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J Thorac Cardiovasc Surg 2004;127:481-489
© 2004 The American Association for Thoracic Surgery

Surgery for congenital heart disease

Extended septal myectomy for hypertrophic obstructive cardiomyopathy with anomalous mitral papillary muscles or chordae

^a Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn, USA
^b Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn, USA
^c The Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, Minn, USA

Read at the Eighty-third Annual Meeting of The American Association for Thoracic Surgery, Boston, Mass, May 4-7, 2003.

Received for publication May 20, 2003; revisions received September 23, 2003; accepted for publication September 29, 2003.

^* Address for reprints: Joseph A. Dearani, MD, 200 First Street SW, Rochester, MN 55905, USA
dearani.joseph{at}mayo.edu

OBJECTIVES: Transaortic left ventricular septal myectomy yields excellent results for most severely symptomatic patients with hypertrophic obstructive cardiomyopathy. However, associated anomalies of the mitral subvalvular apparatus may prevent complete relief of obstruction, and mitral valve replacement has been advocated. We reviewed our results of procedures designed to relieve obstruction with preservation of the mitral valve.

METHODS: Among 291 patients undergoing septal myectomy from 1975 to 2002, 56 (ages 2-77 years) had anomalous mitral subvalvular apparatus including anomalous chordae (n = 28) and papillary muscles with direct insertion into mitral leaflets (n = 13) or fusion to septum (n = 31) or free wall (n = 12); 82% of patients were in New York Heart Association class III or IV. Operation included resection of anomalous chordae (28 patients), relief of papillary muscle fusion (36 patients), and extended septal myectomy, wider at the apex than the base.

RESULTS: There were no early deaths and no patients required mitral valve replacement. Mean peak pressure gradients decreased from 70 ± 28 to 4.9 ± 8.4 mm Hg and mean mitral regurgitation grade decreased from 2.3 to 1.0 (P < .001). Mean follow-up was 2.8 ± 2.6 years. Freedom from reoperation at 4 years was 95%. There were 3 late noncardiac deaths; 98% of patients were in New York Heart Association class I or II.

CONCLUSIONS: Hypertrophic obstructive cardiomyopathy associated with anomalous mitral papillary muscles or chordae can be successfully treated without mitral valve replacement by surgical relief of the anomalies and an extended septal myectomy; early mortality is low, obstruction and mitral regurgitation are significantly reduced, and late results are excellent.

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