukumar L. Challenge in mitral valve intervention: Super-elongated anterior and diminutive posterior mitral valve. JOURNAL OF CLINICAL ULTRASOUND : JCU 2024; 52:92-94. [PMID: 37997479 DOI: 10.1002/jcu.23620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 11/15/2023] [Accepted: 11/17/2023] [Indexed: 11/25/2023]
Abstract
Diminutive posterior mitral valve leaflet with an extremely elongated anterior leaflet is a rare phenomenon. We share such a case discovered in an 82-year-old patient with severe, symptomatic mitral regurgitation. LA, left atrium; LV, left ventricle; MR, mitral regurgitation.
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Affiliation(s)
- Nathan Marzlin
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers, Milwaukee, Wisconsin, USA
| | - Nancy Barrett
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers, Milwaukee, Wisconsin, USA
| | - Dena Burke
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers, Milwaukee, Wisconsin, USA
| | - Tonga Nfor
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers, Milwaukee, Wisconsin, USA
- Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Milwaukee Clinical Campus, Milwaukee, Wisconsin, USA
| | - A Jamil Tajik
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers, Milwaukee, Wisconsin, USA
- Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Milwaukee Clinical Campus, Milwaukee, Wisconsin, USA
| | - Lakshmi Muthukumar
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers, Milwaukee, Wisconsin, USA
- Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Milwaukee Clinical Campus, Milwaukee, Wisconsin, USA
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Smedira NG. Commentary: Is length (of the anterior mitral leaflet) important? J Thorac Cardiovasc Surg 2023; 165:90-91. [PMID: 33678509 DOI: 10.1016/j.jtcvs.2021.01.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Nicholas G Smedira
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.
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Ward AF, Lee R. Commentary: Hypertrophic cardiomyopathy and the mitral valve-the debate continues. J Thorac Cardiovasc Surg 2023; 165:88-89. [PMID: 33583588 DOI: 10.1016/j.jtcvs.2021.01.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 01/11/2021] [Accepted: 01/12/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Alison F Ward
- Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Georgia, Augusta University, Augusta, Ga
| | - Richard Lee
- Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Georgia, Augusta University, Augusta, Ga.
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Timek TA. Commentary: Light on the long shadow of systolic anterior motion. J Thorac Cardiovasc Surg 2023; 165:92-93. [PMID: 33781597 DOI: 10.1016/j.jtcvs.2021.02.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 02/05/2021] [Accepted: 02/08/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Tomasz A Timek
- Division of Cardiothoracic Surgery, Spectrum Health, Michigan State University College of Human Medicine, Grand Rapids, Mich.
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Guigui SA, Torres C, Escolar E, Mihos CG. Systolic anterior motion of the mitral valve in hypertrophic cardiomyopathy: a narrative review. J Thorac Dis 2022; 14:2309-2325. [PMID: 35813751 PMCID: PMC9264047 DOI: 10.21037/jtd-22-182] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 04/15/2022] [Indexed: 11/06/2022]
Abstract
Background and Objective The prevalence of hypertrophic cardiomyopathy (HCM) is estimated to be 1 in 200 to 500 individuals, with systolic anterior motion (SAM) of the mitral valve (MV) and left ventricular outflow tract (LVOT) obstruction present in 60% to 70%. In this narrative review, we aim to elucidate the pathophysiology of SAM-septal contact and LVOT obstruction in HCM by presenting a detailed review on the anatomy of the MV apparatus in HCM, examining the various existing theories pertaining to the SAM phenomenon as supported by cardiac imaging, and providing a critical assessment of management strategies for SAM in HCM. Methods A literature review was performed using PubMed, EMBASE, Ovid, and the Cochrane Library, of all scientific articles published through December 2021. A focus was placed on descriptive studies, reports correlating echocardiographic findings with pathologic diagnosis, and outcomes studies. Key Content and Findings The pathophysiology of SAM involves the complex interplay between HCM morphology, MV apparatus anatomic abnormalities, and labile hemodynamic derangements. Echocardiography and cardiac magnetic resonance (CMR) vector flow mapping have identified drag forces, as opposed to the "Venturi