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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. 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.
4. 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.
5. Patients and material
All 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 .
6. Preoperative data
Between Jan. 2000 & Dec. 2010
Limited experience ( 19 patients )
Age ( years )
Sex 2-47 (23.4 + 12.7)
Male
63.2%
12 9 10
12 10
8
6
4
7 2
0
Female
36.8% < 18 y > 18 y
7. Preoperative data
17 patients had SOB III-IV & 2 had dizziness & syncope
10
8
No. of Patients
6
4
2
0
0 1 2 3 4
NYHA Functional Class
8. Preoperative data
Peak 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
9. 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.
10. 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.
17. 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)
18. Symptomatic improvement
Pre. & postoperative SOB
Preoperative
12
Postoperative
10
No. of Patients
8
6
4
2
0
0 1 2 3 4
NYHA Functional Class
21. 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.
22. References
1 ) Mahboob Alam, Hisham Dokanish, and Nasser M. Lakkis.
European Heart Journal (2009) 30, 1080–1087
2 ) Nicholas G. Smedira, MD, Bruce W. Lytle, MD, et al.
Ann Thorac Surg 2008;85:127–34
3 ) J. Dearani, S. Ommen, B. Gersh et al.
Nature Clinical Practice, cardiovascular medicine. 2007; 4 (9) : 503- 512
