Surgical treatment of hypertrophic obstructive cardiomyopathy.

The complexity of the anatomical substrate that produces obstruction in hypertrophic obstructive cardiomyopathy (HOCM) is reflected by the variety of different surgical strategies that have been reported during the past 30 years[1–12]. These include incision (myotomy)[1] and excision (myectomy)[2,3] of bulging myocardial tissue from the basal septum, in some series together with plication[9] or additional enlargement[10] of the anterior leaflet of the mitral valve, and mitral valve replacement[5–7,12]. In most series left ventricular myotomy-myectomy proved to be effective in reducing left ventricular outflow tract (LVOT) gradients and symptoms of patients[13–17], and a transaortic approach is regularly preferred to left or right or combined ventriculotomies[4,8,18]. Left ventricular myotomymyectomy may thus serve as a ‘gold standard’ modality, whereas the disadvantages of mitral valve replacement are estimated to outweigh its benefits[19]. However, surgeons still consider classical myotomymyectomy to be a technically challenging operation, which is often referred to specialized and experienced centres because it carries inherent risks for ventricular septal defect and incomplete relief. We developed a modified technique[20,21] that enables better exposure of the basal septum, simplifies myectomy, and even allows the myectomy to be extended to the lateral free wall of the ventricle. This extended myectomy allows safe access to the deeper parts of the ventricle, where resection of hypertrophied trabeculae and mobilization or partial excision of papillary muscles lead to correction of the anatomically distorted subvalvular mitral apparatus.