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Three-Step Myectomy, Mitral Plication, and Chordae Cutting for Hypertrophic Cardiomyopathy Through a Transaortic Approach

Monday, September 17, 2018

Vrancic JM, Cervetti MR, Chiappe MA, Benavidez J, Clusa NM, Navia D. Three-Step Myectomy, Mitral Plication, and Chordae Cutting for Hypertrophic Cardiomyopathy Through a Transaortic Approach. September 2018. doi:10.25373/ctsnet.7073015.

The patient was a 61-year-old man with hypertrophic obstructive cardiomyopathy with severe heart failure symptoms (New York Heart Association functional class III). His cardiovascular history included dyslipidemia, smoking, and the death of his father by sudden death. Transthoracic echocardiography showed mild septal hypertrophy (17 mm) confined mainly to anterior, lower-basal, and medium portions of the septum, systolic anterior motion (SAM) of the anterior leaflet of the mitral valve (MV) with mitral septal contact, and moderate left atrial dilation (46 ml/m2). Doppler echocardiography revealed an outflow tract gradient of 80 mm Hg at rest, and the gradient increased to 122 mm Hg upon Valsalva maneuver.

Systematically, in the operating room and prior to incision, the intraoperative transesophageal echocardiogram (TEE) was reviewed. A standard median sternotomy was preferred to provide adequate access to both the aorta and the left ventricle. The patient was placed on cardiopulmonary bypass using moderate hypothermia (32 degrees Celsius). The aorta was cross-clamped, and anterograde and retrograde cold crystalloid cardioplegia was delivered. After transverse aortotomy and retraction of the aortic valve leaflets, the extent of septal hypertrophy and the mitral valve were evaluated.


The authors proceeded to perform the extended myectomy of the basal septum but without exceeding a thickness of 5 mm, given the 17 mm thickness observed on imaging. Briefly, two parallel incisions were made 8 - 10 mm below the nadir of the right coronary valve, extending to the base of the papillary muscles in the form of a trapezoid. The resection was completed apically, and continued to the left to the anterior leaflet of the MV and to the right to the medial postoperative commissure. Two second-order chordae of the anterior valve were resected. Finally, the authors plied the anterior mitral valve using three separate stitches with proline 5-0 sutures. To determine the extent of plication, they integrated the preoperative echo, the degree of SAM, the size of the mitral valve, and the slack and redundancy of the anterior leaflet as assessed with the nerve hook. In general, this results in a plication of 2 - 5 mm, depending on the amount of redundancy and the size of the anterior leaflet.


After final inspection, and irrigation and suctioning to remove any possible residual loose pieces of muscle, the aortotomy was closed with a running 5-0 proline suture as the patient was rewarmed and the heart allowed to fill passively with blood. Standard de-airing was carried out as the cross-clamp was removed. As soon as contractility was restored, the result could be assessed by either partial bypass or temporarily suspending it altogether. Adequacy of the resection and mitral insufficiency was examined.

Intraoperative TEE showed that the MV coaptation point had moved away from the left ventricular outflow tract to a more posterior and normal position within the left ventricular cavity, and that the MV SAM and MV regurgitation were absent. The sternotomy was closed in a standard fashion. The patient had a normal echocardiogram with adequate gradients at a follow-up visit one month postoperatively.

Video References

  1. Balaram SK, Sherrid MV, Derose JJ Jr, Hillel Z, Winson G, Swistel DG. Beyond extended myectomy for hypertrophic cardiomyopathy: the resection-plication-release (RPR) repair. Ann Thorac Surg. 2005;80(1):217-223.
  2. Ralph-Edwards A, Vanderlaan RD, Bajona P. Transaortic septal myectomy: techniques and pitfalls. Ann Cardiothorac Surg. 2017;6(4):410-415.


Congratulations to the authors. This kind of operation is always a real challenge. I make no bones the results were fantastic as we could watch at the echo after repair. However, it's worth highlighting the septum thickness of 17 mm. It seems too me that it's not so thick to go for resection. I mean , it's not the usual. Wasn't he candidate for other medical treatment other the than surgical one? And the second question, why the anterior leaflet plication? I didn't understand it at all this issue. Sometimes, an edge-to-edge Alfieri stitch is needed between A2-P2, but I'd rather say it's nor so common. All these comments above notwithstanding, it only remains for me to congratulate my dear friend Juan Vrancic and his working group for this nice show we've watched herein. Keep up your extraordinary work!
Excellent video and results. RPR procedure is specially helpful in patients with LV septum below 2-1.8 cm. Questions: 1. How long was the MV anterior leaflet? 2. Do you perform Dobutamine stress test in the or post myectomy? Again thanks for sharing this video.
Dear Ovidio Garcia-Villarreal, thank you very much for your comments. As Dr. Pietro Bajona says, the indication of the RPR procedure is mainly for patients with a LV septum below 20 mm considering that it is most likely that the mechanism of their symptomatology is the SAM and not the septal thickness. With respect to the other question, we prefer the horizontal plication of the mitral anterior leaflet because it had an increased length and we have good results with this technique. The edge-to-edge is an accepted procedure, but we have more experience with the plication of the anterior valve.
Dear Dr. Pietro Bajona we really appreciate your comment considering you are an expert in the subject. The length of anterior mitral leafleat was 40 mm. We performe Isoprotenerol stress test after CPB with TEE control. Thank you very much contribution.

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