Apical Myectomy for Nonobstructive Hypertrophic Cardiomyopathy

Objectives

The authors present a video of transventricular apical myectomy in a patient with nonobstructive hypertrophic cardiomyopathy.

Methods

A 20-year-old woman with a diagnosis of apical hypertrophic cardiomyopathy (HCM) presented to the authors’ clinic with syncope, palpitations, and New York Heart Association class IV dyspnea. Two years prior to presentation, she had a cardiac arrest, and an implantable cardioverter defibrillator (ICD) was placed, with two subsequent discharges. Preoperative transthoracic echocardiography (TTE) showed apical HCM with maximum septal wall thickness of 29 mm. There was midventricular obstruction with a resting intraventricular gradient of 31 mmHg. The left ventricular (LV) chamber size was markedly decreased, and indexed stroke volume (SV) was 29 mL/m2 (normal 32-58 mL/m2).

Results

The patient underwent operation to enlarge the LV cavity. After satisfactory general endotracheal anesthesia was induced, a primary median sternotomy was made, and the pericardium was opened in the midline. Cardiopulmonary bypass was commenced, the aorta was cross-clamped, and cold blood cardioplegia was given. The heart was elevated into the wound, and an apical ventriculotomy was made. Working through this incision, the authors removed a large amount of muscle from the septum to enlarge the LV cavity, careful to avoid injury to the anterolateral and posteromedial papillary muscles. Satisfied that they had augmented the LV end-diastolic volume, they closed the ventriculotomy using #1 Ethibond sutures and two felt strips. This was reinforced with an over-and-over 0 Prolene suture. Postoperative TTE showed an enlarged LV cavity with an ejection fraction of 65%. The postoperative indexed SV increased to 37 mL/m2. The patient had an uneventful recovery, and was discharged eight days after surgery.

Conclusion

Apical myectomy is a surgical technique that can enlarge the LV cavity in severely symptomatic nonobstructive HCM patients with diastolic heart failure.

This educational video was originally presented during the STSA 65th Annual Meeting. This content is published with the permission of the STSA. For more information on the STSA and its next Annual Meeting, please click here.