effect", as the main hydraulic forces responsible for SAM. The degree of mitral regurgitation with SAM is variable, and its severity is correlated with degree of LVOT obstruction and outcomes. First line therapy for the amelioration of SAM and LVOT obstruction is medical therapy with beta-blockers, non-dihydropyridine calcium-channel blockers, and disopyramide, in conjunction with lifestyle modifications. In refractory cases septal reduction therapy is performed, which may be combined with a 'resect-plicate-release' procedure, anterior mitral leaflet extension, surgical edge-to-edge MV repair, anterior mitral leaflet retention plasty, or secondary chordal cutting. Conclusions Recent scientific advances in the field of HCM have allowed for a maturation of our understanding of the SAM phenomenon. Cardiac imaging plays a critical role in its diagnosis, treatment, and surveillance, and in our ability to apply the appropriate therapeutic regimens. The increasing prevalence of HCM places an emphasis on continued basic and clinical research to further improve outcomes for this challenging population.
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Affiliation(s)
- Sarah A Guigui
- Echocardiography Laboratory, Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA.,Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
| | - Christian Torres
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
| | - Esteban Escolar
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA.,Coronary Care Unit, Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
| | - Christos G Mihos
- Echocardiography Laboratory, Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA.,Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
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Ahmed EA, Schaff HV, Geske JB, Lee AT, King KS, Dearani JA, Nishimura RA, Ommen SR. Optimal Management of Mitral Regurgitation Due to Ruptured Mitral Chordae Tendineae in Patients With Hypertrophic Cardiomyopathy. Semin Thorac Cardiovasc Surg 2022; 35:476-482. [PMID: 35598764 DOI: 10.1053/j.semtcvs.2022.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 05/13/2022] [Indexed: 11/11/2022]
Abstract
There is continued controversy regarding surgical management of patients with hypertrophic cardiomyopathy (HCM) and intrinsic mitral valve disease; some clinicians favor prosthetic replacement as this corrects left ventricular outflow tract (LVOT) obstruction and valve leakage. In this study, we investigated the management and late outcome of operation for mitral regurgitation (MR) due to ruptured chordae tendineae in patients with HCM. We analyzed 49 consecutive patients with HCM and MR due to ruptured mitral valve chordae. Echocardiograms and operative reports were reviewed to classify valve anatomy and surgical methods. Information on late outcomes was obtained from electronic medical records and follow-up surveys. The mean age of the 36 men and 13 women was 61.9 ± 12.5 years; significant resting or provoked LVOT obstruction was present at the time of surgery in 46 patients. During the index operation, mitral valve repair was performed in 45 patients, and prosthetic replacement was necessary for 4 patients. Concomitant septal myectomy was performed in 46 patients. There were no hospital deaths or deaths within 30 days of operation. Five and ten-year survival estimates (Kaplan-Meier) were 92% and 71%. During follow-up at a median of 7.9 years, 3 patients underwent reoperation for MV replacement, 5 days, 3 years, and 14 years following valve repair. Ruptured mitral chordae may result in severe mitral valve regurgitation in patients with hypertrophic cardiomyopathy. Valvuloplasty at the time of septal myectomy is safe with an acceptably low rate of recurrent MR requiring prosthetic replacement.
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Affiliation(s)
- Eglal A Ahmed
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| | - Jeffrey B Geske
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Alexander T Lee
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Katherine S King
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Rick A Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Steve R Ommen
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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Grau JB, Fortier JH. The mitral valve and its contribution to the generation of left ventricular outflow tract obstruction in hypertrophic cardiomyopathy: Considerations for surgeons. CIRUGIA CARDIOVASCULAR 2022. [DOI: 10.1016/j.circv.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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