Extended myectomy for hypertrophic obstructive cardiomyopathy after failure or contraindication of septal ablation or with combined surgical procedures

Background: Surgical correction of hypertrophic obstructive cardiomyopathy in severely symptomatic patients has been proven to be effective over the long term. The introduction of catheter-based procedures restricts surgical therapy to a subset of patients not suitable for septal ablation or requiring concomitant cardiac surgery. Methods: Between 8/2001 and 8/2003, 25 patients (58 15 years) underwent extended transaortic septal myectomy with partial excision and mobilization of the papillary muscles. Concomitant surgical procedures were performed in 40% (CABG n = 9, aortic valve replacement n = 2). In 24%, prior septal ablation was ineffective. Intraventricular gradient was 80 29 mm Hg at rest and 143 +/- 35 mm Hg during exercise. Mitral regurgitation affected 72% of patients, and 88% were NYHA functional class III or IV. Results: No hospital death, no postsurgical ventricular septal defect, and no complete atrioventricular block occurred. Severe nonfatal complications occurred in 24% of patients. Intensive care was necessary for 1.8 +/- 1.7 days; total hospital stay was 11.8 +/- 3.8 days. Early follow-up was complete in 100% (15 +/- 6 months, total of 376 months) with no late deaths, no relevant mitral regurgitation, or intraventricular gradients. Functional status was markedly improved (NYHA class 1 40%, class II 56%, class III 4%). Conclusions: Early results of extended surgical myectomy and reconstruction of the subvalvular mitral apparatus in hypertrophic obstructive cardiomyopathy remain excellent with respect to mortality, Morbidity, and functional capacity even when restricting surgery to patients earlier supposed to be at high risk.