Extended septal myectomy using a combined trans-aortic and apical approach for long basal and mid-cavity hypertrophic cardiomyopathy

Abstract

Surgical septal myectomy is the treatment of choice for patients of hypertrophic cardiomyopathy who are symptomatic despite maximal medical therapy. Residual obstruction results in the persistence of symptoms and poorer outcomes. The length (depth) of the septum excised as far towards the apex is important. A combined approach of trans-aortic and trans-apical is needed to achieve this in specific cases with associated mid-cavity obstruction. We present a case of a complex long-segment septal hypertrophy which underwent a successful septal reduction using a combined trans-aortic and trans-apical approach.

Supplementary information: The online version contains supplementary material available at 10.1007/s12055-022-01377-4.

Keywords: Cardiomyopathy; Combined; HCM; Myectomy; Trans-aortic; Trans-apical.

Fig. 1

a Cardiac magnetic resonance imaging (CMRI) showing the complex long-segment hypertrophic cardiomyopathy. b Intra-operative trans-oesophageal echocardiogram picture demonstrating the left ventricular outflow tract obstruction (yellow arrow) and the associated systolic anterior motion of the anterior mitral leaflet (pink arrow). c Intra-operative trans-oesophageal echocardiogram demonstrating the turbulence in the left ventricular outflow tract with associated mitral regurgitation. d Intra-cavitary aortic (red font) and left ventricular(yellow font) gradients measured during the surgery

Fig. 2

a Intra-operative image showing the first cut being made. b Graphic representation demonstrating the first cut being made (reprinted from [3]). c Intra-operative image showing the second cut with the anterior wall of the left ventricle depressed using a ‘swab on a stick’ (black arrow). d Graphic representation demonstrating the first cut being made (reprinted from [6])

Fig. 3

a Intra-operative image showing the trans-apical approach. b Graphic representation of the combined approach to respective portions of the hypertrophied septum. c Intra-operative image showing the left apical ventriculotomy closed with Teflon felts on either side. d Intra-operation; post bypass measurement of the intra-cavitary gradients. Aortic gradient (red font) and ventricular gradient (yellow font)