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Ann Thorac Surg 1991;51:585-592
© 1991 The Society of Thoracic Surgeons
b Surgery Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland USA
a Dr Brown is currently at Northwestern Memorial Hospital, Chicago, IL 60611 USA
Accepted for publication November 16, 1990.
* Address reprint requests to Dr Clark, Department of Surgery, Allegheny General Hospital, 320 E North Ave, Pittsburgh, PA 15212-9986.
Five hundred twenty-five patients with hypertrophic cardiomyopathy underwent left ventricular myotomy and myectomy (LVMM) from 1960 to 1990. Four hundred ninety-six had nonregurgitant trileaflet aortic valves before LVMM. In 19 (4%) of these patients, aortic regurgitation developed after LVMM. Age of the 19 patients ranged from 10 to 58 years (mean age, 35 ± 3 years [±standard error of the mean]). Seven were male and 12, female. Five patients underwent LVMM followed immediately by aortic valve replacement or valvuloplasty. Aortic regurgitation developed in 14 patients at a later date. The average New York Heart Association functional class improved from 3.2 ± 0.1 to 1.3 ± 0.1 (p < 0.05, Student's t test) after operation. The average peak systolic left ventricular outflow tract gradient at rest and with provocation decreased from 65 ± 8 to 14 ± 5 mm Hg (p < 0.05) and 108 ± 9 to 45 ± 7 mm Hg (p < 0.05), respectively, 6 to 8 months after operation. Aortic regurgitation occurred in 7 of the 14 patients at 6 months or less after operation, and 3 required operative repair. In the other 7 patients, aortic regurgitation developed 3 years or more after LVMM, and 3 of them also required operative repair. All 12 patients in whom aortic regurgitation developed at operation or within 6 months postoperatively had either a very small aortic annulus (
21 mm, 5 patients), a low mitral-septal contact lesion (
35 mm below the aortic annulus, 3 patients), or both (4 patients). None of the patients in whom aortic regurgitation occurred 3 years or more postoperatively had an aortic annulus of 21 mm or less, and only 1 had a low mitral-septal contact point. A small aortic annulus or a low mitral-septal contact lesion greatly increased the difficulty of the operation and resulted in increased retraction of the aortic valve and annulus (with increased possibility of damage to the valve) to gain exposure to the interventricular septum. We recommend in patients with a very small aortic annulus, a low mitral-septal contact lesion, or both, that caution be exercised when operating through the aortic valve and that the valve be routinely evaluated postoperatively. If LVMM cannot be performed easily in these patients, consideration should be given to using another means of access to the interventricular septum or performing mitral valve replacement.
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