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Myectomy Plus Alfieri Technique for Outflow Tract Obstruction in Hypertrophic Cardiomyopathy

2010; Lippincott Williams & Wilkins; Volume: 122; Issue: 9 Linguagem: Inglês

10.1161/circulationaha.110.969451

1524-4539

Daniel Sado, Andrew Flett, Chris G.A. McGregor, Antonis Pantazis, Perry Elliott, James Moon,

Congenital Heart Disease Studies

HomeCirculationVol. 122, No. 9Myectomy Plus Alfieri Technique for Outflow Tract Obstruction in Hypertrophic Cardiomyopathy Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBMyectomy Plus Alfieri Technique for Outflow Tract Obstruction in Hypertrophic Cardiomyopathy Daniel M. Sado, MRCP, Andrew S. Flett, MRCP, Chris G.A. McGregor, MD, Antonis A. Pantazis, MD, Perry M. Elliott, MD and James C. Moon, MD, MRCP Daniel M. SadoDaniel M. Sado From the Departments of Inherited Cardiac Disease (D.M.S., A.S.F., C.G.A.M., A.A.P., P.M.E., J.C.M.) and Cardiothoracic Surgery (C.G.A.M.), The Heart Hospital, and Department of Medicine, University College London (A.S.F., A.A.P., P.M.E., J.C.M.), London, UK. , Andrew S. FlettAndrew S. Flett From the Departments of Inherited Cardiac Disease (D.M.S., A.S.F., C.G.A.M., A.A.P., P.M.E., J.C.M.) and Cardiothoracic Surgery (C.G.A.M.), The Heart Hospital, and Department of Medicine, University College London (A.S.F., A.A.P., P.M.E., J.C.M.), London, UK. , Chris G.A. McGregorChris G.A. McGregor From the Departments of Inherited Cardiac Disease (D.M.S., A.S.F., C.G.A.M., A.A.P., P.M.E., J.C.M.) and Cardiothoracic Surgery (C.G.A.M.), The Heart Hospital, and Department of Medicine, University College London (A.S.F., A.A.P., P.M.E., J.C.M.), London, UK. , Antonis A. PantazisAntonis A. Pantazis From the Departments of Inherited Cardiac Disease (D.M.S., A.S.F., C.G.A.M., A.A.P., P.M.E., J.C.M.) and Cardiothoracic Surgery (C.G.A.M.), The Heart Hospital, and Department of Medicine, University College London (A.S.F., A.A.P., P.M.E., J.C.M.), London, UK. , Perry M. ElliottPerry M. Elliott From the Departments of Inherited Cardiac Disease (D.M.S., A.S.F., C.G.A.M., A.A.P., P.M.E., J.C.M.) and Cardiothoracic Surgery (C.G.A.M.), The Heart Hospital, and Department of Medicine, University College London (A.S.F., A.A.P., P.M.E., J.C.M.), London, UK. and James C. MoonJames C. Moon From the Departments of Inherited Cardiac Disease (D.M.S., A.S.F., C.G.A.M., A.A.P., P.M.E., J.C.M.) and Cardiothoracic Surgery (C.G.A.M.), The Heart Hospital, and Department of Medicine, University College London (A.S.F., A.A.P., P.M.E., J.C.M.), London, UK. Originally published31 Aug 2010https://doi.org/10.1161/CIRCULATIONAHA.110.969451Circulation. 2010;122:938–939A 56-year-old man presented with breathlessness and chest pain. Echocardiography revealed 14-mm septal hypertrophy, complete systolic anterior motion of the anterior mitral valve leaflet, severe central mitral regurgitation, and a left ventricular outflow tract gradient of 40 mm Hg increasing to 56 mm Hg on Valsalva. A diagnosis of hypertrophic cardiomyopathy was made.Despite medical therapy, the patient's symptoms worsened. Transesophageal echocardiography and cardiovascular magnetic resonance imaging (the Figure, top) revealed elongation of the anterior mitral valve leaflet but no significant intrinsic disease of the valve. The mitral regurgitation was thought to be central rather than posterior (as would be expected to occur as a result of the complete systolic anterior motion) because of the elongated leaflet. Download figureDownload PowerPointFigure. Cardiovascular magnetic resonance cine images before and after surgery demonstrating (left) how the Alfieri technique alters the anatomy of the mitral valve, making it dual orifice, and (right) the resultant complete resolution of the mitral regurgitation.The patient was referred for gradient and mitral regurgitation reduction surgery with septal myectomy and mitral valve repair. This was performed under transesophageal guidance. The myectomy was limited by the mild hypertrophy of the septal wall and by the concern of causing a ventricular septal defect if too much myocardium was excised. Because of the complex nature of the mitral valve anatomy, it was treated with the "edge-to-edge" or "Alfieri" technique, in which the A2 scallop is directly sutured to P2.1 The procedure was successful in abolishing the gradient during surgery.Postoperative convalescence was unremarkable. At 6 months, there was reduced breathlessness, no rest or stress left ventricular outflow tract obstruction, and no mitral regurgitation or stenosis. A repeat cardiovascular magnetic resonance demonstrated how the Alfieri technique had altered the anatomy of the valve, with the suture creating a dual orifice and resulting in both reduced systolic anterior motion and complete resolution