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Echocardiographic Findings Late After Myectomy in Hypertrophic Obstructive Cardiomyopathy

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Echocardiographic Findings Late After Myectomy in Hypertrophic Obstructive Cardiomyopathy Zurich Open Repository and Archive University of Zurich Main Library Strickhofstrasse 39 CH-8057 Zurich www.zora.uzh.ch Year: 1986 Echocardiographic findings late after myectomy in hypertrophic obstructive cardiomyopathy Turina, J ; Jenni, R ; Krayenbuehl, H P ; Turina, M ; Rothlin, M Abstract: Postoperative echocardiograms of 50 patients undergoing myectomy for hypertrophic obstruc- tive cardiomyopathy between 1965 and 1982 have been evaluated. In 21 patients a comparison with preoperative echocardiograms showed that postoperatively there was a significant reduction of septal and free wall thickness, an increase of left ventricular end-diastolic as well as outflow tract dimensions and a reduction or disappearance of systolic anterior motion of the mitral leaflet. Postoperative examination at intervals > 3 years revealed a significant increase of left ventricular and left atrial cavity size with unchanged contractile parameters and little reduction of left ventricular hypertrophy. In 4of 12 patients evaluated > 8 years after myectomy, left ventricular dilatation was observed and 3 of these 4 patients developed congestive heart failure. Development of leftventricular dilatation was independent of whether a transventricular and/or transaortic approach was used for myectomy. These data indicate that the late course after myectomy in hypertrophic obstructive cardiomyopathy may be complicated by dilatation of the left ventricular cavity DOI: https://doi.org/10.1093/oxfordjournals.eurheartj.a062123 Posted at the Zurich Open Repository and Archive, University of Zurich ZORA URL: https://doi.org/10.5167/uzh-154113 Journal Article Published Version Originally published at: Turina, J; Jenni, R; Krayenbuehl, H P; Turina, M; Rothlin, M (1986). Echocardiographic findings late after myectomy in hypertrophic obstructive cardiomyopathy. European Heart Journal, 7(8):685-692. DOI: https://doi.org/10.1093/oxfordjournals.eurheartj.a062123 European Heart Journal (1986) 7, 685-692 Echocardiographic findings late after myectomy in hypertrophic obstructive cardiomyopathy J. TURINA*, R. JENNI*, H. P. KRAYENBUEHL*, M. TURINAf AND M. ROTHLINJ * Medical Policlinic, Division of Cardiology and fClinic for Cardiovascular Surgery, University Hospital, Zurich, Switzerland KEY WORDS: Hypertrophic obstructive cardiomyopathy, echocardiography, myectomy. Postoperative echocardiograms of 50 patients undergoing myectomy for hypertrophic obstructive cardio- myopathy between 1965 and 1982 have been evaluated. In 21 patients a comparison with preoperative echo- cardiograms showed that postoperatively there was a significant reduction ofseptal and free wall thickness, an increase of left ventricular end-diastolic as well as outflow tract dimensions and a reduction or disappear- ance of systolic anterior motion of the mitral leaflet. Postoperative examination at intervals > 3 years revealed a significant increase of left ventricular and left atrial cavity size with unchanged contractile para- meters and little reduction of left ventricular hypertrophy. In 4 of 12 patients evaluated > 8 years after myectomy, left ventricular dilatation was observed and 3 of these 4 patients developed congestive heart failure. Development of left ventricular dilatation was independent of whether a transventricular and/or transaortic approach was used for myectomy. These data indicate that the late course after myectomy in hypertrophic obstructive cardiomyopathy may be complicated by dilatation of the left ventricular cavity. Surgical treatment of hypertrophic obstructive obstructive cardiomyopathy, 34 men and 16 cardiomyopathy began in the early sixties and is women, who underwent surgical resection of the today a well established therapeutic procedure for hypertrophied septum (myectomy) between 1965 symptomatic patients with a high pressure gradient and 1982. The age at the time of operation was 14 across the outflow tract of the left ventricle and to 66 years, the mean age being 37 years. All severe mitral regurgitation. Different surgical patients, except one with severe mitral regurgi- procedures for relief of subaortic muscular obstruc- tation, had a resting pressure gradient across the tion have been used but myectomy of the hyper- outflow tract of the left ventricle. This gradient trophic septal myocardium is usually performed11"3'. exceeded 50mmHg in 42 patients and ranged Despite the very encouraging results of various between 32 and 47 mmHg in the other 7 patients. 