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Objective: Myomectomy is the cornerstone of therapy for hypertrophic obstructive cardiomyopathy (HOCM) in the presence of a high gradient. The importance of mechanical gradient across the left ventricle outflow track (LVOT) vs left ventricular diastolic dysfunction (LVDD) is debatable. Methods: We retrospectively analyzed data on 14 patients with HOCM who underwent myomectomy from 2007 to 2011 at our institution. All patients in this study were symptomatic. The purpose of this study was to assess the significance of immediate reduction of the gradient across the LVOT as well as improved LVDD and its correlation with hemodynamics. Results: A total of 14 patients with a mean age of 52.5 ± 19.0 years (male-female ratio of 5/8) were evaluated. The preoperative LVOT peak gradient was 76.9 ± 63.4 mmHg, the left atrial (LA) diameter was 41.9 ± 6.1 mm, and the septal thickness was 15.4 ± 3.2 mm. The relevant preoperative risk factors included DM (23.0%; n = 3), angina pectoris (15.4%; n = 2), cerebrovascular disease (CVD) (30.8%; n = 4), stroke (15.4%; n = 2), arrhythmias (30.8%; n = 4), and COPD (15.4%; n = 2). The concurrent procedures included mitral valve repair/ replacement (MVR) (30.8%; n = 4), aortic valve replacement (AVR) (23.0%; n = 3), coronary artery bypass grafting (CABG) (15.4%; n = 2), and modified MAZE procedure/ablation (15.4%; n = 2). The perioperative mortality was 7.7% (n = 1), and the long-term survival was 85.6% at a median follow up of 30 months. The postoperative LVOT gradient improved to 32.3 ± 24.4 mmHg and the septal thickness to 12.5 ± 3.8 mm. These differences were not statistically significant, likely due to small sample size. The postoperative complications included iatrogenic small VSD in one patient (who had myomectomy for a third time), atrial fibrillation (n = 4), cardiac arrest (7.7%; n = 1), neurologic adverse event (7.7%; n = 1), and new onset renal failure (7.7%; n = 1). We did not observe any new onset AV block. The length of stay (LOS) in the surgical critical care unit was 95.5 ± 112.7 hours. The overall hospital LOS was 15 ± 11.5 days. Conclusion: The septal myomectomy results showed an immediate reduction of the LVOT gradient, which translates into clinical and echocardiographic improvement.

Background. Benefits of ministernotomy have been reported but not yet fully established in the current literature. Ministernotomy may be associated with less bleeding, less need for transfusion, and reduced hospital length of stay. Methods. We retrospectively evaluated 347 patients who underwent aortic valve replacement between 2007 and 2011 at our institution. Results. Standard sternotomy was performed in 303 patients (154 males, 50.8% and 149 females, 49.2%) and ministernotomy in 44 patients (13 males, 30% and 30 females, 70%); most of the patients in ministernotomy group were female (75%) (P=.0095). The mean age for ministernotomy patients was 71.8±12.6 years and for sternotomy patients 67.4±13.8 years (P=.045). Significant preoperative morbidities (for ministernotomy and sternotomy, resp.) included stroke (11%, n=5 versus 18%, n=55; P=.39), PVD (23%, n=10 versus 16%, n=49; P=.29), COPD (25%, n=11 versus 17%, n=52; P=.21), renal failure (0.0%, n=0 versus 8.8%, n=26; P=.06), and previous heart surgery (9%, n=4 versus 9.5%, n=29; P=1.0). Intraoperative blood transfusion was required in 23% of ministernotomy patients (n=9) and 30% of sternotomy patients (n=91), P=.16. Major postoperative complications (for ministernotomy and sternotomy, resp.) included exploration for bleeding (4.5%, n=2 versus 6%, n=18; P=1) and adverse neurologic events (4.5%, n=2 versus 1.6%, n=5; P=.05). The length of stay (LOS) in the CCU was 75.4±57.1 hours for the ministernotomy group and 125.4±160.3 hours for the sternotomy group (P=.12). The LOS was slightly shorter following ministernotomy (9.00±7.78 days) compared to sternotomy (10.0±9.46 days) (P=.31). Perioperative mortality was 2.3% (n=1) for ministernotomy and 3.3% (n=10) for sternotomy (P=1.0). The 1-, 3-, and 7-year survival following ministernotomy was 93.8%, 93.8%, and 88.3%, respectively; following sternotomy, these rates were 87.7%, 83.7%, and 82.6%, respectively (95% CI 0.273 to 1.325, P=.20). Conclusion. Ministernotomy is less invasive and is associated with less perioperative and postoperative bleeding and reduced LOS in CCU and in hospital.

