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Hypertrophic cardiomyopathy patients with co-existing pathology: the role of heart team

Session Poster Session 4

Speaker Polina Danchenko

Event : Heart Failure 2019

  • Topic : arrhythmias and device therapy
  • Sub-topic : Hypertrophic Cardiomyopathy
  • Session type : Poster Session

Authors : K Rudenko (Kiev,UA), V Lazoryshynets (Kiev,UA), O Krykunov (Kiev,UA), B Cherpak (Kiev,UA), I Ditkivskyi (Kiev,UA), O Chyzhevska (Kiev,UA), L Nevmerzhytska (Kiev,UA), O Trembovetska (Kiev,UA), P Danchenko (Kiev,UA)

Authors:
K Rudenko1 , V Lazoryshynets1 , O Krykunov1 , B Cherpak1 , I Ditkivskyi1 , O Chyzhevska1 , L Nevmerzhytska1 , O Trembovetska1 , P Danchenko2 , 1Amosov Institute of Cardiovascular Surgery AMS of Ukraine - Kiev - Ukraine , 2National O.O. Bohomolets Medical University - Kiev - Ukraine ,

Citation:

Background. The experience of our Center shows that more and more patients with hypertrophic cardiomyopathy (HCM) require multi-disciplinary approach, e.g. Heart Team, consisting of interventional surgeons, radiologists, cardiac surgeons and cardiologists. 
Introduction. 68-year-old male patient came in to the Center with complaints on chest pain, dyspnea on exertion, periodic dizziness and decrease in tolerance to physical activity. In 2013 he underwent the abdominal aneurysm repair. The data obtained from the instrumental studies are presented in Table 1. The following diagnosis was established: HOCM, moderate mitral regurgitation (MR), mild tricuspid regurgitation; ischemic heart disease, exertional angina, class II, multi-vessel coronary artery disease; thoracoabdominal aortic aneurysm, type B (DeBakey); state after abdominal aortic aneurysm repair (2013); heart failure (HF) with preserved EF, functional class II (HYHA).
The Heart Team made a decision to perform two-stage surgical correction. Stage 1 included off-pump CABG-4 of the LAD, Cx and D2 branches of the LCA with autovenous grafts, and on-pump transaortic septal myectomy of the IVS with 6 anomalous chordal attachments cutting, and mobilization of the papillary muscles. Stage 2 involved thoracoabdominal endovascular aortic repair (TEVAR) with 2 stent graft systems, 32-28 mm and 34-30 mm – 200 mm length each. The control angiography performed after surgery showed endoleak, type 1b due to kinking of the distal part of the aorta. As a result, it was decided to perform one more repair with stent graft system 36-36 mm–64 mm length. After the procedure, control angiography showed no significant paraprosthetic leak. Post-operative TEE showed: SPG on LVOT = 12 mmHg. EDV = 92 ml; ESV= 36 ml; SV= 58 ml; EF= 58%, IVS = 0,9 cm. No SAM of the anterior MV leaflet. Mild MR. No complications were observed in the post-operative period.
Conclusion. The treatment of HCM patients with co-existing diseases like coronary artery disease and thoracoabdominal aneurysm requires Heart Team. We suggest performing the surgical correction in such types of patients in two stages – off-pump CABG and on-pump septal myectomy as the fist stage, and TEVAR as the second one.

Table 1. Pre-operative results of the instrumental examination
TEE Dilation of the thoracoabdominal aorta up to 5,6 cm. IVS = 3,2 cm, EDV=94 ml, ESV=39 ml, SV=61 ml, EF=65%, SPG on the LVOT at rest = 65 mmHg with SAM of the anterior MV leaflet
Heart catheterization Multi-vessel coronary artery disease (atherosclerotic obstruction of LAD=75%. Cx=80%, D2=90%). SPG = 70 mmHg
Heart CT Hemodynamically significant atherosclerosis of the coronary arteries; aneurysm of the thoracoabdominal aorta (Ø=6 cm); HOCM
MSCT of the abdominal cavity CT-sings of fusiform aneurysm of the thoracoabdominal aorta (Ø=6 cm)

Cx - circumflex branch of the left coronary artery; D2 - diagonal branch of the left coronary artery; HOCM - hypertrophic obstructive cardiomyopathy; LAD - left anterior descending artery; MSCT - multi-spiral computer tomography; MV - mitral valve; SAM - systolic anterior motion; SPG - systolic pressure gradient.

Pre-operative results of the instrumental examination

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