6 studies'"- ) some objections to surgical treatment Before operation, 6 patients were in New York of hypertrophic obstructive cardiomyopathy have Heart Association class I, 18 in class II, 21 in class 7 8 been put forward' - '. These objections were raised III and 5 in class IV. The indication for surgery because the late outcome may be unsatisfactory were a resting pressure gradient more than due to the development of progressive myocardial 50 mmHg (6 patients in New York Heart Associ- contraction disturbances resembling dilated cardio- 9 ation class I), persistent or progressive symptoms myopathyi '. The purpose of this study is to demon- in spite of medical treatment and severe mitral strate echocardiographic findings after operation regurgitation. We were able to evaluate 75% of the for hypertrophic obstructive cardiomyopathy with entire patient population operated at our institu- special emphasis on late postoperative results. tion. Echocardiography has been performed in our institution since 1974 and thus patients who died before 1974 did not have echocardiographic Material and methods examinations. Postoperative medical treatment of We have studied 50 patients with hypertrophic the patients was not uniform. Twenty-two patients had no medical treatment. At the last follow-up Submitted for publication on 31 October 1985 and in revised form 30 January 1986. examination 11 patients were on betablockers and 9 on verapamil. Diuretics were used in 5 patients Address for correspondence: Juraj Turina, M.D., Medical Policlinic, and in 3 patients with ventricular extrasystoles University Hospital, CH-8091 Zurich, Switzerland. amiodarone was given. 0195-668X/86/080685 + 08 $02.00/0 © 1986 The European Society of Cardiology 686 J.Turina etal. SURGICAL PROCEDURE at the peak of the R-wave of the electrocardiogram All patients except one have been operated on and the end-systolic dimensions at the beginning in our hospital. Surgical techniques for septal of the second sound of the phonocardiogram. myectomy varied: in 23 patients myectomy was Outflow tract dimensions were expressed as the ' performed via an apical ventriculotomy according distance between the mitral valve and the septum to SenningW and in 20 patients by the aortic at the very beginning of the systole. Postoperative approach; a combined transventricular and trans- end-systolic dimensions and percent systolic short- " aortic approach was used in 7 patients. Additional ening of the left ventricular diameter are not reconstructive procedures of the mitral valve were reported for all patients because two-thirds of the performed in 3 patients. Until 1976 most of the patients had left bundle branch block existing .-. patients underwent transventricular myectomy. postoperatively. These values are presented only in Since that time transaortic approach was gener- the 30 patients undergoing repeated postoperative ally used but the type of operation depended also measurements where we looked for a change in on localization and amount of septal hyper- systolic contractile function during the follow-up trophy. Intraoperative myocardial protection with period. Presented data are the average of the magnesium-asparaginate, hypothermia and peri- measurements of 3 beats. cardial irrigation was used from 1975 to 1977 and since 1978 hypothermic potassium cardioplegia Results and pericardial irrigation were applied. POSTOPERATIVE ECHOCARDIOGRAMS Figure 1 summarizes the most relevant echo- * FOLLOW-UP cardiographic data of all 50 patients. In the The patients were followed for 1 to 19 years, patients having more than one postoperative study mean follow-up being 7-5 years. None of the the data of the last available echocardiogram (in patients died during the perioperative period; 2 the average 6-5 years after operation, range 0-3-18 patients died 3 and 9 years after surgery suddenly years) are presented. For each variable the normal and unexpectedly and one patient 6 years after sur- range in our laboratory is also depicted. The nor- gery from acute heart failure. Ten-year cumulative mal range is based on measurements of 50 healthy actuarial survival was 89%. Two patients under- subjects 18-62 years old, 36 men and 14 women. < went reoperation within 6 months of myectomy for Postoperative left ventricular end-diastolic dimen- severe aortic regurgitation and ventricular septal sions were within normal limits in the majority of defect; reconstruction of aortic valve and closure the patients; in 9/50 (19%) left ventricular cavity of septal defect were performed. A significant size was still below the normal limit and 4 patients improvement in New York Heart Association class had clearly enlarged left ventricular dimensions. from 2-5 preoperatively to 1-6 postoperatively Left ventricular outflow tract dimensions were ) (/ <0-01) was noted. Postoperative cardiac cath- within the normal range in the majority of the r eterization was performed at different times during patients; in 12/50 (24%) a narrow outflow tract the follow-up in 17 patients: 7 had no resting persisted despite
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