INTRODUCTION: Management of aortic root aneurysm or dissection has been the subject of much discussion that has led to some modifications. The current trend is a valve-sparing root replacement. We compared the outcome following valve sparing root repair with Bentall procedure. METHODS: We retrospectively evaluated 70 patients who underwent root replacement for aneurysm or dissection and compared the outcomes of valve-sparing root replacement with those of the Bentall procedure from January 2007 to December 2011 at our institution. RESULTS: Twenty-five patients had valve-sparing aortic root replacement (VSR, including reimplantation or remodeling) (23 males and 2 females), and 45 patients had the Bentall procedure (34 males and 11 females). Patients who underwent a VSR were younger with a mean age of 55.4 ± 14.8 years compared to those who underwent the Bentall procedure with a mean age of 60.6 ± 12.7 (P=ns). The preoperative aortic insufficiency (AI) in the VSR group was moderate in 8 (32%) patients, and severe in 6 (24%). Preoperative creatinine was 1 ± 0.35 mg/dl in the VSR group and 1.1 ± 0.87 mg/dl in the Bentall group. In the VSR group, 3 (12%) patients had emergency surgery; by contrast, in the Bentall group, 8 (17%) patients had emergent surgery. Concomitant coronary artery bypass grafting (excluding coronary reimplantation) was performed in 8 (32%) patients in the VSR group and in 12 (26.6%) patients in the Bentall group (P=0.78); additional valve procedures were performed in 2 (8%) patients in the VSR group and in 11 (24.4%) patients in the Bentall group. The perioperative mortality was 8% (n=2) and 13.3% (n=6), for the VSR and Bentall procedures, respectively (P=0.7, ns). The total duration of intensive care unit stay was 116.6 ± 106 hours for VSR patients and 152.5 ± 218.2 hours for Bentall patients (P=0.5). The overall length of stay in the hospital was 10 ± 8.1 days for VSR and 11 ± 9.52 days for Bentall (P=0.89). The one-year survival was 92% for the VSR group and 79.0% for the Bentall group. The seven-year survival for the VSR group was 92% and 79% for the Bentall group (95% CI [1.215 to 0.1275], P=0.1). CONCLUSION: Aortic valve-sparing root replacement can be performed with acceptable morbidity and mortality with a comparable long-term survival to the Bentall procedure. INTRODUÇÃO: Manejo de aneurisma da aorta ou dissecção da raiz tem sido objeto de muita discussão que levou a algumas modificações. A tendência atual é o uso da técnica de substituição valve-sparing (VSR). Nós comparamos o resultado da reparação da raiz utilizando a técnica de substituição valve-sparing com o procedimento de Bentall. MÉTODOS: Foram avaliados, retrospectivamente, 70 pacientes submetidos à substituição da raiz de aneurisma ou dissecção, comparando os resultados da técnica de substituição valve-sparing com os do procedimento Bentall de janeiro de 2007 a dezembro de 2011 em nossa instituição. RESULTADOS: Vinte e cinco pacientes foram submetidos à substituição da valva aórtica com o uso da técnica valve-sparing (VSR, incluindo o reimplante ou remodelação) (23 homens e duas mulheres), e 45 pacientes pelo procedimento de Bentall (34 homens e 11 mulheres). Pacientes que se submeteram à VSR eram mais jovens, com idade média de 55,4 ± 14,8 anos em comparação àqueles que foram submetidos ao procedimento Bentall, idade média de 60,6 ± 12,7 anos (P = ns). A insuficiência aórtica pré-operatória no grupo VSR foi moderada em oito (32%) pacientes e grave em seis (24%). Creatinina pré-operatória foi 1 ± 0,35 mg/dl, no grupo do VSR, e 1,1 ± 0,87 mg/dl, no grupo de Bentall. No grupo VSR, três (12%) pacientes foram operados em caráter de emergência e, no grupo de Bentall, oito (17%). Revascularização do miocárdio concomitante (excluindo reimplante coronariano) foi realizada em oito (32%) pacientes no grupo VSR e, em 12 (26,6%), no grupo de Bentall (P=0,78); procedimentos valvares adicionais foram realizados em 2 (8%) pacientes no grupo do VSR e em 11 (24,4%) no grupo de Bentall. A mortalidade perioperatória foi de 8% (n = 2) e 13,3% (n = 6), para os procedimentos de VSR e Bentall, respectivamente (P=0,7, ns). O tempo de internação na unidade de terapia intensiva foi de 116,6 ± 106,0 horas para pacientes VSR e 152,5 ± 218,2 horas para pacientes Bentall (P=0,5). O tempo de permanência no hospital foi de 10 ± 8,1 dias para VSR e 11 ± 9,52 dias para Bentall (P=0,89). A sobrevida em um ano foi de 92,0 % para o grupo VSR e 79,0% para o grupo de Bentall. A sobrevivência de sete anos para o grupo VSR foi de 92% e 79% para o grupo de Bentall (IC95% [1,215 a 0,1275], P=0,1). CONCLUSÃO: A técnica valve-sparing substituição da raiz aórtica pode ser realizada com a morbidade e mortalidade aceitáveis, e sobrevivência aceitável a longo prazo comparável com o procedimento de Bentall.