Advertisement

Clinical Profile of Nonresponders to Surgical Myectomy with Obstructive Hypertrophic Cardiomyopathy

Published:January 15, 2018DOI:https://doi.org/10.1016/j.amjmed.2017.12.031

      Abstract

      Background

      Surgical myectomy reverses heart failure symptoms in the vast majority of obstructive hypertrophic cardiomyopathy patients. However, a small subgroup fails to experience sustained postoperative improvement despite relief of obstruction. Clinical profile of such patients has not been well defined.

      Methods

      Consecutive obstructive hypertrophic cardiomyopathy patients undergoing myectomy at Tufts Medical Center for drug-refractory New York Heart Association III/IV heart failure symptoms, 2004 to 2017, were followed postoperatively for 2.5 ± 2.8 years and assessed for outcome.

      Results

      Of the 503 patients, there were 4 postoperative deaths (0.8%); 480 patients (96%) had sustained improvement to New York Heart Association classes I or II (responders), but 19 (3.8%) developed advanced symptoms (classes III or IV) in the absence of obstruction (nonresponders). Compared with responders, nonresponders were younger (40 ± 13 vs 53 ± 14 years; P < .001) and had greater septal thickness (25 ± 9 vs 20 ± 4 mm; P < .001). Massive hypertrophy (≥30 mm) was 5-fold more common in nonresponders (P < .01). Seven nonresponders developed systolic dysfunction (ejection fraction 20%-47%), 2 days to 6.1 years postoperatively. Four nonresponders underwent heart transplant 3.4 to 9.2 years after myectomy, and 2 others have been listed.

      Conclusions

      Surgical myectomy is highly effective at reversing heart failure symptoms in the vast majority of patients with obstructive hypertrophic cardiomyopathy. However, a small minority experience persistent functional limitation despite surgical relief of outflow obstruction. Predictors of adverse postoperative course were substantial/massive septal thickness and youthful age. Patients who failed to respond symptomatically to myectomy were considered for advanced heart failure treatment, including heart transplantation.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The American Journal of Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Maron B.J.
        • Ommen S.R.
        • Semsarian C.
        • et al.
        Hypertrophic cardiomyopathy: present and future, with translation into contemporary cardiovascular medicine.
        J Am Coll Cardiol. 2014; 64: 83-99
        • Gersh B.J.
        • Maron B.J.
        • Bonow R.O.
        • et al.
        2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy.
        Circulation. 2011; 124: 2761-2796
        • Ommen S.R.
        • Maron B.J.
        • Olivotto I.
        • et al.
        Long-term effects of surgical septal myectomy on survival in patients with obstructive hypertrophic cardiomyopathy.
        J Am Coll Cardiol. 2005; 46: 470-476
        • Parry D.J.
        • Raskin J.A.
        • Ribero I.B.
        • et al.
        Short and medium term outcomes of surgery for patients with hypertrophic obstructive cardiomyopathy.
        Ann Thorac Surg. 2015; 99: 1213-1219
        • Desai M.Y.
        • Bhonsale A.
        • Smedira N.G.
        • et al.
        Predictors of long-term outcomes in symptomatic hypertrophic obstructive cardiomyopathy patients undergoing surgical relief of left ventricular outflow tract obstruction.
        Circulation. 2013; 128: 209-216
        • Iacovoni A.
        • Spirito P.
        • Simon C.
        • et al.
        A contemporary European experience with surgical septal myectomy in hypertrophic cardiomyopathy.
        Eur Heart J. 2012; 33: 2080-2087
        • Woo A.
        • Williams W.
        • Choi R.
        • et al.
        Clinical and echocardiographic determinants of long-term survival after surgical myectomy in obstructive hypertrophic cardiomyopathy.
        Circulation. 2005; 111: 2033-2041
        • Liebregts M.
        • Vriesendorp P.A.
        • Mahmoodi B.K.
        • et al.
        A systematic review and meta-analysis of long-term outcomes after septal reduction therapy in patients with hypertrophic cardiomyopathy.
        JACC Heart Fail. 2015; 3: 896-905
        • Maron B.J.
        • Dearani J.A.
        • Ommen S.R.
        • et al.
        Low operative mortality achieved with surgical septal myectomy.
        J Am Coll Cardiol. 2015; 66: 1307-1308
        • Kotkar K.D.
        • Said S.M.
        • Dearani J.A.
        • Schaff H.V.
        Hypertrophic obstructive cardiomyopathy.
        Ann Cardiothorac Surg. 2017; 6: 329-336
        • Rastegar H.
        • Boll G.
        • Rowin E.J.
        • et al.
        Results of surgical septal myectomy for obstructive hypertrophic cardiomyopathy.
        Ann Cardiothorac Surg. 2017; 6: 353-363
        • Tang B.
        • Song Y.
        • Cui H.
        • et al.
        Prediction of mid-term outcomes in adult obstructive hypertrophic cardiomyopathy after surgical ventricular septum myectomy.
        J Am Coll Cardiol. 2017; 70: 2092-2094
        • Nagueh S.F.
        • Otto A.S.
        • Appleton C.P.
        • et al.
        Recommendations for the evaluation of left ventricular diastolic function by echocardiography.
        J Am Soc Echocardiogr. 2016; 29: 277-314