Skip to main content
Download PDF

Surgical management of left ventricular outflow obstruction in hypertrophic cardiomyopathy

Echo Research & Practice volume 2, pages R37–R44 (2015)Cite this article

Abstract

Hypertrophic cardiomyopathy is the single most common form of inherited heart disease. Left ventricular outflow tract obstruction (LVOTO) is a recognised feature of this condition which arises when blood leaving the outflow tract is impeded by systolic anterior motion of the mitral valve. In an important minority of patients, breathlessness, chest pain and syncope may result and persist despite the use of medications. In suitable candidates, surgery may relieve obstruction and its associated symptoms, and normalise life expectancy. Refinements in surgical techniques have marked improvements in the understanding of mechanisms underlying LVOTO. In this review, we hope to provide the reader with an understanding of how contemporary surgical practice has developed, which patients should be considered for surgery, and what results are anticipated. The role echocardiography plays in this area is highlighted throughout.

References

  1. Nagueh SF, Bierig SM, Budoff MJ, Desai M, Dilsizian V, Eidem B, Goldstein SA, Hung J, Maron MS, Ommen SR et al. 2011 American Society of Echocardiography clinical recommendations for multimodality cardiovascular imaging of patients with hypertrophic cardiomyopathy: endorsed by the American Society of Nuclear Cardiology, Society for Cardiovascular Magnetic Resonance, and Society of Cardiovascular Computed Tomography. Journal of the American Society of Echocardiography 24 473–498. (doi:10.1016/j.echo.2011.03.006)

    Article  Google Scholar 

  2. Cleland WP 1963 The surgical management of obstructive cardiomyopathy. Journal of Cardiovascular Surgery 4 489–491.

    CAS  PubMed  Google Scholar 

  3. Morrow AG, Fogarty TJ, Hannah H III Braunwald E 1968 Operative treatment in idiopathic hypertrophic subaortic stenosis. Techniques, and the results of preoperative and postoperative clinical and hemodynamic assessments. Circulation 37 589–596. (doi:10.1161/01.CIR.37.4.589)

    Article  CAS  Google Scholar 

  4. Cooley DA, Leachman RD, Hallman GL, Gerami S, Hall RJ 1971 Idiopathic hypertrophic subaortic stenosis. Surgical treatment including mitral valve replacement. Archives of Surgery 103 606–609. (doi:10.1001/archsurg.1971.01350110108017)

    Article  CAS  Google Scholar 

  5. Cooley DA, Bloodwell RD, Hallman GL, LaSorte AF, Leachman RD, Chapman DW 1967 Surgical treatment of muscular subaortic stenosis. Results from septectomy in twenty-six patients. Circulation 35 (4 Suppl) I124–I132.

    CAS  PubMed  Google Scholar 

  6. Moro E, ten Cate FJ, Leonard JJ, Hugenholtz PG, Roelandt J 1987 Genesis of systolic anterior motion of the mitral valve in hypertrophic cardiomyopathy: an anatomical or dynamic event? European Heart Journal 8 1312–1321.

    Article  CAS  Google Scholar 

  7. Sherrid MV, Gunsburg DZ, Moldenhauer S, Pearle G 2000 Systolic anterior motion begins at low left ventricular outflow tract velocity in obstructive hypertrophic cardiomyopathy. Journal of the American College of Cardiology 36 1344–1354. (doi:10.1016/S0735-1097(00)00830-5)

    Article  CAS  Google Scholar 

  8. Grigg LE, Wigle ED, Williams WG, Daniel LB, Rakowski H 1992 Transesophageal Doppler echocardiography in obstructive hypertrophic cardiomyopathy: clarification of pathophysiology and importance in intraoperative decision making. Journal of the American College of Cardiology 20 42–52. (doi:10.1016/0735-1097(92)90135-A)

    Article  CAS  Google Scholar 

  9. Kim DH, Handschumacher MD, Levine RA, Choi YS, Kim YJ, Yun SC, Song JM, Kang DH, Song JK 2010 In vivo measurement of mitral leaflet surface area and subvalvular geometry in patients with asymmetrical septal hypertrophy: insights into the mechanism of outflow tract obstruction. Circulation 122 1298–1307. (doi:10.1161/CIRCULATIONAHA.109.935551)