of the mitral regurgitation (the Figure, bottom).The phenotypic manifestations of hypertrophic cardiomyopathy include abnormalities of the mitral valve and subvalvular apparatus that may contribute to left ventricular outflow tract obstruction if present.2 The Alfieri technique has previously been evaluated in a subgroup of 14 patients with hypertrophic cardiomyopathy undergoing myectomy and mitral repair to prevent or treat systolic anterior motion.3 Although that article reported only pooled medium-term follow-up data for a variety of mitral valve pathologies in which the technique was used, both this and other work suggests that for nonischemic mitral regurgitation treatment, the Alfieri technique is effective and durable and only rarely causes significant mitral stenosis.4 In the case discussed here, a combination of myectomy and Alfieri modification obviated the need for mitral replacement and relieved both left ventricular outflow tract obstruction and the patient's symptoms.DisclosuresNone.FootnotesCorrespondence to James C. Moon, MD, MRCP, Department of Inherited Cardiac Disease, The Heart Hospital, 16–18 Westmoreland St, London, UK W1G 8PH. E-mail [email protected]References1 Fucci C, Sandrelli L, Pardini A Torracca L, Ferrari M, Alfieri O. Improved results with mitral valve repair using new surgical techniques. Eur J Cardiothorac Surg. 1995; 9: 621–627.CrossrefMedlineGoogle Scholar2 Maron MS, Olivotto I, Zenovich AG, Link MS, Pandian NG, Kuvin JT, Nistri S, Cecchi F, Udelson JE, Maron BJ. Hypertrophic cardiomyopathy is predominantly a disease of left ventricular outflow tract obstruction. Circulation. 2006; 114: 2232–2239.LinkGoogle Scholar3 Bhudia SK, McCarthy PM, Smedira NG, Lam BK, Rajeswaran J, Blackstone EH. Edge-to-edge (Alfieri) mitral repair: results in diverse clinical settings. Ann Thorac Surg. 2004; 77: 1598–1606.CrossrefMedlineGoogle Scholar4 Kherani AR, Cheema FH, Casher J, Fal JM, Mutrie CJ, Chen JM, Morgan JA, Vigilance DW, Garrido MJ, Smith CR, Oz MC. Edge-to-edge mitral valve repair: the Columbia Presbyterian experience. Ann Thorac Surg. 2004; 78: 73–76.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Gharibeh L, Smedira N and Grau J (2021) Comprehensive left ventricular outflow tract management beyond septal reduction to relieve obstruction, Asian Cardiovascular and Thoracic Annals, 10.1177/02184923211034689, 30:1, (43-52), Online publication date: 1-Jan-2022. Jiang Z, Tang M, Liu H, Ma N, Ding F, Bao C and Mei J (2021) Minimally Invasive Surgery for Hypertrophic Obstructive Cardiomyopathy With Mitral Regurgitation, The Annals of Thoracic Surgery, 10.1016/j.athoracsur.2020.06.028, 111:4, (1345-1350), Online publication date: 1-Apr-2021. Del Forno B, De Bonis M, Agricola E, Melillo F, Schiavi D, Castiglioni A, Montorfano M and Alfieri O (2020) Mitral valve regurgitation: a disease with a wide spectrum of therapeutic options, Nature Reviews Cardiology, 10.1038/s41569-020-0395-7, 17:12, (807-827), Online publication date: 1-Dec-2020. Bogachev-Prokophiev A, Afanasyev A, Zheleznev S, Pivkin A, Sharifulin R, Kozmin D and Karaskov A (2019) Septal Myectomy With Vs Without Subvalvular Apparatus Intervention in Patients With Hypertrophic Obstructive Cardiomyopathy: A Prospective Randomized Study, Seminars in Thoracic and Cardiovascular Surgery, 10.1053/j.semtcvs.2019.01.011, 31:3, (424-431), Online publication date: 1-Nov-2020. Okada M, Watanuki H, Sugiyama K, Futamura Y and Matsuyama K (2017) Mitral Valve Repair for Mitral Valve Regurgitation with Papillary Muscle Displacement and Posterior Leaflet Prolapse, Open Journal of Thoracic Surgery, 10.4236/ojts.2017.73006, 07:03, (39-45), . 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Gimeno J, Tomé M and McKenna W (2012) Alcohol Septal Ablation in Hypertrophic Cardiomyopathy: An Opportunity to Be Taken, Revista Española de Cardiología (English Edition), 10.1016/j.rec.2011.11.014, 65:4, (314-318), Online publication date: 1-Apr-2012. Roscher C, Reidy C and Augoustides J (2011) Progress in Perioperative Echocardiography: Focus on Safety, Clinical Outcomes, 3-Dimensional Imaging, and Education, Journal of Cardiothoracic and Vascular Anesthesia, 10.1053/j.jvca.2011.02.009, 25:3, (559-564), Online publication date: 1-Jun-2011. Afanasyev A, Bogachev-Prokophiev A, Zheleznev S, Sharifulin R, Zalesov A, Kozmin D and Karaskov A (2018) SEPTAL MYECTOMY WITH SUBVALVULAR APPARATUS INTERVENTION IN PATIENTS WITH HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY: IMMEDIATE RESULTS, Siberian Medical Journal, 10.29001/2073-8552-2018-33-3-71-77, 33:3, (71-77) August 31, 2010Vol 122, Issue 9 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.110.969451PMID: 20805440 Originally publishedAugust 31, 2010 PDF download Advertisement SubjectsCardiovascular SurgeryComputerized Tomography (CT)