Esct 18th

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ESCTS 2012

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Esct 18th

  1. 1. Surgery of Hypertrophic Obstructive Cardiomyopathy, Kasr El-Aini limited experience Elsayed K. AKL, Tarek A. Mohsen, Amal Khalifa and Sameh Zaghloul. Faculty of medicine, Cairo university
  2. 2. Background Hypertrophic obstructive cardiomyopathy ( HOCM) is the most common genetic cardiovascular disease. It affects 1:500 of population in different parts of the world. However, it did not attain enough attention for many years. There is a definite recent increasing interest in this disease because of the dramatic fatal events of sudden death in young patients.
  3. 3. Aim of work We sought to : 1- Evaluate our learning curve of septal myectomy 2- Investigate whether Egyptian patients have different phenotypic characteristics from other reported large series.
  4. 4. Patients and materialAll patients with: symptomatic obstructive cardiomyomathy with maximum medical treatment and a resting or provoked peak systolic gradient > 60 mmHg. were enrolled in this study. All patients were operated by one surgeon .
  5. 5. Preoperative data Between Jan. 2000 & Dec. 2010 Limited experience ( 19 patients ) Age ( years ) Sex 2-47 (23.4 + 12.7) Male63.2% 12 9 10 12 10 8 6 4 7 2 0 Female 36.8% < 18 y > 18 y
  6. 6. Preoperative data 17 patients had SOB III-IV & 2 had dizziness & syncope 10 8No. of Patients 6 4 2 0 0 1 2 3 4 NYHA Functional Class
  7. 7. Preoperative dataPeak S. gradient (mmHg) SWT (cm) 60-174 (105+30) 1.8-3.4 (2.37+0.4) Degree of MR 7 6 6 5 5 4 No. of Patients 4 3 2 2 1 0 Grade 1 Grade 2 Grade 3 Grade 4
  8. 8. Operative Technique All patients underwent cautious septal myectomy through transaortic approach. Excision extends to the base of the papillary muscles. Attention to release of both fibrous trigones was added during the last 3 years. Septal endocardium is cautiously peeled off if thickened Only one patient required mitral repair excising prolapsing p1. Immediate postoperative peak systolic geardient was measured in each case by pull back or simultaneous left ventricular / aortic pressure tracing. TEE was used in most of the cases.
  9. 9. RESULTS ( 19 patients ) NO op. mortality Immediate peak gradient dropped from a mean of 105 + 30 to a mean of 11.5 + 6.1 mmHg. Significant reduction in pressure gradient was achieved in every patient. All patients came out of OR with no or trivial mitral incompetence. No incidence of iatrogenic VSD, aortic valve injury or complete heart block.
  10. 10. Examples of excised septal muscle P1Thickened septal endocardium
  11. 11. Pre. & Immediate postoperative MSPG Preoperative Postoperative 120 100 80 60 40 20 0 Mean PG 105 + 30 11+6.1
  12. 12. Pre. & postoperative PG for individual patients Preoperative 200 Postoperative 150PG in mmHg 100 50 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Serial Number
  13. 13. Post myectomy peak gradient
  14. 14. Pre. & postoperative MR12 Preoperative Postoperative10 8 6 4 2 0 Grade 0 Grade 1 Grade 2 Grade 3 Grade 4
  15. 15. Histopathology
  16. 16. Follow Up is 100% 2 w -132 m ( mean 34.4 + 31.9) One patient ( 11 y ) died 3 years after operation out of chronic renal failure. He had family history of sudden death, was born with one kidney and had ICD 3 years before operation. One patient ( 35 y ) with preoperative hepato- renal failure died 5 weeks after operation during dialysyis session. One patient ( 16 y ) developed an attack of VT 5 years later and treated medically. All survivors are well and free of SOB (FC 0-1)
  17. 17. Symptomatic improvement Pre. & postoperative SOB Preoperative 12 Postoperative 10No. of Patients 8 6 4 2 0 0 1 2 3 4 NYHA Functional Class
  18. 18. Place for treatment modalities
  19. 19. CONCLUSIONS 1 – Awareness of the disease and its consequences is mandatory. 2 – Training with experts allows safe learning to properly perform septal myectomy that gives excellent short and long term results with excellent relief of gradient and symptoms. 3 –Patients with preoperative renal problems seem to be at higher risk after operation. 4- Compared to large reported series (1,2&3), Egyptian patients with HOCM are younger and present with higher gradients. This may be explained by particular genetic variations which needs to be explored.
  20. 20. References1 ) Mahboob Alam, Hisham Dokanish, and Nasser M. Lakkis.European Heart Journal (2009) 30, 1080–10872 ) Nicholas G. Smedira, MD, Bruce W. Lytle, MD, et al. Ann Thorac Surg 2008;85:127–343 ) J. Dearani, S. Ommen, B. Gersh et al. Nature Clinical Practice, cardiovascular medicine. 2007; 4 (9) : 503- 512

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