    Article  Google Scholar 

  10. Qin JX, Shiota T, Lever HM, Rubin DN, Bauer F, Kim YJ, Sitges M, Greenberg NL, Drinko JK, Martin M et al. 2002 Impact of left ventricular outflow tract area on systolic outflow velocity in hypertrophic cardiomyopathy: a real-time three-dimensional echocardiographic study. Journal of the American College of Cardiology 39 308–314. (doi:10.1016/S0735-1097(01)01722-3)

    Article  Google Scholar 

  11. Shah PM, Raney AA 2011 Echocardiography in mitral regurgitation with relevance to valve surgery. Journal of the American Society of Echocardiography 24 1086–1091. (doi:10.1016/j.echo.2011.08.017)

    Article  Google Scholar 

  12. Cho YH, Quintana E, Schaff HV, Nishimura RA, Dearani JA, Abel MD, Ommen S 2014 Residual and recurrent gradients after septal myectomy for hypertrophic cardiomyopathy-mechanisms of obstruction and outcomes of reoperation. Journal of Thoracic and Cardiovascular Surgery 148 909–915; discussion 915–916. (doi:10.1016/j.jtcvs.2014.05.028)

    Article  Google Scholar 

  13. Elliott PM, Anastasakis A, Borger MA, Borggrefe M, Cecchi F, Charron P, Hagege AA, Lafont A, Limongelli G, Mahrholdt H et al. 2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy: the Task Force for the Diagnosis and Management of Hypertrophic Cardiomyopathy of the European Society of Cardiology (ESC). European Heart Journal 35 2733–2779. (doi:10.1093/eurheartj/ehu199)

    Article  Google Scholar 

  14. Messmer BJ 1994 Extended myectomy for hypertrophic obstructive cardiomyopathy. Annals of Thoracic Surgery 58 575–577. (doi:10.1016/0003-4975(94)92268-3)

    Article  CAS  Google Scholar 

  15. Mohr FW, Seeburger J, Misfeld M 2013 Keynote lecture-transmitral hypertrophic obstructive cardiomyopathy (HOCM) repair. Annals of Cardiothoracic Surgery 2 729–732. (doi:10.3978/j.issn.2225-319X.2013.11.05)

    PubMed  PubMed Central  Google Scholar 

  16. Seeburger J, Passage J, Borger MA, Mohr FW 2010 A new concept for correction of systolic anterior motion and mitral valve regurgitation in patients with hypertrophic obstructive cardiomyopathy. Journal of Thoracic and Cardiovascular Surgery 140 481–483. (doi:10.1016/j.jtcvs.2010.01.010)

    Article  Google Scholar 

  17. Iacovoni A, Spirito P, Simon C, Iascone M, Di Dedda G, De Filippo P, Pentiricci S, Boni L, Senni M, Gavazzi A et al. 2012 A contemporary European experience with surgical septal myectomy in hypertrophic cardiomyopathy. European Heart Journal 33 2080–2087. (doi:10.1093/eurheartj/ehs064)

    Article  Google Scholar 

  18. ten Cate FJ, Soliman OI, Michels M, Theuns DA, de Jong PL, Geleijnse ML, Serruys PW 2010 Long-term outcome of alcohol septal ablation in patients with obstructive hypertrophic cardiomyopathy: a word of caution. Circulation. Heart Failure 3 362–369. (doi:10.1161/CIRCHEARTFAILURE.109.862359)

    Article  Google Scholar 

Download references

Funding

This review did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.

Author information

Authors and Affiliations

  1. Department of Cardiothoracic Surgery, New Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK

    Neil Howell PhD

  2. Department of Cardiology, New Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK

    William Bradlow MD

Authors
  1. Neil Howell PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. William Bradlow MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to William Bradlow MD.

Rights and permissions

This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the articles Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the articles Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Howell, N., Bradlow, W. Surgical management of left ventricular outflow obstruction in hypertrophic cardiomyopathy. Echo Res Pract 2, R37–R44 (2015). https://doi.org/10.1530/ERP-15-0005

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1530/ERP-15-0005

Key Words

Echo Research & Practice

ISSN: 2055-0464

Contact us